Medicine

PRESERVING THE PASSION

IN THE 21ST CENTURY
 Also by Lois DeBakey, Ph.D.
The Scientific Journal:
Editorial Policies and Practices
 Medicine
PRESERVING THE PASSION
IN THE 21ST CENTURY
SECOND EDITION

Phil R. Manning, M.D.

Professor of Medicine Emeritus
Paul Ingalls Hoagland-Hastings Foundation Professor of Continuing Medical Education
Former Associate Vice President for Health Affairs
Former Associate Dean for Postgraduate Affairs
Keck School of Medicine of the University of Southern California
Los Angeles, California

Lois DeBakey, Ph.D.

Professor of Scientific Communication
Baylor College of Medicine
Houston, Texas
 PHIL R. MANNING, M.D. LOIS D E BAKEY, PH.D.
Keck School of Medicine Professor of Scientific Communication
University of Southern California Baylor College of Medicine
1975 Zonal Avenue One Baylor Plaza
Los Angeles, CA 90033 Houston, Texas 77030
USA USA
...
L I B R A R Y O F C O N G R E S S C ATA L O G I N G - I N - P U B L I C AT I O N D ATA
Manning, Phil R., 1921–
Medicine: preserving the passion in the 21st century / Phil R. Manning, Lois DeBakey.—
2nd ed.
p. ; cm.
Rev. ed. of: Medicine: preserving the passion. c1987.
Includes bibliographical references and index.
ISBN 0-387-0046-2 (h/c : alk. paper) ISBN 0-387-00427-0 (s/c : alk. paper)
1. Medicine—Study and teaching (Continuing education) I. DeBakey, Lois.
II. Manning, Phil R., 1921—Medicine: preserving the passion. III. Title.
[DNLM: 1. Education, Medical, Continuing—trends. W 20 M284m 2003]
R845.M36 2003
610'.71'5—dc21 2003042484

P R I N T E D O N A C I D - F R E E PA P E R .

ISBN 0-387-00426-2 (hardcover)

ISBN 0-387-00427-0 (softcover)

© 2004 Springer-Verlag New York, Inc.

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 Dedicated to

practicing physicians,

who have invested many years

in medical school and graduate training,

often at great personal and financial sacrifice,

and who place the highest priority

on the health and welfare

of their patients.
 The outstanding advances in information
technology are simplifying and encour-
aging independent, practice-related study,
making it easier for physicians to enhance
learning in the practice environment.
Phil R. Manning, M.D.

An inquiring, analytical mind; an un-

quenchable thirst for new knowledge; and a
heartfelt compassion for the ailing—these
are prominent traits among the committed
clinicians who have preserved the passion
for medicine, even with the advent of
“managed” care.
Lois DeBakey, Ph.D.
The education of the doctor which goes on after
he has his degree is, after all,
the most important part of his education.
J O H N S H AW B I L L I N G S
Boston Med Surg J. 1894; 131:140.

...
The art of medicine cannot be inherited,
nor can it be copied from books . . . .
PA R A C E L S U S
Foreword, Das zweite Buch der
Grossen Wundarznei, 1536 (verso
of leaf b, ed. 1562)

...
[T]he student begins with the patient,
continues with the patient,
and ends his studies with the patient,
using books and lectures as tools,
as means to an end.
WILLIAM OSLER
Aequanimitas, with Other Addresses,
“The Hospital as a College,” 1903
 Foreword

...

T he Association of American Medical Colleges recently recom-

mended that the traditional model for lifelong learning, which fo-
cused on attendance at courses, should be replaced by individualized
study closely related to personal medical practice. Phil R. Manning
has dedicated almost all of his professional life to demonstrating that
continual medical education should occur precisely in this fashion.
Lois DeBakey has devoted much of her professional life to instructing
physicians and biomedical researchers in critical reasoning and its
companion, clarity of thought, writing, and speech. Together, they
have created a highly readable book that shows physicians how to
gain the most from their clinical experience and, in doing so, preserve
their passion for clinical practice and lifelong education.
The authors describe techniques used by highly successful clini-
cians and academicians to achieve these goals, synthesizing lessons
from their clinical experience with reading of medical publications

ix
 M E D I C I N E : P R E S E R V I N G T H E PA S S I O N I N T H E 2 1 S T C E N T U R Y

and discussions of clinical problems with colleagues. Personal essays

and reflections by distinguished physicians are woven into the text.
The book’s emphasis is on immersion in practice, with tips on how to
live with this commitment.
Chapters discuss the remarkable advances in information technol-
ogy and medical library services that facilitate the active approach to
learning. In fact, Manning insists that “With the current information
services, there is no excuse for a physician not to remain current.”
On the other hand, the traditional mental model of “information re-
trieval” as equivalent to “staying current” runs aground fairly quickly
when the current medical advances outpace the doctor’s education and
understanding. Few practitioners today attended medical school lec-
tures on introns, exons, transposons, or epigenetics (to name just a few
of the bewildering concepts in the most recent medical journals). Con-
sequently, the highly fragmented research papers that reach us so
quickly via computer searches must fail to educate us if we have not—
somehow, somewhere—gotten a satisfactory understanding of the sci-
entific theories and assumptions that underlie the “current” progress.
This is difficult. Manning and DeBakey include an emphasis on a
physician’s continuing need to be part of the profession, part of a net-
work of colleagues. The computer can, indeed, retrieve facts with great
facility. Yet for us to advance our understanding of difficult areas
needs the interplay of minds. Here, too, this update of the popular first
edition of Medicine: Preserving the Passion in the 21st Century gives
the reader a good start in getting both understanding and facts.
D ONALD A. B. L INDBERG , M.D.
Director
National Library of Medicine

x
 Preface

...

S ince the first edition of Medicine: Preserving the Passion was pub-
lished in 1987, the practice of medicine has changed notably and
so, therefore, has the physician’s approach to lifelong learning. The
spread of managed care has discouraged many physicians for several
reasons: (1) they must often obtain approval from healthcare organiza-
tions for certain procedures, (2) because employers often shop for
more economical health plans, patients may be required to change
physicians, (3) paperwork has increased, and (4) physicians must see
more patients to maintain their income. On a more positive note,
healthcare organizations routinely collect data on individual prac-
tices for financial reasons, and these data can be used to identify ed-
ucational needs of practitioners.
Unprecedented educational opportunities on the Internet are rev-
olutionizing physicians’ access to information, both reliable and unre-
liable. Although the rapid growth of electronic services precludes

xi
 M E D I C I N E : P R E S E R V I N G T H E PA S S I O N I N T H E 2 1 S T C E N T U R Y

precise predictions of such resources during the next five years, it is

safe to say that the Internet services will continue to expand and im-
prove, making it ever easier for physicians to remain current. Infor-
mation sources include easy access to MEDLINE, and range from
brief news reports and summaries of recent developments to abstracts
or entire journal articles online. The potential is promising for quick
and accurate information at the time and place a physician sees pa-
tients. Prompt access, coupled with improved methods for the study
of clinical practice and collegial discussions of patient problems,
should facilitate education and thus enhance patient care.
We describe the experiences of physicians who use new ap-
proaches as an adjunct to traditional methods, such as reading med-
ical textbooks and journals, attending conferences, and holding
informal discussions with colleagues. For methods that rely on record-
ing experiences on paper, ledgers, and note cards, computer software
is usually available to simplify the input and analysis of legible data.
We address the recent emphasis on avoiding medical errors, and we
review the meaning and state of professionalism.
Rather than rely solely on our experience and study of medical
publications, we have organized this edition, like the first, using in-
terviews and written materials sent to us by academic and practicing
physicians who have described their successful learning techniques.
Thus, we are emphasizing the practical rather than the theoretical.
We maintain our belief that the implementation of the highest
ideals of the science and art of medicine and the opportunity to serve
patients combine to make the practice of medicine the most fulfilling
and gratifying of all professions. Medicine will be most rewarding to
physicians who immerse themselves in the profession and who prac-
tice the principles found on the following pages. And it is those prin-
ciples that will preserve the passion.
P HIL R. M ANNING , M.D.
L OIS D E B AKEY, P H .D.

xii
 Acknowledgments
PHIL R. MANNING, M.D.

...

I have always been motivated to discover how outstanding scholars,

and especially medical practitioners, maintain their interest in
lifelong learning and how they go about it. Although I have diligently
studied educational principles, my true interest has always been what
actually goes on in the field. This interest, I believe, sprang from my
Father, a perpetual student who studied two to three hours each night
almost until his death at 104 years. He was, in addition, a very prac-
tical man who cut through jargon and got to the basis of performance
as quickly as anyone I have met. My Mother’s persistence in my re-
ceiving a good education impressed on me from childhood the impor-
tance of continuing education for life.
The numerous outstanding clinicians and academicians who pro-
vided real-life examples of the methods they use to continue their ed-
ucation throughout life form the basis of this book. We all can be
grateful to them for their descriptions of the techniques that facili-
tated their careers.

xiii
 M E D I C I N E : P R E S E R V I N G T H E PA S S I O N I N T H E 2 1 S T C E N T U R Y

I owe a great deal to my colleagues and students at the University

of Southern California School of Medicine, now the Keck School of
Medicine of the University of Southern California. The opportunity to
discuss educational and medical problems with outstanding profes-
sionals has surely been one of my greatest assets. The continued sup-
port I have received from the medical school administration has
enabled me to pursue my investigations to improve methods of life-
long learning.
The experience I gained working with colleagues and staff in the
American College of Physicians as a Regent and as chairman of sev-
eral educational committees of the American College of Cardiology
greatly enriched my understanding of medical practice and the im-
portance of specialty societies. My friends in the Society of Academic
Continuing Medical Education have enhanced my professional life
and have added to my enjoyment of learning, as have my colleagues
at the American College of Medical Informatics.
Of course, the support I received from my wife Mary, our daughter
Carol and her husband Mark Boettger, our son Robert, and now our
grandchildren David and Linda Boettger has added to my satisfac-
tion and enhanced my passion for life and enthusiasm for lifelong
learning.
I shall always be indebted to my coauthor, Lois DeBakey, for her
diligence in achieving excellence. Lois sees through fuzzy thinking
and provides precision in the written and spoken word. The clarity
that I believe the reader will find throughout the book is her doing. If
there are passages that are not clearly expressed, I am probably the
culprit.
I appreciate the work of the Postgraduate Division staff of the
Keck School of Medicine for its excellent organizing of educational
programs for the practicing physician.
My special appreciation goes to Mr. David Arriola, who typed
successive drafts of the manuscript and kept everything in order. He
did much more than this by providing constructive criticism, detect-
ing errors, verifying references, offering suggestions, and keeping

xiv
 ACKNOWLEDGMENTS / PHIL R. MANNING, M.D.

calm during the various emendations the authors found it necessary to

make.
I am also indebted to the Hastings Foundation, which supported
much of my career by creating an endowed chair in continuing edu-
cation and naming me the Paul Ingalls Hoagland-Hastings Founda-
tion Professor of Continuing Medical Education.

xv
 Acknowledgments
L O I S D E B A K E Y, P H . D .

...

M edicine: Preserving the Passion in the 21st Century is a clear ex-

ample of the benefits of collegiality. This book grew out of a pro-
fessional relationship with Phil Manning that dates some years back
when we both served on a committee of the National Library of Medi-
cine. Shared standards of excellence in medical education and med-
ical communication and a shared interest in ethical and human
values led to what has been a rewarding and productive collegial as-
sociation of many years.
Phil, a leading international expert in lifelong medical education,
conceived the basis for the book, and because I had observed and ad-
mired his ardent dedication to the highest principles of medicine and
ethics, I eagerly agreed to collaborate. As with the first edition, I have
benefited from my co-author’s intellectual acuity and expertise, and
from the knowledge and wisdom contained in the contributions of var-
ious distinguished physicians and surgeons.

xvii
 M E D I C I N E : P R E S E R V I N G T H E PA S S I O N I N T H E 2 1 S T C E N T U R Y

I am indebted to those who led me into a scholarly career, primar-

ily my beloved family. Even before I began my formal schooling, my
parents stimulated my intellectual curiosity about the wonders of the
world and introduced me to the delight of learning, the pleasure of
reading, and the excitement of opening the mind to new knowledge
and new ideas. They fully supported my undergraduate and postgrad-
uate studies and endorsed my choice of an academic career. My debt
to them is incalculable, not only because they were peerless models
of love, intelligence, altruism, and probity, but also because they in-
stilled in their children the reach for excellence and provided the op-
portunities to achieve that goal. My brothers, Michael and Ernest,
both distinguished surgeons, and my sisters all served as strong role
models to whom I am deeply and affectionately grateful for their en-
couragement and support of all my scholarly endeavors. My brothers’
lofty standards as surgeons, their noble character, and their many
silent humanitarian deeds, like those of my parents, have been a life-
long inspiration. My brother Michael directed my sister Selma and me
into a truly exciting and fulfilling career. A man of vision, dedication,
and ingenuity, he recognized the need for instruction in medical writ-
ing, editing, and speech, and he encouraged us to establish this new
discipline. To Selma—my preceptor and alter ego—goes my un-
bounded gratitude, not only for her sage counsel during the prepara-
tion of this and all my other publications, but for her superb tutelage,
unstinting support, and sororal devotion throughout my life.
We thank our publisher, Springer-Verlag, for assistance in pro-
cessing our manuscript. To David Arriola, we are indebted for his out-
standing professional efforts throughout the successive drafts and
final manuscript of the second edition; his dedication to accuracy,
precision, and excellence made the authors’ work much easier. To
Janice Brookes, I am deeply grateful for meticulous proofreading of
the various drafts, her diligent reference verification, and her superb
assistance in scrutinizing the proof.

xviii
 A C K N O W L E D G M E N T S / L O I S D E B A K E Y, P H . D .

We are especially indebted to all the physicians who granted us

the benefit of their academic and clinical experience. Their raw ma-
terial provided a basis for our analysis, interpretation, and commen-
tary. Finally, to you, our readers, we are grateful for your own service
to humanity and your intellectual curiosity. We hope that you will feel
rewarded for your investment in reading this book.

xix
 Contents

...

F O R E W O R D : Donald A.B. Lindberg, M.D. ix

P R E FA C E : Phil R. Manning, M.D. and Lois DeBakey, Ph.D. xi
A C K N O W L E D G M E N T S : Phil R. Manning, M.D. xiii
A C K N O W L E D G M E N T S : Lois DeBakey, Ph.D. xvii
I N T R O D U C T I O N : Phil R. Manning, M.D. and Lois DeBakey, Ph.D. xxvii

CHAPTER 1 Enjoying the Struggle 1

P E R S O N A L E S S AY: Michael E. DeBakey, M.D. 21

R E F L E C T I O N S : J. Willis Hurst, M.D. 41

CHAPTER 2 Reading: Keeping Current 57

REFLECTIONS: Eugene Braunwald, M.D. 77

R E F L E C T I O N S : Philip A. Tumulty, M.D. 83
R E F L E C T I O N S : Bobby R. Alford, M.D. 89

xxi
 M E D I C I N E : P R E S E R V I N G T H E PA S S I O N I N T H E 2 1 S T C E N T U R Y

REFLECTIONS: William W. Parmley, M.D. 99

R E F L E C T I O N S : Norton J. Greenberger, M.D. 107
R E F L E C T I O N S : Robert J. Luchi, M.D. 113
R E F L E C T I O N S : Andrew Schafer, M.D. 117

CHAPTER 3 Evidence-based Medicine 123

REFLECTIONS: R. Brian Haynes, M.D., Ph.D. 135

CHAPTER 4 Medical Information Technology:

An Instrument for Learning 145

REFLECTIONS: Joshua Lederberg, Ph.D. 179

R E F L E C T I O N S : George D. Lundberg, M.D. 185

CHAPTER 5 The Medical Library 191

CHAPTER 6 The Collegial Network 201

CHAPTER 7 Learning from Formal Consultations 217

CHAPTER 8 Formal Courses and Conferences 227

REFLECTIONS: David A. Davis, M.D. 243

R E F L E C T I O N S : Catherine D. DeAngelis, M.D. 251

CHAPTER 9 Learning by Teaching 255

CHAPTER 10 Analysis of Practice 267

REFLECTIONS: A. McGehee Harvey, M.D. 291

xxii
 CONTENTS

CHAPTER 11 Social, Ethical, and Economic

Problems in Medicine 297

REFLECTIONS: C. Rollins Hanlon, M.D. 303

CHAPTER 12 The Physician–Patient Relationship,

Physical Examination, and New Procedures 311
REFLECTIONS: Steven G. Clemenson, M.D. 327
R E F L E C T I O N S : Sherman M. Mellinkoff, M.D. 333

CHAPTER 13 “Medical Errors” and Other Problems in

Practice Unrelated to Medical Knowledge 339

C O M M E N TA RY: Don Harper Mills, M.D., J.D. 357

CHAPTER 14 Organized Medicine and Lifelong Learning 371

REFLECTIONS: Dennis K. Wentz, M.D. 379

CHAPTER 15 Women Physicians 385

REFLECTIONS: Nora Goldschlager, M.D. 401

R E F L E C T I O N S : E. Connie Mariano, M.D. 407

CHAPTER 16 Professionalism 417

REFLECTIONS: Jordan J. Cohen, M.D. 421

R E F L E C T I O N S : Kenneth I. Shine, M.D. 429

A F T E RW O R D : Phil R. Manning, M.D., and Lois DeBakey, Ph.D. 437

I N T E RV I E W E E S A N D C O R R E S P O N D E N T S 443
NAME INDEX 451
SUBJECT INDEX 457

xxiii
 Photographs

...

Bobby R. Alford 89 Robert J. Luchi 113

Eugene Braunwald 77 Ian R. Mackay 287
Jordan J. Cohen 421 Connie E. Mariano 407
David A. Davis 243 Sherman M. Mellinkoff 333
Catherine D. DeAngelis 251 Robert H. Moser 66
Michael E. DeBakey 21 Kunio Okuda 314
Nora Goldschlager 401 Claude H. Organ, Jr. 324
Norton J. Greenberger 107 William W. Parmley 99
R. Brian Haynes 135 Sheila Sherlock 390
J. Willis Hurst 41 Kenneth Shine 429
Wu Jieping 230 Linda D. Shortliffe 394
Joshua Lederberg 179 Dennis K. Wentz 379
Donald A. B. Lindberg 193

xxv
 Introduction

...

N o one denies that physicians must be lifelong students. Self-

directed and practice-linked learning are also well accepted in
principle, but techniques that enhance their execution have not
been emphasized in medical schools. By the time physicians enter
residency training and practice, many have become too busy to de-
velop their own methods. As a result, they lose the opportunity to
profit maximally from their experience. Classroom instruction has
therefore been called upon to perform functions that it is ill-
equipped to do.
Since the turn of the century, the classroom has dominated con-
tinuing medical education in the United States. In 1906, the Ameri-
can Medical Association (AMA) sent J. N. McCormack to several
states to stimulate interest in postgraduate education. Under this
stimulus, several states began to organize courses. At the request of
the AMA, John Blackburn, Director of the Bowling Green County

xxvii
 M E D I C I N E : P R E S E R V I N G T H E PA S S I O N I N T H E 2 1 S T C E N T U R Y

Society in Kentucky, submitted a national plan and designed weekly

programs on basic sciences and therapy for use by county medical
societies.1
By 1909, about 350 county societies were sponsoring programs,2
but because of a decline in attendance, these were ultimately discon-
tinued. In 1916, W. S. Rankin, a North Carolina state health officer,
developed circuit courses that took education to rural physicians. The
instructors traveled to various communities delivering lectures and
discussing the diagnosis and treatment of patients brought in by class
attendees.3
In 1927, the University of Michigan established the first depart-
ment of postgraduate medicine within a medical school.1 Eight years
later, John B. Youmans, under the aegis of the Commonwealth Fund,
made surprise visits to 30 physicians in small towns and rural com-
munities of Tennessee who had completed formal postgraduate
courses at Vanderbilt University School of Medicine and graded them
against a standard developed to assess improved quality of practice.4
Although there was no precourse visit for comparison, Youmans de-
cided that practical programs dealing with patients and technical pro-
cedures were more beneficial than didactic lectures.
In 1932, the Commission on Medical Education of the Associa-
tion of American Medical Colleges concluded that “Continued educa-
tion of physicians is synonymous with good medical practice . . .” and
called for cooperation of medical associations, medical schools, and
hospitals in conducting comprehensive programs of postgraduate ed-
ucation.5 In 1936, the University of Minnesota constructed the first
permanent center to house continuing medical education. Four years
later, in accordance with a resolution adopted by the Advisory Board
for Medical Specialties, the Commission on Graduate Medical Educa-
tion was organized. The Commission, led by Willard C. Rappleye,
concluded that undergraduate medical education did not strongly mo-
tivate busy practitioners to pursue continuing education.6
After World War II, the W. K. Kellogg Foundation awarded grants
to 18 medical schools to broaden and innovate continuing medical

xxviii
 INTRODUCTION

education.7 Since then, the growth of formal continuing medical edu-

cation has been explosive, with hospitals, medical societies, and
medical schools acting as the main sponsors. Mandatory continuing
medical education and accreditation of organizations offering courses
further stimulated the growth of postgraduate classroom instruction.
Thus, the emphasis on formal classroom courses has overshadowed
individual methods linking education more directly to the physician’s
own practice. The concept of lifelong learning, in fact, has seemed al-
most locked in the classroom.
Despite the continued emphasis on classroom education, various
authorities, including Osler Peterson,8 George Miller,9 John William-
son,10 and Clement Brown,11 have demonstrated the limitations of for-
mal continuing education. Miller and his followers have advocated
that physicians analyze their practices to identify specific educa-
tional needs and thus direct their own education efficiently. In
Miller’s words, “. . . the practitioner-learner must progress steadily
from listener to questioner to participant to contributor.”9
Medicine: Preserving the Passion in the 21st Century calls attention
to the systematic methods that physicians have used to continue their
learning, hone their skills, and benefit maximally from their experi-
ence. Although traditional classroom approaches will continue to be
useful, we expect a major shift in emphasis, if not a revolution, away
from the conventional classroom enterprise to individual techniques
devised by physicians to address their own educational requirements.
The major advances in information technology have converted self-
directed, practice-linked continuing medical education from a desir-
able dream to a reality within our grasp. With the advent of “managed”
care, lifelong learning is more important than ever, not only for optimal
healthcare delivery but also to preserve the passion for medicine.

P HIL R. M ANNING , M.D.

L OIS D E B AKEY, P H .D.

xxix
M E D I C I N E : P R E S E R V I N G T H E PA S S I O N I N T H E 2 1 S T C E N T U R Y

REFERENCES
1. Bruce JD. Postgraduate education in medicine. J Mich State
Med Soc. 1937; 36:369–377.
2. The American Medical Association, Council on Medical Ed-
ucation and Hospitals. Graduate Medical Education in the
United States: I—Continuation Study for Practicing Physi-
cians 1937 to 1940. Chicago: American Medical Associa-
tion; 1940:216.
3. Adams FD. The North Carolina extension plan: an experi-
ment in postgraduate medical teaching. JAMA. 1923;
80:1714–1717.
4. Youmans JB. Experience with a postgraduate course for
practitioners: evaluation of results. J Assoc Am Med Coll.
1935;10:154–173.
5. Commission on Medical Education. Postgraduate medical
education. In: Final Report of the Commission on Medical
Education. New York: Office of the Director of Study;
1932:136.
6. Commission on Graduate Medical Education (W. C. Rappl-
eye, Chm.). Graduate Medical Education. Chicago: Univ of
Chicago Press; 1940:168.
7. Shepherd GR. History of continuation medical education
in the United States since 1930. J Med Educ. 1960;
35:740–758.
8. Peterson OL, Andrews LP, Spain RS, Greenberg BG. An an-
alytical study of North Carolina general practice 1953–54.
Part 2. J Med Educ. 1956;31:1–8.
9. Miller GE. Continuing education for what? J Med Educ.
1967;42:324.
10. Williamson JW, Alexander M, Miller GE. Continuing educa-
tion and patient care research: physician response to
screening test results. JAMA. 1967;201:118–122.
11. Brown CR, Uhl HSM. Mandatory continuing education:
sense or nonsense? JAMA. 1970;213:1660–1668.

xxx
 1

Enjoying the Struggle

...
In a highly regimented, regulated, or restrictive envi-
ronment, medical practice can frustrate, oppress, and
enslave—unless the physician holds his noble purpose
uppermost in mind. In a humanitarian and intellectu-
ally stimulating environment, on the other hand, medi-
cine can be intriguing, exhilarating, and engrossing. It
is the continual search for ways to maintain or restore
health and well-being to patients and the achievement
of that goal that preserve the passion for medicine.
L OIS D E B AKEY, P H .D.

A t once one of the most demanding and most rewarding of all pro-
fessions, medicine can be tyrannizing or exhilarating. If the
pressing responsibilities, sensitive interpersonal relationships, and
strenuous time pressures in caring for patients are allowed to escalate
to tedium or drudgery, the passion for medical practice will vanish. If
patient care becomes overly demanding, onerous, or boring, enthusi-
asm and pleasure will fade, and both patient and physician will suffer.
But that does not have to happen. The practice of medicine is admit-
tedly a strict taskmaster, requiring daily decisions about puzzling,
often life-threatening illnesses, as well as constant awareness of the
newest, most authentic information. But medicine also offers endless

1
 M E D I C I N E : P R E S E R V I N G T H E PA S S I O N I N T H E 2 1 S T C E N T U R Y

opportunities for enjoyment, satisfaction, and exhilaration through in-

tellectual advancement and service to patients.
Can physicians organize their daily work to make the practice of
medicine more gratifying? Our extensive communications indicate that
those who immerse themselves most deeply in clinical work derive the
greatest fulfillment. Such engagement includes daily reading and inter-
acting with colleagues about medical problems, continually examining
the nature and results of practice, and modifying performance accord-
ingly. Physicians who practice such immersion base their continuing
education largely on the puzzling problems that arise in their practice
(individual patients as well as aggregate practice) and the defects they
uncover in their performance. And they take prompt remedial steps.
The result is improved patient care, gratification, and gusto.
We are not advocating that physicians limit their potential for ful-
fillment and satisfaction to medical practice, since family, friends, the
arts, sports, and hobbies all offer additional rewards. Physicians can-
not, however, escape spending inordinate time in practice, so it be-
hooves them to find ways to make the long hours more pleasurable
and gratifying. Patients of physicians who enjoy their work, moreover,
receive the best care. This book shows how some outstanding physi-
cians have kept the flame of professional fervor alive despite exces-
sive demands on their time and energy.

THE NEED FOR LIFELONG LEARNING

All good physicians realize that they must perpetually revise their
knowledge base; they must discard and add continually. Underlying
lifelong study are the need to remain aware of the state of medicine,
the need to find solutions to specific problems in practice, and the de-
sire for intellectual stimulation, with its attendant personal and social
pleasure. The patient is the ultimate beneficiary of all.1,2 In Garrett
Lynch’s words, “Lifelong learning is indispensable to maintaining
zest for medical practice. One of the greatest joys of medicine is its
dynamism, continuously building on, and adding to, previous knowl-

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edge—an exciting phenomenon to experience daily. And to see a pa-

tient with a metastatic testicular malignancy, for example, finish col-
lege, establish a career, and have children makes all the diligent,
time-consuming work worthwhile.”

R E WA R D S F R O M L E A R N I N G F R O M E X P E R I E N C E
Some of the benefits of lifelong learning are subtle, whereas others
are more obvious.

Confidence, Self-respect, and Pride

A primary reward of an expanded intellect is greater self-confidence.
As Osler wrote, “If you do not believe in yourself how can you expect
other people to do so? If you have not an abiding faith in the profes-
sion you cannot be happy in it.”3 Paul Sanazaro agreed: “You need
the motivation that stems from pride and security in your knowledge.
You must know what you are doing and how it compares with the best
you can do; any discrepancy should prompt you to do better.” A driv-
ing force among the outstanding physicians whom we interviewed is
their pride in performance—a desire never to be or seem profession-
ally inadequate.

Enjoyment
Since people tend to invest more of themselves in what is enjoyable,
patients benefit when physicians like their work. Emphasizing the
salutary relationship of work and pleasure, George Bernard Shaw, in
John Bull’s Other Island, looked forward to a commonwealth where
“work is play and play is life.”4 Osler was fond of quoting John
Locke’s definition of education as a relish for knowledge. “Get early
this relish,” Osler advised, “this clear, keen joyance in work, with
which languor disappears and all shadows of annoyance flee away.”5

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Irvine Page described the engrossing quality of medicine thus:

“Medicine makes life worthwhile. If you lose that attitude at any point
in your life, you have essentially lost your life. You can combat that
danger by remembering that medicine is a grand and rapidly posses-
sive discipline that requires a lifelong interest in things human. If you
give that up at any time in your practice, you are lost.”
“The method a physician selects for lifelong learning must give
pleasure or other rewards,” said Eugene Stead, “because human be-
ings will not continue a program that does not have tangible divi-
dends.” To make lifelong learning enjoyable, physicians need to
organize their time and practice to allow for regular, but not necessar-
ily rigidly scheduled, study in a pleasant, relaxed atmosphere—one
that is comfortable, uninterrupted, and unhurried.
The merging of personal and professional pleasure is not uncom-
mon among eminent physicians. To some physicians, the greatest
pleasure in medicine comes from seeing a patient improve, and that
pleasure is dependent on steady learning. As Michael DeBakey put
it, “In medicine, helping others while solving complex intellectual
puzzles is our special reward.”

AT T R I B U T E S T O B E N U R T U R E D

Curiosity

Curiosity is, in great and generous minds, the first pas-

sion and the last. . . .
S AMUEL J OHNSON 6

“In research,” said Baruch Blumberg, “and probably also in practice,

maintaining and fostering curiosity—the ability to ask questions each
time a new phenomenon occurs—is indispensable.” Most physicians
we interviewed considered an insatiable curiosity to be innate or to be
established in early childhood, but they also recognized the need to
nourish it. The drama and complexity of medicine, by providing op-

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portunities for the thrill of discovery, can arouse curiosity despite the
inhibitory effect of time pressures. Not being satisfied with an imme-
diate answer, but wanting to go beyond is the mark of the intellectu-
ally curious. As Lazar Greenfield said, “In the quest for lifelong
learning, we are usually interested in the answer to a question, but
that answer will often raise more questions. The result is the opportu-
nity to discover new knowledge, upon which all advances are based.
Curiosity will always be the mother of discovery.”
Jean Hamburger of Paris related an incident in medical history
that illustrates how curiosity can guide genius, allowing a researcher
to explain an experimental result that others may dismiss. “In
1879–1880, Pasteur and his coworkers studied the fowl cholera germ.
It was a most virulent agent, killing all exposed hens within 24 to 48
hours. After some time, however, some cultures of the germ were un-
able to kill the animals. ‘I am possibly responsible for this failure,’
said someone in the laboratory, ‘since I left the cultures exposed to air
for several days before using them. I shall not repeat this mistake, and
the next experiment will be made with fresh cultures.’ So the same
hens were inoculated some weeks later with germs that were sup-
posed to be very virulent. But Pasteur’s coworkers were astonished to
find that again the hens did not succumb. ‘We are sorry,’ they said to
Pasteur. ‘Something must be wrong with our technique or with the
hens we use.’ But Pasteur turned the negative results to advantage,
and out of this ‘failed’ experiment came the discovery of vaccination
with attenuated germs.”
Alfredo Sadun recalled an incident involving David Glendenning
Cogan, Chief at the Massachusetts Eye and Ear Infirmary of Harvard
Medical School. “Dr. Cogan lived in a large townhouse on Beacon
Hill, one of the most exclusive areas but not far from where the
drunks reside. One evening the doorbell rang, and when Mrs. Cogan
opened the door, she found a drunk who was asking for money. He be-
haved obstreperously, and when she found it difficult to get rid of him,
she enlisted Dr. Cogan’s help. Mrs. Cogan then returned to the
kitchen. An hour later, she realized that she had not heard from her

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husband. Unable to find him in the apartment, she feared he may

have come to harm in turning away the drunk. Frantically, she left her
apartment and raced down the stairs, only to find Dr. Cogan sitting on
the street curb next to the drunk under a street light. Scattered around
them were a variety of prisms, which Dr. Cogan was using to measure
the extent of the drunk’s alcohol-induced strabismus. Dr. Cogan was
having the drunk fixate (on dollar bills) at varying distances and was
then measuring the induced esotropia. He was carefully logging all
the data. This incident illustrates the master clinician’s child-like cu-
riosity and the constant enthusiasm, which transcend the oddest situ-
ation. Even in the most unclinical setting, David Cogan saw an
opportunity for gaining further understanding of a subject of interest.”
Stimulating Curiosity. You can promote curiosity by engaging in
academic interests; relating knowledge to experience; associating
with stimulating colleagues, mentors, and students; carefully delin-
eating questions rather than seeking immediate answers to ill-defined
problems; and developing pet interests in medicine. The burden of
too much to do in too short a time, however, is sure to stifle curiosity.
Associating with intellectually inquisitive people stimulates cu-
riosity. Curiosity thrives in an open atmosphere that permits absolute
intellectual honesty. Exposure to medical students, residents, fellows,
and young colleagues who challenge traditional concepts can also ex-
cite curiosity.
Artful teachers nurture curiosity, especially at the bedside, and
teachers who continually ask “Why?” arouse curiosity in their stu-
dents. Students and house officers who ask provocative questions can
have a similar effect on their teachers.
The pursuit of knowledge in a field of special interest and the
thrill of resolving previously unanswered or unasked questions are re-
markably energizing. To formulate a theoretical answer and then to
validate it scientifically provide genuine excitement. Concern about
peer judgment and an intense desire to compete with peers for higher
levels of knowledge also kindle intellectual curiosity.

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Discipline, Diligence, and Determination

Lifelong learning, like the study and training leading to an M.D. de-
gree, requires discipline, diligence, and determination. Charles
Brunicardi believes that “Staying current is essential to optimal med-
ical practice, and principles of time management can help establish a
disciplined program for learning. Learning should be a daily priority;
by incorporating learning techniques into your daily work routine,
you will ensure currency in the rapidly changing medical advances.”
“No matter how much you read or know,” said Norton Green-
berger, “you have to keep refurbishing your information. In 1958,
when I was a senior medical student at the Massachusetts General
Hospital, I went on rounds with the Chief Resident, John Knowles.
He seemed to know everything about everything. I asked him how he
became so smart, and he replied that he had gotten into the habit of
reading every day. If you read ten pages a day, that is about 3,000
pages a year, the equivalent of a textbook.”
The challenge of teaching stimulates physicians to study and to
organize their thoughts. Having a target date encourages reserving
time to review and master a topic. In fact, the most effective way to
ensure self-discipline, according to Saul Farber, is to make teaching a
part of your daily life.

Compassion and a Sense of Service

In dedicated physicians, an encounter with sick or troubled patients
triggers empathy and stimulates the desire to serve. Truly compas-
sionate physicians hone their skills continually to serve their patients
better. Willis Hurst considers competence to be an important sign of
the physician’s compassion, for the compassionate physician cares
enough about the patient to seek answers to the clinical questions
posed by the patient’s illness. The methods described in this book
permit the physician to channel his compassion into action benefiting
his patients.

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The importance of compassion becomes evident when one consid-

ers the vulnerability of patients and the trust they place in their
physicians. As Sir Berkeley Moynihan wrote: “A patient can offer you
no higher tribute than to entrust you with his life and his health, and,
by implication, with the happiness of all his family. To be worthy of
this trust we must submit for a lifetime to the constant discipline of
unwearied effort in the search of knowledge, and of most reverent de-
votion to every detail in every operation that we perform.”7
When asked if he took his work home with him, Michael DeBakey
responded: “Of course I take my work home with me. Any physician
who doesn’t should not be practicing medicine. There may be five or
six open-heart operations scheduled the next day. All represent indi-
vidual lives to me. I care about every patient; I worry about them. I
think about all of them—their families and their hopes. I may be hav-
ing dinner with you and talking about baseball, but my mind is with
those patients. I wouldn’t be a real physician if I didn’t do that.” We
observed the same concern, compassion, and caring in all the out-
standing physicians we interviewed, and we are convinced that, be-
cause of these noble human qualities, they are able to perform above
the average in ministering to their patients.

LEARNING FROM EXPERIENCE

To study the phenomena of disease without books is to
sail an uncharted sea, while to study books without pa-
tients is not to go to sea at all.
W ILLIAM O SLER , M.D. 8

All physicians have experiences from their own practices that rein-
force Osler’s views. Observations made under the pressure and ex-
citement of patient care are usually remembered. Physicians can
recall for decades lessons learned from specific patients and their
problems. To be most reliable, the memory must, of course, be sub-
stantiated by a review of records and notes and must be integrated
into current observations.

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Robert Manning related an anecdote illustrating the value of such

experience. “One of Dr. Richard Vilter’s former residents mustered
his courage, approached Dr. Vilter, and asked, ‘Dr. Vilter, you are
such a marvelous clinician. To what do you attribute your success?’
Vilter replied, ‘Good judgment.’ The questioner thought for a moment
and, not completely satisfied with the response, asked, ‘But Dr. Vilter,
to what do you attribute your good judgment?’ Vilter replied: ‘Experi-
ence.’ Still not satisfied, the questioner pursued it one step further.
‘But Dr. Vilter, how does one gain experience?’ Vilter’s response: ‘Bad
judgment.’ ”
In subsequent chapters, we describe conventional as well as idio-
syncratic methods used by practicing physicians and academic clini-
cians to submerge themselves in their professional work and to gain
maximal benefit from their experience. But, first, let us review the un-
derlying philosophic principles. The methods used by our interview-
ees to gain the most from experience and from reading, conferences,
and colleagues represent a blending of study and first-hand experi-
ence, as advocated by Osler.

First-hand Knowledge
First-hand knowledge is the ultimate basis of intellec-
tual life. To a large extent book-learning conveys
second-hand information, and as such can never rise to
the importance of immediate practice.
A LFRED N ORTH W HITEHEAD 9

Mortimer Adler underscored the importance of experience when he

wrote: “[T]he difference between a man and a child is a difference
wrought by experience, pain and suffering, by hard knocks. It cannot
be produced by schooling.”10 William Osler echoed that idea when he
admonished physicians: “Let not your conception of the manifesta-
tions of disease come from words heard in the lecture room or read
from the book. See, and then reason and compare and control. But see
first.”11 Oliver Wendell Holmes concurred: “The most essential part

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of a student’s instruction is obtained . . . not in the lecture-room, but

at the bedside. Nothing seen there is lost; the rhythms of disease are
learned by frequent repetition; its unforeseen occurrences stamp
themselves indelibly in the memory.”12
Wu Jieping, Honorary President of the Chinese Academy of Med-
ical Sciences, stresses the importance of physicians summarizing and
documenting their clinical experiences, as well as keeping up with
medical progress through reading and attending conferences. These
are complementary. Masterful physicians emphasize skills in the
physician–patient relation and a high standard of ethics, both of
which are integral to lifelong learning.
Somerset Maugham, who studied medicine, noted his vivid memo-
ries of clinical experiences. “Even now that forty years have passed I
can remember certain people so exactly that I could draw a picture of
them. Phrases that I heard then still linger on my ears. I saw how men
died. I saw how they bore pain. I saw what hope looked like, fear and re-
lief; I saw the dark lines that despair drew on a face; I saw courage and
steadfastness. I saw faith shine in the eyes of those who trusted in what I
could only think was an illusion and I saw the gallantry that made a man
greet the prognosis of death with an ironic joke because he was too proud
to let those about him see the terror of his soul.”13
“Clearly at the heart of continuing medical education,” said
James Young, “is the passion for learning about disease, patients, and
healthcare. This is difficult in today’s harried patient-care environ-
ment, but it is the surest way to nurture the passion. One cannot help
being awestruck in the clinic with the resilience of patients, as well as
their occasional imprudence and intransigence. The human spirit is
remarkable—undaunted and unparalleled. Even the most seemingly
mundane patient can spark a question in the physician’s mind: Will I
see benefit from a particular procedure or medication? What if I
change the treatment protocol? Can the treatment plan be simplified?
These questions can stimulate the physician to search for answers,
and that search is what I enjoy most about my profession: the total un-
predictability of what the day will bring, along with the certainty of

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learning something new from each patient. Often, it is searching out

nuances of a patient’s personality, or that of a relative or friend, that
can make a perverse interaction pleasant and rewarding. By turning
difficult encounters into golden moments with smiles and questions,
the stage is set to explore both scientific and personally introspective
continuing medical education.”
Monitoring One’s Own Practice. The most fruitful education for a
profession, Cyril Houle wrote, “occurs when its practitioners con-
stantly monitor their own work, making judgments about success or
failure and subsequently altering behavior as a consequence.”2 Such
monitoring requires techniques that permit analysis of what the
physician actually does in the aggregate and the lessons learned from
puzzling individual patients. When physicians know the types of
problems seen, the drugs prescribed, and the procedures performed,
they can direct their study for maximal benefit to their patients. Med-
ical school faculties, despite lip service to the contrary, still empha-
size the didactic transfer of information, and most physicians have
therefore not been taught to organize their practices in a way to pro-
duce objective data that can direct their education. Fortunately, there
are simple ways of organizing and analyzing everyday work, and we
describe these throughout the book.
Self-directed Learning. Malcolm Knowles cited accumulating evi-
dence that “Whatever people learn through their own initiative, they
understand better, internalize more effectively, apply more generally,
and retain longer than anything they are taught didactically.” Since the
most valuable continuing education is linked to practical experience
and since each physician has individual experiences, physicians can
direct their own learning best from an analysis of their practice.
George Miller wrote: “There is ample evidence to support the
view that adult learning is not most efficiently achieved through sys-
tematic subject instruction; it is accomplished by involving learners
in identifying problems and seeking ways to solve them. It does not
come in categorical bundles but in a growing need to know.”14

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Harold Jeghers summarized the basic premises of lifelong learn-

ing in medicine thus: “The secret is to learn to educate oneself. One
remembers best what one learns by personal effort. Strong initiative
and motivation are important. Reading should be directed primarily
toward solving a problem with a specific goal in mind. Since patient
care is basic to the practice of medicine, reading and learning are
most effective when they involve discussion and solution of clinical
problems. Beyond formal education, a well-developed personal med-
ical information center supports continued personal education.”
On July 1, 2000, Jordan Cohen, President of the Association of
American Medical Colleges (AAMC), distributed a document enti-
tled “Association of American Medical Colleges Statement on Life-
long Professional Development and Maintenance of Competence,”
which was developed by the Council of Academic Societies Admin-
istrative Board in association with AAMC Division of Medical Edu-
cation.15 A relevant passage reads: “Recent evidence suggests that
to be effective, CME [continuing medical education] should be
highly self-directed with content, learning methods, and learning
resources selected specifically for the purpose of maintaining or im-
proving the knowledge, skills, and attitudes which physicians need
on a regular basis in their practices. Individual CME activities
should incorporate interactive learning formats, and include prac-
tice enabling and reinforcing strategies. To the degree possible, the
learning experiences should be accessible within physicians’ prac-
tice or work settings. In order for CME to be effective, physicians
must recognize the knowledge, skills, and attitudes they need to
maintain competence in their specialty or practice, and participate
in CME activities designed specifically for that purpose.
“The AAMC believes that specialty societies and specialty boards
are best able to assist physicians in their efforts to maintain their clini-
cal competence. To this end, the societies and boards should set forth
on a regular basis the attributes that are needed to practice medicine on
a specialty-specific basis, and should identify for physicians the valid
kinds of CME activities that will allow them to maintain or acquire

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those attributes. The societies and boards also must develop new as-
sessment methods that will allow them to determine whether or not in-
dividual physicians have developed and maintained the attributes
needed for practice. While some specialty boards are in the process of
actually implementing new assessment methodologies to achieve this
purpose, the majority of boards are not.”

Make the Most of Your Situation

Some physicians fail to become immersed in their practice because
they allow it to become too routine. This is primarily an attitudinal
problem, for almost any practice environment can be made stimulat-
ing. Mansell Pattison uses his regular resident clinical case confer-
ence to stimulate forays into “forgotten and new paths of clinical
investigation.” “My teacher, Dr. Maury Levine of Cincinnati,” he re-
called, “used to admonish us that each clinical case is a research
project. I similarly ask my residents to look for the unanswered re-
search question in every routine case. The rewards have been ample.
In just the past year, ‘routine’ cases uncovered interesting informa-
tion. A depressed patient with porphyria led to a literature review and
the discovery that porphyric psychosis is omitted from current text-
books of medicine; a case of pseudo-seizure led to the demonstration
of a basic linkage in the thought-speech process; a case of self-muti-
lation led to the description of a new clinical syndrome; a case of dis-
sociation led to the analysis of visceral brain components of
consciousness. Four simple cases led to four major research projects.
That is surely enough excitement in one year to keep a jaded admin-
istrator alive and enthusiastically on his toes to see what the next
‘routine case’ will turn up.”

C O M PA N I O N S H I P I N M E D I C I N E
Self-directed learning does not, of course, require isolation. In medi-
cine, the collegial network provides strong support for physicians by

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allowing them to share experiences, knowledge, and inspiration in an

atmosphere of fellowship while remaining responsible for their own
learning. Discussions with colleagues about patients and medical
problems afford excellent opportunities to gain information enjoyably.
“Encouragement of medical companionship is important,” said
Sherman Mellinkoff, “whether in group practice, participation in
rounds, attendance at courses to update important subjects, or atten-
dance at medical meetings. When a complicated problem needs clar-
ification, I sometimes go to the library, but I usually turn to one of my
colleagues for a consultation. It is so useful for doctors to have little
groups or affinities that provide someone near at hand with whom to
exchange ideas and discuss patients or published articles. Such inter-
action makes learning more vibrant and useful.”
“One reason we academicians like our work,” noted Norton
Greenberger, “is that we learn a lot by osmosis. We go to conferences,
and we seek out people who have the answers to our questions. So my
advice to young physicians is to surround yourself with people who
can educate you.”

R E D U C I N G R E L I A N C E O N M E M O RY
Acquiring knowledge when it is needed is more effective than memo-
rizing facts that may not be used for weeks or months. “I have never
tried to convert medical students into textbooks,” said Eugene Stead.
“If we did, we would clearly be forced to lower tuition, since the best
composite of medical knowledge can be purchased for $150.” Alfred
North Whitehead, too, cautioned against the evil of “bare knowledge”
and “inert ideas.” He defined education as the art of the use of knowl-
edge, whose importance lies in our active mastery of it—that is to say,
it lies in wisdom. “Get your knowledge quickly, and then use it. If you
can use it, you will retain it.”16 He wisely noted that “Knowledge does
not keep any better than fish.”17
Lawrence Weed has long objected to our expectation that physi-
cians remember the details in the numerous textbooks they were re-

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quired to memorize in medical school to pass their examinations. He

laments that we further expect them to keep abreast of the newest
medical information published and presented at meetings and to
apply all this knowledge effectively in their practices. Failure, he be-
lieves, is built into those expectations.18
Instead of describing methods that rely too heavily on memorizing
and learning facts unrelated to current problems, we shall emphasize
manual and electronic methods that help physicians access and use
information sources efficiently at times when patient problems actu-
ally arise. Fortunately, with the explosion of information sources
available on the computer, the need for physicians to memorize de-
clines, but they must now concentrate more heavily on seeking and
evaluating information and applying the new knowledge prudently.

FRAMING THE RIGHT QUESTIONS

“One learns by asking oneself questions, then finding the answers,”
said Eugene Stead. The physician must decide what he knows and
what he does not know. He must then formulate questions and consult
the proper source to answer the questions. With emphasis on methods
of organization, storing, and accessing pertinent information, the skill
for formulating proper questions becomes essential. “I would be very
happy if every student, every resident, and every cardiac fellow felt
that it is more important to learn how to ask questions and pursue the
answers, themselves, than it is for me to ask questions for them to an-
swer,” said Willis Hurst. “I believe that asking questions is what they
should do all their lives.”
Reading, conferences, and discussions with colleagues alert the
physician to knowledge deficits. Associating with other physicians
with similar interests helps in formulation of the right questions, and
an exchange of information leads to recognition of what needs to be
answered. Unanswered questions should stimulate the physician, but
one must guard against frustration from failing to find all the answers
alone.

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KNOWLEDGE IS NOT ENOUGH

The purpose of knowledge and information is to apply them properly in
patient care. Proper application of knowledge is not automatic; many
advances in patient care are never applied. Physicians who immerse
themselves in their practice are likely to learn current developments
from their general reading, discussions with peers, attending courses,
and browsing an electronic information service. By focused searches
for evidence-based information to help them solve diagnostic and ther-
apeutic problems on puzzling patients, they may continually strengthen
their knowledge base. How can they assure themselves and their pa-
tients that they are applying evidence-based knowledge? (See p. 123)
The classic study by Fox, Mazmanian, and Putnam describes sev-
eral factors that encourage change,19 such as curiosity, sense of per-
sonal or financial well-being, the desire to be more competent, and
stimuli in the clinical environment (opinion of peers, hospital regula-
tions, and community needs).
Most studies have concluded that changes in a physician’s deliv-
ery of care are due to several factors rather than a single intervention.
General practitioners described an average of 3.2 reasons for change
and consultants an average of 2.8 reasons. The three most common
categories for change were (1) organizational changes, such as regula-
tion by a hospital or health maintenance organization (HMO), (2) an
educational activity, such as reading medical journals or attending an
educational event, and (3) discussions with a physician or another
health professional.20
Mazmanian and coauthors found that, after a conference on multi-
ple risk factors in atherosclerotic vascular disease, physicians who
indicated on a questionnaire that they planned to change were more
likely than those with no commitment to state 45 days later that they
made the change.21
Evidence indicates that strategies, such as providing feedback re-
ports on practice22 and the effect of influential peers,23 are effective in
fostering change. Interventions aimed at physicians preparing for

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change can target the office staff and even patients as well. Re-
minders and checklists are helpful.24 Ornstein and coauthors re-
ported that an added benefit of combining patient and physician
reminders was an increased adherence of patients receiving preven-
tive services.25 Patients are a major motivating force to encourage
physicians to consider using new knowledge or altering manage-
ment.26
In regularly scheduled meetings with office staff members, dicus-
sions are often helpful to determine problems that are inhibiting deliv-
ery of the best care. Writing a plan to effect a change is useful as a
commitment as well as a reminder to the physician and office staff.
Physicians who systematically study their practice performance have
an added advantage of determining what needs to be changed.

S TA R T N O W
The supreme value is not the future but the present.
The future is a deceitful time that always says to us,
“Not yet,” and thus denies us.
O CTAVIO PAZ 27

To Roy Behnke, the complaint of some physicians that they are so far
behind they can never catch up is merely an excuse. “Many of my col-
leagues say that the task is so overwhelming, what is the use of trying to
catch up? But you must start somewhere. Those who try to make con-
tinuing education too formal never get it done: the system beats them.
Medicine offers the advantage of informal education. You can pursue it
at almost any hour of the day, and five minutes is time enough if you
have arranged for the information to be easily accessible.” So resist the
temptation to procrastinate or defer the task. Remember:

The Bird of Time has but a little way

To fly—and Lo! the Bird is on the Wing28

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REFERENCES

1. Richards RK, Cohen RM. Why physicians attend traditional

CME programs. J Med Educ. 1980; 55:479–485.

2. Houle CO. Continuing Learning in the Professions. San

Francisco: Jossey–Bass; 1980:208–209.

3. Osler W. The reserves of life. Address delivered at St. Mary’s

Hospital, London, 1907 Oct 2. St. Mary’s Hosp Gaz.
1907;13:97.

4. Shaw GB. John Bull’s Other Island. In: Bernard Shaw: Se-
lected Plays with Prefaces. Vol 2. New York: Dodd, Mead &
Co.; 1957:611.

5. Osler W. After twenty-five years. An address at the opening

of the session of the medical faculty, McGill University,
1899 Sep 21. Montreal Med J. 1899;28:832.

6. Johnson S. The Rambler. Vol 5. No. 150, 1751 Aug 24. Lon-
don: J. Payne and J. Bouquet; 1752:120.

7. Moynihan B. Abdominal Operations. Vol 1. Revised, preface

to the 4th ed. Philadelphia: W.B. Saunders; 1926:11–12.

8. Osler W. Books and men. In: Aequanimitas, with Other Ad-

dresses to Medical Students, Nurses and Practitioners of Med-
icine. 3rd ed. Philadelphia: Blakiston ; 1945:210.

9. Whitehead AF. Technical education and its relation to sci-

ence and literature. In: The Aims of Education and Other Es-
says. New York: MacMillan; 1959:79.

10. Adler M. Why only adults can be educated. In: Gross R, ed.
Invitation to Lifelong Learning. Chicago: Follett; 1982:92.

11. Osler W. In: Bean WB, ed. Sir William Osler: Aphorisms from
His Bedside Teachings and Writings. Springfield, IL: Charles
C Thomas; 1968:36.

12. Holmes OW. Scholastic and bedside teaching. In: Medical

Essays; 1842–1882. Vol 9. Boston: Houghton Mifflin;
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13. Maugham WS. The Summing Up. Garden City, NY:

Doubleday; 1946.
14. Miller GE. Continuing education for what? J Med Educ.
1967;42:322.
15. Cohen JJ. Association of American Medical Colleges Memo-
randum No. 00-32. 2000 Jul 31.
16. Whitehead AN. The rhythmic claims of freedom and disci-
pline. In: The Aims of Education and Other Essays. New
York: MacMillan; 1959:57.
17. Whitehead AN. Universities and their function. In: The
Aims of Education and Other Essays. New York: Macmillan;
1959:147.
18. Weed LL. Your Health and How to Manage It. Essex Junc-
tion, VT: Essex Publishing; 1975:91.
19. Fox RD, Mazmanian PE, Putnam RW. Changing and Learn-
ing in the Lives of Physicians. New York: Praeger; 1989.
20. Allery LA, Owen PA, Robling MR. Why general practition-
ers and consultants change their clinical practice: a critical
incident study. BMJ 1997;314:870–874.
21. Mazmanian PE, Daffron SR, Johnson RE, David DA,
Kantrowitz MP. Information about barriers to planned
change: a randomized controlled trial involving continuing
medical education lectures and commitment to change.
Acad Med. 1998;73:882–886.
22. Eisenberg JM. Doctors’ Decisions and the Cost of Medical
Care. Ann Arbor, MI: Health Administration Press; 1986.
23. Stross JK, Hiss RG, Watts CM, Davis WK, MacDonald R.
Continuing education in pulmonary disease for primary care
physicians. Am Rev Respir Dis. 1983;127:739–746.
24. McDonald CJ. Protocol-based computer reminders, the
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Med. 1976;295:1351–1355.
25. Ornstein SM, Garr DR, Jenkins RG, Rust PF, Arnon A.
Computer-generated physician and patient reminders. Tools

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to improve population adherence to selected preventive ser-

vices. J Fam Pract. 1991;32:82–90.
26. Towle A. Shifting the culture of continuing medical edu-
cation: what needs to happen and why is it so difficult?
J Contin Educ Health Prof. 2000;20:208–218.
27. Paz O. Development and other mirages. In: The Other Mex-
ico: Critique of the Pyramid. Kemp L, trans. New York:
Grove Press; 1972:68.
28. Khayyam O. Rubaiyat of Omar Khayyam. Fitzgerald E,
trans. London: John Lane the Bodley Head Ltd; 1922: quat-
rain 7.

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 P E R S O N A L E S S AY: M I C H A E L E . D E B A K E Y, M . D .

P E R S O N A L E S S A Y
...

Medicine is an absorbing, even possessive, profession,

but the intellectual rewards, humanitarian service, and
fulfillment are unsurpassed.
M ICHAEL E. D E B AKEY, M.D.

T he inscription on the bust of Dr. Michael DeBakey in The

Methodist Hospital, Texas Medical Center in Houston, reads
“Surgeon, Educator, Medical Statesman. In recognition of one who
served so many.” Universally recognized as an ingenious medical
inventor and researcher, a gifted and dedicated teacher, the pre-
mier surgeon of the world, and an international medical statesman,
Dr. DeBakey is esteemed and admired by colleagues, students, and
the general public for his indefatiguable dedication to the service of
mankind and is loved by his patients for his skillful and compas-
sionate ministrations.

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Dr. DeBakey received his B.S., M.S., and M.D. degrees from
Tulane University in New Orleans, served his internship at Charity
Hospital in New Orleans, and completed his residency in surgery at
Charity Hospital, the University of Strasbourg, France, and the
University of Heidelberg, Germany. He served on the Tulane Med-
ical School surgical faculty from 1937 to 1948. On military leave
from 1942 to 1946, he was assigned to the Office of the Surgeon
General and received the Legion of Merit Award for his outstanding
service in 1945. His efforts in the Surgeon General’s office led to
the development of Mobile Army Surgical Hospitals (MASH units).
In 1948, he joined the Baylor faculty, where he served simultane-
ously as Chairman of the Department of Surgery (now the Michael
E. DeBakey Department of Surgery) and President of the College,
then Chancellor, and now Chancellor Emeritus.
As an undergraduate medical student, Dr. DeBakey devised a
roller pump that later became an essential component of the
heart–lung machine and thus helped launch open-heart surgery. He
has devised countless new medical devices and operations, as well
as more than 50 surgical instruments for the improvement of patient
care. In 1939, with his mentor, Dr. Alton Ochsner, he noted an as-
sociation between smoking tobacco and lung cancer. Best known
for his trailblazing efforts in the treatment of cardiovascular dis-
eases, Dr. DeBakey was the first to perform successful excision and
graft replacement of aneurysms of the thoracic aorta and obstruc-
tive lesions of the major arteries. In 1953, he established the field
of surgery for strokes when he performed the first successful carotid
endarterectomy. In 1964, he and his associates performed the first
successful aortocoronary artery bypass with autogenous vein graft.
Four years later, he led a team of surgeons in a historic multiple
transplantation procedure in which the heart, kidneys, and one lung
of a donor were transplanted to four recipients. A pioneer in artifi-
cial heart research, he was the first, in 1966, to use a partial artifi-
cial heart successfully—a left ventricular bypass pump, precursor
of the current miniaturized DeBakey Left Ventricular Assist De-
vice. It was Dr. DeBakey’s testimony before Congress in early 1963
that initiated federal support for artificial heart research.

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 P E R S O N A L E S S AY: M I C H A E L E . D E B A K E Y, M . D .

Dr. DeBakey was a member of the Medical Advisory Committee

of the Hoover Commission and was Chairman of President John-
son’s Commission on Heart Disease, Cancer, and Stroke. He served
an unprecedented three terms on the National Heart, Lung, and
Blood Advisory Council of the National Institutes of Health and
also served as Chairman of the Board of Regents of the National Li-
brary of Medicine, which he was instrumental in establishing.
For his pioneering achievements in cardiovascular surgery and
his vast humanitarian endeavors, Dr. DeBakey has received more
than 50 honorary degrees from prominent colleges and universities.
His countless national and international honors and awards, many
from heads-of-state throughout the world, include the Presidential
Medal of Freedom with Distinction from President Johnson, the Na-
tional Medal of Science from President Reagan, the prestigious Al-
bert Lasker Award for Clinical Research, and the Living Legend
Award from the Library of Congress. Author of more than 1600 arti-
cles and books, many considered landmark publications, he has
been the president of various eminent medical organizations,
Founding Editor of the Journal of Vascular Surgery, Editor of the
Year Book of General Surgery, and Coeditor of Christopher’s Minor
Surgery.1 He has also served as editor or editorial board member of
many other distinguished surgical journals and as consultant to
governmental agencies in the United States and throughout the
world. The New Living Heart,2 written for the lay public, was a New
York Times bestseller. Dr. DeBakey was an early advocate of edu-
cating the public about health issues and has long been a frequent
guest on network news for this purpose. He has also written widely
about medicine and health in the major news media.
As a tribute to his selfless efforts to improve human health, a
number of facilities, awards, and scholarships have been named
in his honor, including the Michael E. DeBakey Center for Bio-
medical Education and Research at Baylor College of Medicine, the
Metohodist DeBakey Heart Center in Houston; the Michael E. De-
Bakey High School for Health Professions in Houston; the Texas
A&M University Michael E. DeBakey Institute for Cardiovascular
Science and Biomedical Devices; the Michael E. DeBakey Heart In-

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 M E D I C I N E : P R E S E R V I N G T H E PA S S I O N I N T H E 2 1 S T C E N T U R Y

stitutes in Hays, Kansas, and in Kenosha, Wisconsin; the Michael E.

DeBakey International Military Surgery Award and The DeBakey
USU Brigade of the Uniformed Services University of the Health Sci-
ences; the Michael E. DeBakey International Surgical Society
(formed by his students and residents); the Michael E. DeBakey
Award in Journalism of the Foundation for Biomedical Research; and
the Michael E. DeBakey Library Services Outreach Award of the
Friends of the National Library of Medicine.
As a world-renowned surgeon, he has operated on princes and
paupers, providing all with the same dedicated humanitarian ser-
vice. Known as the “King of Surgeons,” Dr. DeBakey has been first
and foremost the patient’s advocate.

*****
Dr. DeBakey’s total commitment to, and fascination
with, medical science and its humanitarian aims have
been an inspiration to patients, students, and associates
alike. Mike does a tremendous amount of surgery. Many
people look upon this as a highly impersonalized, me-
chanical venture. But you ought to make rounds with
Mike about ten o’clock in the evening and watch him go
through and touch his people. No one else can do such
technical work in a highly personal way as Mike can.
E UGENE A. S TEAD , J R ., M.D.

Because of his warmth, compassion, and humanity that

symbolize the finest ideals of his profession, he has
been beloved by his students, colleagues, and many es-
teemed friends in every walk of life.
D AVID C. S ABISTON , J R ., M.D.

REFERENCES

1. Ochsner A, DeBakey ME, eds. Christopher’s Minor Surgery.

Philadelphia: W.B. Saunders; 1955, 1959.
2. DeBakey ME, Gotto AM, Jr. The New Living Heart.
Holbrook (MA): Adams Media; 1997.

24
Medicine: Preparing for and Enjoying
an Intellectually, Emotionally,
and Morally Fulfilling Career

Michael E. DeBakey, M.D.

Chancellor Emeritus
Olga Keith Wiess and Distinguished Service Professor
Michael E. DeBakey Department of Surgery
Director, DeBakey Heart Center
Baylor College of Medicine,
Houston, Texas

E A R LY I N F L U E N C E S

Parents

I have often been asked what inspired me to take the path I have
pursued in life. The answer lies in my boyhood. My parents, with
their keen intellects, natural curiosity, and high standards, were su-
perb models because they sought excellence in everything they did.
Anything worth their time was worth doing well. By example, they in-
spired and encouraged me in that philosophy. They valued education
and gave their children every opportunity to learn and to fulfill their
potential, not only in school but in music, the arts, and athletics. All
of us had music lessons as children; I learned to play several instru-
ments and was a member of the school band. At home, we were sur-
rounded by books, but we were also encouraged to read, in addition to
our schoolwork, at least one book a week from the city library. We
learned early that books were wonderful companions.

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At a very early age, we were also given an opportunity to experi-

ence gratification from some special achievement—whether it was
mastering a subject in our schoolwork, learning to play a musical
composition well, or excelling in sports or gardening. Our parents
helped us discover the delight of learning, and they often made our
new knowledge more significant by relating it to some interesting
story in their own lives or to some current or historical event. Al-
though they did not prod or nag us about studying, they did encour-
age, direct, and support our learning. Almost every family event was
a learning experience—whether it was a picnic, where we learned
about nature; a hunting trip, where we learned about sportsmanship;
or a family meal, where conversations were always stimulating.
When we asked questions, our parents satisfied our immediate cu-
riosity with an explanation, but then encouraged us to delve further
into the subject by reading about it. If the children had disagree-
ments about certain issues—and children can be extremely opin-
ionated—our parents suggested we could settle the matter by
consulting a dictionary, encyclopedia, or other authoritative source.
They explained that our opinions would be respected more if we
could support them with some evidence, and so we were discour-
aged from formulating firm opinions without a valid basis or, to ex-
press it differently, from developing raw prejudices. Reason and
common sense were highly respected in our home.
One incident illustrates how our parents nurtured our education.
When I was a very young boy, my Father took me on a hunting trip, and
when he set me down in the field, he said, “Now stay right here; I won’t
be far away.” He would go a short distance, glancing back at me often
and returning every little while to bring back the ducks that he had
shot. On one such occasion, he noticed that I had my hands behind my
back, and he said, “What’s wrong with your hands?” Eventually, I had
to reveal my hands, which were bloody. He was immediately alarmed
and asked, “What did you do? Did you cut yourself?” I confessed that I
had taken a knife out of the pouch and had opened the ducks. “Why did

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you do that?” he asked. “I wanted to find out how they fly,” I explained.
Shortly after that, my Father read me a book about birds flying. He
noted my early curiosity, and he encouraged and stimulated it.
Throughout my student years, he and my Mother supported my fascina-
tion with medicine and surgery.
We hear much today about the disintegration of the American
family, and my heart goes out to those who have missed the joys of be-
longing to a close-knit, loving family. Our parents’ affection for us was
evident in everything they did, but they also imposed discipline, often
in subtle ways. We all had tasks assigned and were expected to exer-
cise personal responsibility and self-reliance in performing them.
I feel fortunate in having received moral and spiritual guidance as
a child, because I think it is valuable for everyone, and especially for
physicians. Largely by parental example, we learned that honesty, in-
tegrity, compassion, and personal and social responsibility enrich life
and enhance peace of mind. Intellectual development without these
values is compromised, in my view. The family integrity that my par-
ents cherished so deeply gave me a sense of purpose and gave my life
direction. It is, perhaps, the greatest legacy anyone can receive, and
for a physician, it is indispensable.

Teachers
Having dedicated teachers who reinforced my parents’ interest in
education encouraged me to do my best in my assignments. I was for-
tunate to come under the guidance of a number of college professors
who took an interest in me, among them my zoology professor. I be-
came so interested in zoology that when I went home on vacation, I
set up a large aquarium in my parents’ garage and filled it with vari-
ous kinds of marine life so I could continue my study during the
summer. That professor appointed me as a student assistant, and
during subsequent summers I continued to work in his department. I
taught courses, including graduate courses, and I had to read and

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study the material thoroughly in order to teach it. My professor of

English Literature showed a similar interest in me and invited me to
major in that subject. His guidance nurtured my literary bent.
Perhaps the professor who influenced me more than anyone else
was Dr. Alton Ochsner, under whose influence I came as a medical
student. At that time, I was not sure I wanted to practice surgery, but
he and his associate, Dr. Mims Gage, encouraged me to go into sur-
gery and engaged me in laboratory research. I spent a lot of time in
the laboratory, and so did Dr. Ochsner. I invented my first medical de-
vice when I was still in medical school—a roller pump, which later
became an essential component of the heart–lung machine. I think
my interest in inventions was whetted by watching my Father con-
stantly improving devices he used and seeking, and usually finding,
more efficient ways of accomplishing tasks.
Dr. Ochsner also engaged me in writing papers with him, and, as
my early bibliography attests, we wrote a lot of papers together. So I
was trained in academic work, and I liked it very much because it
permitted continual learning. Dr. Ochsner suggested that I go
abroad, where he had received some of his own training and where,
in those days, American physicians often studied in prestigious Eu-
ropean universities. Although it was around the time of the Great De-
pression, my parents financed my stay abroad—another indication of
how highly they valued education. I worked in the research laborato-
ries of two eminent professors: René Leriche at the University of
Strasbourg and Martin Kirschner at the University of Heidelberg. I
learned to speak French and German, and I developed valuable as-
sociations. It was an extremely rewarding period.

SELF-DISCIPLINE
Next to intellectual curiosity, perhaps self-discipline is most impor-
tant for continuing education. I see a lot of young students who have
not yet developed the self-discipline required for effective organiza-
tion of their studies and other activities. They flit from one thing to

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another, allowing themselves to be distracted by matters that are not

really helpful. They tend to associate diversion with passive enter-
tainment. Television has probably been responsible, in great mea-
sure, for promoting passivity. The enigma is that people can become
glued to their television set when the programming is generally so
poor. Learning, however, is anything but passive; it is a highly active
process that can also be extremely gratifying. Electronic devices rep-
resent a remarkable technologic advance, especially because of the
speed with which they can provide masses of information, but they
are no substitute for human reasoning. And reasoning is at the crux of
the physician’s daily work.

Reasoning
Few experiences are more enjoyable than reasoning and learning,
whether your subject is nature, science, history, or the arts. The exhila-
ration of solving a difficult problem is hard to match. And when you put
your whole heart and soul into whatever you do, your sense of self-worth
soars. You gain self-confidence, and you are more at peace with yourself.
Today, entrepreneurs make millions selling books and giving courses on
“self-actualization” and on finding out “who you are,” but if you develop
self-discipline and invest your full attention and effort in whatever you
do, you will not need a course to tell you who you are. You will know.
Most physicians recognize the need for a good foundation in the
sciences, but seem less aware of the importance of the humanities.
Since, however, literature deals with all aspects of the human experi-
ence—the happy and the tragic, the base and the ennobling—it
teaches much about human nature and human life that is useful to the
physician. Continuing to read good literature, including history,
throughout life is an asset. Our society no longer emphasizes a knowl-
edge or a sense of history, and that is unfortunate. I would urge every
young physician to read the major works on medical history. Not only
are the lives of the great achievers inspiring, but history puts the pres-
ent in perspective, and so helps us better understand what is going on

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now and what the most judicious course might be for the future. In med-
icine, history also prevents us from duplicating experiments for which
the answers are already known.
Philosophy, including ethics and logic, is also an intriguing subject,
and those who study it are likely to consider all aspects of an issue, in-
cluding dissenting views, rather than form dogmatic opinions. Because
mathematics enhances reasoning ability, it is useful for physicians. In-
tellectual and cultural development should go hand in hand with phys-
ical development, and all are definite assets for the physician. Athletics
improve coordination and physical well-being, in addition to advancing
socialization by teaching cooperation and a sense of fair play. A diver-
sity of activities not only affords balance, but provides a stable base for
pursuits in adulthood.

Language
And then there is language—the crucial instrument of communication.
The whole thinking process is entwined with language—terms and
their meanings. Yet I see young people coming out of college today with
little understanding of the need for clarity and precision in their speech
and writing. Deficiencies in such education can lead to sloppy think-
ing. Medical students, in presenting a case, will say that a patient had a
tumor of the breast without identifying which breast, or pain in the leg
without stating which leg. They know that the tumor was in the right
breast, but they do not convey that information to their audience. In
medicine especially, precision is paramount. To say that a patient has
an infarction without precisely defining its site and extent is to withhold
information crucial to effective treatment. Simplicity and clarity of ex-
pression are as important as precision for the physician, especially in
communications with patients. Taking the time to explain a patient’s
symptoms can relieve anxiety about imagined grave health problems.
The compassionate physician will sense a patient’s anxiety and will try
to assuage it. Moreover, patients who understand their diagnosis and

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prescribed treatment are likely to be more cooperative in following their

physician’s advice for remaining well after recovery.

C O N T I N U I N G E D U C AT I O N
As every physician knows, the competent practice of medicine re-
quires lifelong learning. I have been able to obtain the kind of infor-
mation that meets my specific needs by keeping abreast of current
publications, by studying topics of special interest more deeply, by
arranging regular interdisciplinary discussions, including meetings
on research, and by continually analyzing my own surgical results. In
The DeBakey Heart Center, we hold weekly meetings at which the
staffs in various basic and clinical research disciplines present their
current work and bring up complex matters for general discussion.
These regular meetings afford a remarkable educational opportunity.

Writing
Writing is also a superb method of continuing education, particularly
in medicine, because it requires comprehensive, critical reasoning.
Teachers and scientists have an obligation to disseminate new knowl-
edge in this way. Since my early years, when my parents encouraged
all of us to write letters and keep journals, I have had an interest in
writing. When, as a grammar-school student, I went abroad with my
family, I wrote letters to my teachers about our trip and was pleased
when the letters were published in the local newspaper. That, of
course, further encouraged my literary efforts.
When I began collaborating on manuscripts with my chief, Dr.
Alton Ochsner, I would retire to my office or laboratory at the medical
school after completion of my routine teaching and clinical duties and
would remain there until midnight doing laboratory research, reading
published articles, and preparing reports of our results. One long
counter in my office was always stacked high with library books, and I

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spent hours abstracting articles, verifying references, documenting

statements, and reverifying statistics. I learned early to take personal
responsibility for every step in the preparation of a manuscript for pub-
lication or presentation. That self-discipline has been most rewarding.
When I write articles for presentation or publication, I read mate-
rial that I might not otherwise see in journals I routinely review. At
meetings in which I participate throughout the world, I have been
able to learn what research is being done and how medicine is prac-
ticed in different regions. As a member of various editorial boards
over the years, I have also had the opportunity of reviewing manu-
scripts of research work at the forefront of medicine and have thus
been kept informed of the latest scientific developments.

BIBLIOGRAPHIC TECHNOLOGY
When I was a medical student, and until the latter twentieth century,
bibliographic searches had to be done manually. This was a tedious,
labor-intensive, time-consuming process, involving consulting succes-
sive yearly bound volumes of the Index Medicus—first selecting arti-
cles whose titles suggested pertinence to the subject, then pulling each
journal from the library shelves and scanning it for relevance before
reading thoroughly those culled for specific information. Today, stu-
dents cannot conceive of such a laborious process; they search the In-
ternet and find desired sources at the press of a button. As facile as the
present process is, you should be aware that current databases usually
include references from only the latter twentieth century, so failure to
search manually for earlier publications may mean missing historically
or otherwise important sources. Research questions you are planning to
pursue, for example, may already have been answered, and rare cases
may have been described, but missed because they are not entered in
current bibliographic databases. You may also inadvertently misat-
tribute priority for certain innovations, discoveries, or advances. My
own policy is to make as thorough and as comprehensive a search as

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possible. One other caveat: do not allow the ease of mechanization to

quench your intellectual curiosity or your determination to examine
critically, to reason meticulously, and to pursue problems intellectually.
Learn to evaluate what you read instead of giving credence to every-
thing that is published. And make sure that the databases you consult
are authentic, complete, and current.

Analysis of Clinical Experience

Another excellent method of continuing education for the physician is
periodic analysis of personal clinical experience for presentation at
meetings or for publication. In my own analyses, I try to determine the
factors that affect survival, complications, and mortality. If I am ana-
lyzing my clinical results for aortic valve replacement, for example, I
do a bibliographic search for articles on a variety of valves and then
compare my experience with the results of other surgeons. Such a
study may lead me to use a certain valve. After another interval, I will
do another comparative analysis of my results with that valve and of
results obtained by others. In this way, you can determine whether
your techniques are better or worse than those of your peers.
One technique that I use for follow-up is to write the physicians of
patients, or the patients themselves, at regular intervals to inquire
about their progress and state of health. Not only does this assure pa-
tients of my personal interest and concern, but it also provides valu-
able feedback about treatment or progress of the disease.
In the practice of medicine, you must continually expand your
knowledge if you are to give your patients the best available care. When
a new surgical technique is introduced, my colleagues and I first study
it, and if we decide that it shows promise as a safe and effective proce-
dure, we try it, sometimes modifying and improving it. Continually
seeking better ways of treating patients is every physician’s obligation,
and in my specialty that has sometimes led me to design a new surgical
instrument or develop a new operative technique.

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From time to time, every physician will have an extraordinarily

difficult case about which more information is needed. There are two
ways to obtain it. One is to review previous publications to see if any-
one has had such a case and, if so, how it was managed. The other is
to review your own clinical experience to see if you have had that par-
ticular problem before and what the results were. In managing the
complex problems referred to me from throughout the world, I have
found a continual study of my clinical experience to be invaluable.
Reviewing accumulated clinical cases can disclose extremely useful
information. The analysis of angiograms of my patients with occlusive
arterial disease, for example, allowed me to recognize certain patterns
of disease and their segmental nature. Recognition of such patterns
led me to devise the surgical treatment for aneurysms before the
cause of the underlying disease was fully understood.
We found, also, that the most common cause of death in patients
with certain types of vascular disorders was coronary disease. In ana-
lyzing that experience, we focused on coronary disease as an impor-
tant factor contributing to death, and this led us to do specific studies
on patients with vascular disease to determine whether they had coro-
nary disease. That analysis showed that in some patients it is impor-
tant to deal with the coronary disease before you deal with any other
vascular disease. We did the same type of study with carotid arterial
occlusive disease.

Keeping Current
You can facilitate your continuing medical education by developing
a routine for keeping abreast of scientific publications: regularly re-
viewing selected journals related to your particular practice, and
having in your personal medical library or electronic database, for
ready reference, books and articles dealing with your own medical
discipline. Further, you can attend meetings related to the clinical
problems you see in your practice. And if you can set aside several
hours a week to participate in hospital or medical school activities,

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you will not only find them intellectually stimulating, but will also
learn of new developments almost as they occur. In most centers
such as ours, activities of this kind are well organized. Every hospi-
tal, even in small communities, should have a continuing education
program, with regular meetings for its medical and allied health
staffs. Preparing presentations for such meetings is certainly educa-
tional for the speaker, and the information disseminated is useful to
the listeners. When such discussions center on patients under con-
sideration at the time, they have a special impact for retention of
that knowledge. The interchanges with colleagues and students are
mutually stimulating.
In our Surgery Department, we have regular weekly conferences,
at which the staff presents analyses of various cases. Clinical data re-
garding complications and deaths are thoroughly discussed, and in-
teresting cases are presented. Our journal conference is designed
largely for residents, who report on designated current journal arti-
cles, after which there is a general discussion. When faculty members
have been to a medical meeting elsewhere, they summarize the pro-
ceedings for the staff, and a discussion follows. For those of us inter-
ested in cardiovascular disease, the cardiology and cardiovascular
surgery units hold combined conferences, in which basic science per-
sonnel engaged in cardiovascular work often participate. When I de-
signed our Cardiovascular Research and Clinical Center, I insisted on
having basic scientists and clinicians from all pertinent disciplines
housed in the Center, an interdisciplinary arrangement that has been
one of its most important and productive features.
My hope is that formal medical education will not become too
rigid—that the emphasis will not focus on structure more than on the
actual educational process. Continuing education means active learn-
ing, and whereas guidance, counseling, and direction are helpful, ed-
ucation should not be rigidified. If, for example, the purpose in
studying is solely to pass an examination, the student is not going to
retain a great deal of knowledge—or gain very much wisdom. The ex-
amination should be a means of evaluating one’s own state of knowl-

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edge, and the emphasis should be on the knowledge, not on the test. I
would hope that medical education would not be restricted to the ab-
sorption of facts, but that it would encourage critical thinking, would
include ethical issues, and would foster a humanitarian approach to
the care of patients. All learning is useful in expanding the mind and
its limits and benefits others when the acquired knowledge is applied
for their advantage. In the case of physicians, the application of
knowledge often yields dramatic humanitarian results, and we are
therefore uniquely motivated, and obligated, to continue our educa-
tion throughout life. In medicine, helping others while solving com-
plex intellectual puzzles is our special reward.

“MANAGED” CARE
Medicine has undergone dramatic changes over the past few decades,
not only because of stunning new discoveries, but also because of
proliferating government and managed-care regulations, oppressive
administrative burdens, and the enforced ceding of medical decision-
making to distant entities.1–5 Despite the promise that such a plan
would control costs, the effort has failed as costs have continued to
rise. Not only that, but medical schools and medical centers have had
less financial support for medical education, training, and research,
all indispensable for optimal healthcare.6,7
The advent of managed care has altered medical practice dramat-
ically in ways that few could have anticipated. For those of us who
practiced many years before this phenomenon arrived, the transfor-
mation imposed by the new system was inconceivable. Who would
have believed that a physician—after years of premedical and med-
ical education, followed by three to five or more years of residency
training—would be required to submit to managed-care fiats, ren-
dered by distant entities that have never seen the patient? Decisions
in medicine have traditionally been made on the basis of the physi-
cian’s best clinical judgment and scientific evidence, always in the
patient’s best interests, whereas managed care (more appropriately

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managed costs) is driven by the desire to control costs and gain max-
imum profits, directed substantially to the corporate executives. We
have all heard and read many heartbreaking stories of patient misad-
ventures with the new healthcare system, including fatal outcomes,
and the mounting patient protests may lead to remedial action.
When the time a physician may spend with a patient is severely
limited (15 minutes or less in some managed-care organizations), the
quality of care may suffer, for the amount of information and conver-
sation is curtailed. The patient, moreover, senses the hastiness and
feels shortchanged and less trusting. A system that restricts, rather
than facilitates, needed healthcare may be cost-saving but is not cost-
effective. Physicians, frustrated by these intrusions into professional
care, are opting increasingly for early retirement. Physician shortages
are already being predicted.
With the new system came a new lexicon imposed on medicine:
physicians became “healthcare providers,” and patients became
“consumers,” terms that encourage the concept of medicine as a
trade, not a profession with high ethical standards and noble princi-
ples. Such a concept not only lacerates the revered physician–patient
relationship, so critical to proper rapport, effective therapy, and the
maintenance of good health, but also devalues the time-honored hu-
manitarian code of medicine. Do we want professional physicians to
minister to patients or health salesclerks to serve health customers?
Of late, the “high cost of healthcare” has been overattributed to the
physician’s compensation and to the costly technologic procedures pa-
tients now expect, less to governmental and managed care restrictions
and paperwork. Physicians, like all others, deserve to be compensated
fairly for their work. This is not to say that profit should be the primary
focus, for I don’t believe it should, but it is difficult to understand why
physicians, who study longer and at greater personal and financial
sacrifice, who work longer hours, and who perform an important pub-
lic and social service, should receive less remuneration than, for ex-
ample, attorneys, entertainers, professional athletes, managed-care
executives, or a host of other careerists in our society. Physicians

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today face a choice: If they order the advanced technologic proce-

dures now available, they may be criticized for increasing costs, and if
they fail to order them, they may face costly malpractice litigation. Pa-
tients expect to receive the latest and best available care, but must un-
derstand that increasingly sophisticated and more precise technology
carries a higher price tag.
Above all, medicine is a moral profession, with a tradition of hu-
manitarianism and public service. With the intrusion of nonmedical
entities into healthercare decision-making, some adverse effects
have occurred. Our society must decide whether we want medicine
to continue its tradition as a profession, with its code of ethics, or to
become a trade, with a compromise in quality. High technology can
coexist with humanity. But society must also be realistic; its expec-
tations must be consonant with the realities of the increasing costs
of ever more sophisticated technology. No one wants rationing, yet if
demands far exceed funds available to pay for them, something has
to give. We cannot expect ultrasophisticated healthcare at bargain-
basement prices. Medicine’s very advances have created thorny eth-
ical and economic problems amid changing social values and an
aging population. Physicians today must become informed not only
about the scientific aspects of medicine, but also about the eco-
nomic, ethical, legal, and public policy issues. How can patients
become fully informed as partners in their health decisions when a
visit of only 12 to 15 minutes is sometimes allowed with their physi-
cians? And how can they become educated in their health mainte-
nance with so little time for communication?

PROFESSIONALISM
Professionalism has intellectual as well as ethical components. Profes-
sionalism means being well informed, an expert, in fact, making life-
long learning a sine qua non for physicians. In medicine, it means being
honest, compassionate, and dedicated—placing the patient’s welfare

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above all other considerations, including personal and financial re-

wards. The medical professional is ipso facto the patient’s advocate.
In the words of Oliver Holmes, “The best a physician can give is
never too good for the patient.”8 It means sharing your knowledge and
experience with colleagues, students, and patients. That educational
mission can take various forms: writing, speaking, formal and informal
consultations, and educating patients so that they can make informed
decisions associated with their diagnosis, treatment, and prevention.9
With commercial pressures from managed-care organizations, it
is more important than ever for physicians to nurture and maintain
professionalism.

PLEASURE IN WORK
Despite the frustrations, strictures, and voluminous, time-consuming
paperwork that plague physicians today, if you were attracted to med-
icine because of a genuine desire to help others and because you
enjoy intellectual challenges, you will still find immense satisfaction
in your daily work and can preserve the passion for medicine by
adopting some of the advice offered in this book by physicians of high
achievement. As physicians, we are invited into the most intimate
chambers of our patients’ lives. We should acknowledge that unfet-
tered trust with dignity, deference, and respect. For a physician, car-
ing for patients is not only a duty; it is a privilege. Alleviating pain
and restoring health for another human being induce an exhilaration
that few others experience in their careers. That professional gift de-
serves exquisite care.
Finally, I consider it essential to select a career that greatly ap-
peals to you instead of taking the line of least resistance and indis-
criminately or fortuitously entering a path to which you must then
commit yourself for life. If your work is not enjoyable, you will look
for any diversion or distraction you can find; you will rarely do your
best; and you will feel no pride or satisfaction in your performance. If,

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on the other hand, the career you choose is as enjoyable as mine is to

me, you will look forward to going to work each day, and you will feel
no desperate need to “escape” periodically. You will preserve the pas-
sion. Medicine is an absorbing, even possessive, profession, but the
intellectual rewards, humanitarian service, and fulfillment are unsur-
passed.

REFERENCES

1. DeBakey ME, DeBakey L. The ethics and economics of

high-technology medicine. Compr Ther. 1983;9(12):6–16.
2. DeBakey ME. The winds of change in medicine [editorial].
South Med J. 1993;86:1316–1317.
3. DeBakey ME, DeBakey L. Medicine in the managed care
era. Houston Business Rev. 1996; Summer: 70–75.
4. DeBakey ME. Rx for the health care system. The Wall Street
Journal. 1998 Oct 8;CII(70):A18.
5. DeBakey ME, DeBakey L. Should physicians unionize? The
Wall Street Journal. 1999 Jul 7;CIV(4):A22.
6. DeBakey ME. Medical centers of excellence and health re-
form. Science. 1993;262:523–525.
7. DeBakey ME. Prescription for disaster. The Wall Street Jour-
nal. 1994 Jun 23; XCIII(122):A14.
8. Holmes OW. Medical Essays. Boston: Houghton Mifflin;
1891.
9. DeBakey ME, Gotto AM Jr. The New Living Heart. Hol-
brook, MA: Adams Media; 1997.

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 REFLECTIONS / J. WILLIS HURST

R E F L E C T I O N S
...

I consider it more important for students, house offi-

cers, and fellows to ask questions about their patients
and to pursue the answers themselves than it is for me
to dispense information to them. For the remainder of
their lives, they should ask themselves questions about
their patients and seek their own answers. A master
teacher guides students in how to learn, so that self-
learning becomes a lifelong practice.
J. W ILLIS H URST, M.D.

T hat Dr. Willis Hurst is a master teacher has been validated by his
numerous awards, including the Master Teacher Award and the
Gifted Teacher Award of the American College of Cardiology, the
Distinguished Teacher Award of the American College of Physi-
cians, the prestigious Evangeline Papageorge Teaching Award by
former Emory graduates, and numerous other teaching awards. He

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has also received both the Gold Heart Award and the Herrick
Award from the American Heart Association. Author of countless
articles on the heart and the teaching process, he published the
classic textbook of cardiology, The Heart.1 He was Chairman of the
Subspecialty Board of Cardiovascular Diseases, a member of the
National Advisory Heart, Lung, and Blood Council, President of the
American Heart Association, President of the Association of Pro-
fessors of Medicine, President Lyndon Johnson’s cardiologist for 18
years.

*****
Willis Hurst’s interest in teaching and his genius for in-
struction are as fresh and powerful today as they were
38 years ago when I graduated from Emory. I have many
vivid pictures of Willis striding to the podium with sev-
eral worn and aged books, ready to read the words of
past masters to us. Willis brings to his medicine and his
teaching a first-rate mind and a potent style. He has an
unerring focus on the fundamentals of medicine. His
every action, mannerism, and felicitous phrase are in
the service of teaching. He is a striking role model, ex-
emplifying the best qualities to be found in physicians:
compassion; clear thinking; and concern for patients,
students, and house officers.
K ENNETH WALKER , M.D.

REFERENCE
1. Hurst JW. The Heart. New York: McGraw-Hill.

42
 A Profession at Risk,
but Reasons for Optimism

J. Willis Hurst, M.D.

Consultant to the Division of Cardiology
Former Professor and Chairman
Department of Medicine (1957–1986)
Emory University School of Medicine
Atlanta, Georgia

E A R LY I N F L U E N C E S

M y father, who was a school superintendent, greatly influenced

my interest in, and keen desire for, knowledge and excellence.
When I was a child, we lived in a large, dormitory-like house near the
school where my Father worked. My aunt, who taught the first three
grades at the school, lived in the same building and taught me before
I started school. She called on me to read the first day of school, and
the entire class laughed; I suppose my class members thought it was a
joke on the teacher. Through the third grade, I was exposed to this su-
perb teacher all day long and at night as well. My Father recognized
the ability of my next teacher, who lived upstairs in our large two-
story house, and transferred her from the fourth to the fifth to the sixth
grades as I progressed each year. So, I had only two teachers during
the first six grades.

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I was also blessed with good high-school teachers, many of

whom were an inspiration to me, but my Father’s interest in educa-
tion probably had the greatest influence of all. When I was about
13 years old, he gave up teaching to work for the Federal Savings
and Loan Association because he could not support his family on
the low salary teachers received during the Depression. But he al-
ways loved teaching; he read a great deal and encouraged me to
read. I recall my great joy when we purchased our first Encyclopae-
dia. I spent many hours on cold winter days simply turning the
pages of the Encyclopaedia, and I remember many of the pages
until this day.

R E S I D E N C Y A N D PA U L D U D L E Y W H I T E
During my internal medicine house-staff training under Dr. V.P.
Sydenstricker at University Hospital in Augusta, Georgia, I was fortu-
nate to meet Dr. Paul Dudley White on a visit to our school. Dr. Harry
Harper, the cardiologist at the Medical College of Georgia and a
friend of Dr. White’s, recommended me to our visitor, who offered me
a cardiac fellowship at the Massachusetts General Hospital for 1948,
and I quickly accepted. From that point on, Dr. White stimulated me
in every conceivable fashion. My friendship with him and Mrs. White
continued for many years, and I was honored to give his eulogy at
Cambridge.
Paul White used to say that the excitement of medicine had to do
with the fact that medicine could link science to humanism. He was a
kind, gentle man who did not urge, cajole, or plead with people to per-
form, but because of his own standard of excellence, he inspired oth-
ers to achieve. Those who worked with him did their best because he
was the recognized authority in cardiology. He had worked with Sir
Thomas Lewis and had known Sir James MacKenzie and all the lead-
ing cardiologists of the world. He became known as the father of car-
diology in this country.

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How Paul White Worked and Influenced People

Dr. White recorded the data he collected from his own patients on
4-by-6-inch cards and created what he called a complete cardiac di-
agnosis. He defined a complete diagnosis as one including the etiol-
ogy, altered anatomy, altered physiology, and functional cardiac
status—a classification later adopted by the New York Heart Associ-
ation. He took this large collection of cards, along with his bride, Ina,
to the Isle of Capri, and wrote his first book, published in 1931. He
exemplified the way a scholar works: carefully collecting data on
enough patients, interpreting the data, and reporting the results. I
think it was that mammoth effort behind the first edition of his book
that put cardiology ahead of many other disciplines. That book made
the field a recognized specialty in this country, and it remains good
reading today. The first edition contained innumerable old references
that, regrettably, had to be eliminated in the later editions because of
limited space.
Paul White was not only an investigator, superb teacher, excellent
physician, writer, and humanitarian, he was also a prophet. He pre-
dicted the role of “risk factors” in cases of coronary atherosclerotic
disease and taught how to prevent the disease in the late 1940s. Paul
White taught me cardiology, but he also taught me what a professional
person should strive to be, and he influenced me to teach and write.
He used to say that a trainee should see patients one-third of the day,
teach one-third of the day, and write one-third of the day.

TEACHING AND LEARNING

I write every day. Writing focuses the mind and, for me at least, is es-
sential for good teaching. Teaching and learning go hand in hand.
Physicians should live up to their title, doctor, which means teacher.
One can always find someone to teach; practicing physicians should
teach patients, just as they should interact instructively with col-
leagues. Instead of dispensing numerous details, the true teacher dis-

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cusses concepts and approaches to learning. For example, lectures

should create interest, stimulate students’ curiosity, and motivate them
to seek further information. Attending the usual lecture is not the best
way to learn. Most often, the information imparted can be read in a
fraction of the duration of the lecture. Teachers must also have a good
sense of timing and know when to introduce each subject. Success de-
pends in part on personality. The common denominator in the person-
ality of true teachers is their ability to stimulate students to work on
problems when the teacher is not present. The true teacher then eval-
uates the ability of the trainee to think rather than regurgitate facts.

C O M P E T E N C E A S A N I M P O R TA N T C O M P O N E N T O F C O M PA S S I O N
Today, when so much is being said about compassion, we overlook
competence as an important sign of the physician’s compassion. If the
physician cares enough about the patient to ask the necessary ques-
tions and is self-disciplined enough to seek the answers, competence
becomes a component of compassion. The most competent physicians
are usually compassionate. Because they have great concern about
being wrong, they make a concerted effort to be right. The most com-
petent, most compassionate physicians have no psychologic problem
requesting consultation or admitting that they do not know something.

ASKING THE RIGHT QUESTION AND IDENTIFYING THE PROBLEMS

Most physicians are stimulated to learn as a result of questions arising
about the care of their patients. When a question arises about one of
my patients, I try to define the problem clearly. In other words, the so-
lution to a problem starts with a clear and simple statement of the
problem. I often refer to this process as focusing the mind. The next
step is to look up the answer in an authoritative general textbook of
medicine and then bring the information up to date by reviewing the
index issues of journals published since the latest edition of the text-
book. Since the medical library is so close to my office, I use it as my

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primary information resource. If I were in a different environment, I

undoubtedly would rely more on the computer. Finally, I may consult a
colleague who knows more about the subject than I do. I learned long
ago that experts in a field often know more about individual patients
than the information found in a textbook, which presents a generic
view of the subject, but not the knowledge honed by valuable clinical
experience.
In the hope of initiating a lifelong practice, I encourage students,
residents, and fellows to create a problem list on each patient. They are
then encouraged to seek the answers to the questions and problems
they record. Young children are curious and do not hesitate to ask ques-
tions, but as we grow older, the child-like questioning is blocked by ex-
ternal forces, and students are expected only to answer the teachers’
questions. I have no objection to testing students by having them an-
swer questions so long as they are also encouraged to ask questions of
their teachers and, more important, of themselves. If the medical
trainee phrases questions properly and has the self-discipline to pursue
specific answers in print or electronic textbooks or journals, or in con-
sultations with others, then the teacher has succeeded.
In medicine, as Kipling admonished reporters, we need to ask
who, what, when, where, and how.1 Remember, however, that many
obstacles will interfere with asking those simple questions. Medical
trainees often have difficulty describing the discomfort of angina pec-
toris, and they may discuss the irrelevant. Finally, I will say: “What
does it feel like to the patient? When does it occur? Where is the dis-
comfort? How does it occur?” Not a bad set of guidelines for the de-
scription of ischemic coronary atherosclerosis.
When my publisher wanted me to prepare a self-assessment book
to help readers test their knowledge of my textbook, The Heart, I en-
listed the cooperation of second-year cardiac fellows. They had been
residents for three years, so they had been out of medical school for
five years. I had them formulate questions about each chapter in The
Heart. I was astounded because the fellows I thought would do a good
job did not do well, and vice versa. We had the usual problems with

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grammar and with clear delineation of the questions—deficiencies

that are well known to all teachers. But more than that, some of them
wrote questions that had no teaching value, such as: What is the im-
portant item on the page? It took about four times longer than I had
anticipated to complete this project. I learned that people who are
skilled at answering a teacher’s questions may not be skilled at asking
questions, and vice versa. Those capable of asking themselves impor-
tant questions, I believe, will be the leaders if they also have the self-
discipline to pursue the answers.

E D U C AT I O N O U T S I D E O F S P E C I A LT Y
All specialists should participate at least once a week in discussions
in general medicine. Cardiologists need to talk with other cardiolo-
gists, but they also need to listen to gastroenterologists, surgeons,
ophthalmologists, dermatologists, obstetricians, and other specialists.
This is vital to physicians who wish to make good decisions about
their patients’ problems. We must all concentrate on what should be
done for a patient rather than what can be done. We can do many
things today, but this does not mean that we should do them. The ex-
cellent subspecialist must make decisions about patients after re-
viewing all the problems the patient has. Such decisions, made in that
manner, improve the judgment of the physician. Commingling with
colleagues outside your own specialty is crucial to enhancing judg-
ment in your own field.

C H A I R I N G T H E D E PA R T M E N T O F M E D I C I N E F O R 3 0 Y E A R S
(1957–1986)
I joined the faculty of Emory University School of Medicine in Atlanta
in 1950 when Dr. Paul Beeson was Chairman of the Department of
Medicine. I worked with Dr. Bruce Logue to develop Cardiology at
Emory University Hospital. In February, 1957, at the age of 36, I be-
came Chairman of the Department of Medicine, a position I held for

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30 years. Being Professor and Chairman of the Department of Medi-

cine was exciting and rewarding. I enjoyed the long hours spent in
teaching, consulting on private cardiology patients, organizing, writ-
ing, developing, and investigating. The full-time faculty grew from 13
to 147 during my tenure. The teaching program attained national
recognition, and new research facilities had improved the research
thrust of the department. All subspecialties had been developed, and
patients came from across the country and abroad. The students,
house officers, fellows, and faculty were happy, and the system en-
couraged learning from one another.

DARK CLOUDS OF UNDESIRABLE CHANGE

I wrote a short paper in 1971, describing the clouds I thought I saw
accumulating that would influence the future.2 I was concerned that
the wonderful progress of medicine, which was easily seen, would
bring with it new and detracting problems. The cost of medical care
would, I feared, create new systems that would displace the physi-
cian as the central figure in the care of patients. I believed then that
medicine, in general, and medical schools, in particular, would be
influenced adversely by changes in the delivery of medical care.
In 1986, as President of the Association of Professors of Medi-
cine, I delivered a short speech, tongue-in-cheek, in which I
pointed out that Departments of Medicine in the future would no
longer have Divisions of Cardiology, Gastroenterology, Hematology,
Oncology, Rheumatology, and the like, but would have Divisions of
Legal Affairs, Business, Parking, and Public Relations. The point
was that the new approaches to the delivery of healthcare would
profoundly influence how a chairman would direct the department.

AFTER CHAIRMANSHIP
I relinquished the chairmanship of Medicine in 1986, but continued
as Chief of Medicine and Chief of Cardiology at Emory University

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Hospital for several more years. Now, as a Consultant in the Division

of Cardiology, I teach nine sessions each week and write the remain-
der of the time. When asked when I will retire, I answer, “When my
memory is not as good as that of the house officers.”

I VIEW WITH ALARM

During the past few years, I have written and published, under the
title “I View with Alarm,”3–5 my concerns about certain aspects of
medicine that trouble me, including the following:
True teaching has deteriorated, returning many institutions to the
simple delivery of information by lecture, assignments in books, or
surfing the Internet. Teachers make schedules and give examinations
to determine if trainees have, for at least one day, remembered the in-
formation. This type of performance is not teaching, and the people
doing it should not be called teachers—they are announcers of infor-
mation.
The true teacher does much more than the announcer. The true
teacher understands how people learn. Learning certainly includes
information, but the true teacher leads the trainee to use the informa-
tion thoughtfully. Thinking is the realignment of information into a
new perception for the person doing the thinking. The true teacher’s
goal is to lead the trainee to think. Not to do so implies that the early
years in medical school meant nothing to the teacher or trainee.
Learning is a step beyond thinking. Learning is successful when
trainees practice and practice until they become adept at the skills
they are trying to develop, including the skill of thinking.
This discussion is included because it is the basis of the educa-
tional process that physicians must use as long as they see patients.
True teachers understand that, but announcers do not. I view with
alarm the current trend of more and more lectures and less and less
true teaching.
The role of the teaching-attending physician has changed for two
reasons. First, the managed-care control of medicine diminishes the

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time true teachers, who are functioning as teaching-attendings, can

spend with their patients or with the trainees assigned to them. This is
disastrous for the physician, patient, and trainee. Second, teaching-
attending physicians must be reminded that true teaching entails
more than simply showing trainees abnormalities or how to manage
patients. The less time there is to teach, the more true teaching de-
clines. It is through the teaching-attending physicians’ efforts that
trainees develop their medical thinking, which entails the use of in-
formation previously stored in memory.

A P R O F E S S I O N AT R I S K
What follows here is not written with great pleasure, because I see the
profession of medicine at risk. Although it is painful to face the facts, I
cannot bury my head in the sand. Admittedly, medical science has ad-
vanced with breathtaking speed, additional effective diagnostic and
therapeutic procedures becoming available every few months. The
downside of this magnificent progress is that the high cost of healthcare
makes it inaccessible for many people. In addition, a serious war exists
among insurance companies, the government, physicians, patients, and
hospitals. The level of happiness of physicians and patients has de-
clined measurably. A more serious problem than the agonizing battle
physicians and patients face in the managed-care era is the deterioration
of the trust most patients formerly had in physicians.
A number of events suggest that everyone does not understand
the attributes of a profession. This confusion is understandable be-
cause, for decades, the concept has been popularized that a person
who is not paid to perform an act is an amateur and one who is paid to
perform the same act is a professional. This superficial thinking has
led to such misnomers as professional boxing and wrestling and a
number of other “professions” while the finer attributes of a profes-
sion are seldom considered.6
The November 30, 1999, issue of The New York Times contained a
two-page article, “When Physicians Double as Businessmen,” stating

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that physicians were working for profit-making companies, or had

developed companies themselves, and were creating medical devices
for sale. The physicians would perform “research” using the device
they created and would then use “educational meetings” to market
their new product. Some such medical entrepreneurs made millions
of dollars by selling their souls at the marketplace while many dedi-
cated physicians watched their properly earned incomes diminish.
On the same day, The Atlanta Constitution reported on “Medical Mis-
takes Are Killers,” pointing out that medical mistakes cause an esti-
mated 48,000–98,000 deaths each year in the United States. The
National Academy of Sciences reported this devastating news and
urged the creation of a new federal agency to protect patients. Both
stories undoubtedly had a heavy impact on patients.
In an earlier story in The New York Times, reporters discussed
their discovery of the “unethical” behavior of physicians who re-
ceived money from pharmaceutical houses to enroll patients in clini-
cal trials. The trials were often conducted by physicians who had no
research training, and many of them had clear-cut conflicts of inter-
est. The story implied that many drugs released during the past few
years might not perform as advertised. Many readers undoubtedly
concluded that some medical participants in such activity love money
more than their patients’ welfare.
None of the three scathing reports encourages the public to trust
practicing physicians or biomedical researchers. Certainly, with the
information in the news reports, the public has a right to question the
motives of the physician participants.
At this uneasy juncture, it seems fitting to reemphasize some of
the time-honored attributes of a profession.
I have always believed that the medical profession was created to
meet the public need for healthcare, not that patients were created to
meet physicians’ financial needs. I submit that the activities in the
news stories mentioned deviate from the professionalism the public
expects and deserves. The physicians functioning as businessmen ig-
nored the contribution the public makes to their incomes. The physi-

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cians who developed and marketed devices ignored that they used a
hospital’s equipment and drawing power to perform their work. They
forgot that the public gave money to create the facility where they
used their products and generously enhanced their incomes. I suspect
the physicians would have been highly disturbed if the hospitals had
charged them a handsome user fee according to the money they made
from marketing the products they created. The public must trust the
restaurant staff to serve them clean food, and they must trust the me-
chanic to repair their cars. Surely, patients should be able to trust
their physicians.
The remarkable Mortimer Adler defined “professional” as fol-
lows: “. . . in the original and deeper meaning of the term, a profes-
sional man is one who does skilled work to achieve a useful social
goal. . . . In other words, the essential characteristic of a profession is
the dedication of its members to the service they perform.”7
Adler noted that the English economist R.H. Tawney defined a
profession as “a body of men who carry on their work in accordance
with rules designed to enforce certain standards both for the better
protection of its members and for the better service of the public.”7
I was just beginning my 30-year stint in 1957 as Chairman of
the Department of Medicine at Emory when the brilliant and coura-
geous Judge Elbert Tuttle uttered these unforgettable words (repro-
duced here with permission) at our graduation exercises: “The
professional man is in essence one who provides service. But the
service he renders is something more than that of the laborer, even
the skilled laborer. It is a service that wells up from the entire com-
plex of his personality. True, some specialized and highly developed
techniques may be included, but their mode of expression is given
its deepest meaning by the personality of the practitioner. In a very
real sense his professional service cannot be separate from his per-
sonal being. He has no goods to sell, no land to till; his only asset is
himself. It turns out that there is no right price for service, for what
is a share of a man worth? If he does not contain the quality of in-
tegrity, he is worthless. If he does, he is priceless. The value is ei-

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ther nothing or it is infinite. So do not try to set a price on your-

selves. Do not measure out your professional services on an apothe-
cary’s scale and say, ‘Only this for so much.’ Do not debase
yourselves by equating your souls to what they will bring in the
market. Do not be a miser, hoarding your talents and abilities and
knowledge, either among yourselves or in your dealings with your
clients, patients, or flock. Rather be reckless and spendthrift, pour-
ing out your talent to all to whom it can be of service! Throw it away,
waste it; and in the spending it can be of service. Do not keep a
watchful eye lest you slip and give away a little bit of what you
might have sold. Do not censor your thoughts to gain a wider audi-
ence. Like love, talent is useful only in its expenditure, and it is
never exhausted. Certain it is that a man must eat, so set what price
you must on your service. But never confuse the performance, which
is great, with the compensation, be it money, power or fame, which
is trivial.”8
Those words became the motto for the department I was develop-
ing. Over the years, I have quoted this portion of his speech whenever
the opportunity arose. Read it—think about it—read it again—and
then pass it on to others to read, because it should be an addendum to
the Hippocratic oath.
James Fowler, Charles Howard Candler Professor of Theology and
Human Development at Emory University, gave me permission to use
the following statements:

• Professionals, and the groups they form, are self-regulating. They

set standards for education, apprenticeship, and admission. They
administer discipline and have the power and authority to remove
colleagues from services for incompetence, malpractice, or char-
acter failure.
• The professions carry a public trust. They stand in a fiduciary rela-
tionship with those they serve. They must be trustworthy with re-
gard to confidential information, the disclosure of which could be

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harmful to those they serve. They also have responsibility to exert

moral influence on their clients at points where their intents or an-
ticipated actions may do injury to others or to the common good.
• Professionals are, traditionally, expected to provide services—
personally or through a collegial network—for persons who have
need of professional services, regardless of capacity to pay for
their services. Their object is service, not the use of their profes-
sional status and skills primarily for personal gain.

While these elements of the traditional understandings of the ethics

of the professions may sound quaint to some contemporaries, they
offer important windows into the special personal and social responsi-
bilities associated with professional status.

AN OPTIMISTIC NOTE
As I write this, I am optimistic about the future of medicine for the
following reasons:
Our knowledge of medicine continues to improve. Despite all the
problems, it is better to be sick in 2003 than it was in 1949.
A group of people cannot be persistently repressed. Physicians
feel repressed because they cannot always function according to the
rules of good medical care. There are definite signs that managed
care is failing to satisfy both employees (physicians) and “cus-
tomers” (formerly called patients). This implies that the managed-
care administrators, despite their enormous incomes, are running a
bad business, good businesses strive to satisfy their customers.
There is light at the end of the tunnel; the current system of health-
care delivery is not working, and patients, as well as physicians,
will assist in the changes that must be made.
True teaching is making a comeback.6 Many medical schools and
teaching hospitals are beginning to recognize that the future of good
medicine lies in the development of true teachers who are supported

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by funds that are not derived from personal services to patients. There
will, in time, be a sufficient number of true teachers serving as teach-
ing-attendings who know how to teach and have the time to do it.

REFERENCES

1. Kipling R. The elephant’s child. In: Just So Stories. New

York: Lancer; 1968:47.
2. Hurst JW. Ten reasons why Lawrence Weed is right. N Engl
J Med. 1971;284:51–52.
3. Hurst JW. I view with alarm. Am J Cardiol. 1995;
75:832–834.
4. Hurst JW. I view with alarm (1997). Am J Cardiol. 1997;
80:769.
5. Hurst JW. I view with alarm (1999). Am J Cardiol. 1999;
84:1339–1340.
6. Hurst JW. Teaching Medicine: Process, Habits, and Actions.
Atlanta: Scholars Press; 1999.
7. Adler MJ. Great Ideas from the Great Books. New York:
Washington Square; 1966:280–282.
8. Tuttle EJ Sr. Heroism in war and peace. Emory Univ Q.
1957;13(3):129–130.

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 2

Reading: Keeping Current

...
All that goes on in medicine is to be the chief matter of
interest to you. Hence you must be busy readers; and,
as habits form, you will learn to look to medical journals
with avidity, and new publications will be examined
with keen relish. But to become distinguished, nay, to
become even respectable in your profession, you must
be something more than readers, you must become ac-
tive thinkers and sifters of knowledge, learn, as Bacon
counsels, to weigh and consider books.
J ACOB M. D A C OSTA 1

R eading is the primary source of physicians’ medical information.

Print is not only the most highly developed and plentiful medium
for medical information, but is also relatively economical, convenient,
and easily accessible. The electronic media have become competitive
with, if they have not surpassed, print media because so much infor-
mation is readily available at the press of a button. Many physicians
are using the Internet to gain easy access to the emerging array of in-
formation sources. Almost all the world’s recent medical information
is readily available to computer-literate physicians. Although this
chapter deals primarily with print publications, remember that most
recent information is available both electronically and in print.

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Beyond new developments in medical care, the need to review

fundamental principles necessitates a lifelong plan of reading. In the
words of Robert Moser, “Reading is as important a habit for a physi-
cian as brushing his teeth and watching his waistline. It becomes a
part of his lifestyle, for it is needed to screen useful advances in the-
ory, diagnosis, and therapy and to solve specific clinical problems
confronting the practicing physician. If properly engrained, the habit
never wanes for the duration of his practice.” Just as nonphysicians
derive pleasure from reading novels and magazines, many practition-
ers enjoy reading medical journals. Joseph Van Der Meulen enjoys
making new associations with previous knowledge: “The insight that
comes with such associations provides the pleasure. I spend leisure
time reading practical material in science and medicine that rein-
forces my medical knowledge.”
Physicians who take for granted the accessibility of reading mate-
rial may find that the words of Shen Jiaqi of Shanghai will give them a
better appreciation of their opportunities for enlarging their knowl-
edge. “Throughout his lifetime,” Shen stated, “a doctor needs to be
informed about new developments in medicine. And there is no short-
cut to it beyond reading, but conditions sometimes suppress reading.
That the tyrant of the Qin Dynasty burned books and buried intellec-
tuals is a historical fact. During the last disastrous so-called cultural
revolution, the ‘Gang of Four’ spread a fallacy that the more knowl-
edge you have, the more reactionary you are. They duped virtuous
people for years into reading little, and the education of a whole gen-
eration of youngsters was therefore delayed. Luckily, the horror is
over, and the People’s Republic of China is now setting off an upsurge
of intellectualism. Everyone, old and young, has been moving into the
tide of reading to make up for what has been lost in the past.
“With the rehabilitation of Confucius, China’s great ancient
philosopher and educationist, I would again recommend his famous
quotations about reading: ‘Reading without thinking is null and void,
whereas thinking without reading is critical and riskful.’ ‘Reviewing old

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articles yields new ideas.’ ‘To read constantly is a great happiness.’ I

think these proverbs are still instructive as guidelines for reading.”

GUIDING PRINCIPLES
“Read with two objects,” advised Osler, “first, to acquaint yourself
with the current knowledge on a subject and the steps by which it has
been reached, and secondly, and more important, read to understand
and analyse your cases.”2 General undirected reading helps the
physician stay current with the state of the art, whereas reading about
puzzling individual cases (or a series of cases seen in practice) has an
immediate, specific, and practical purpose.

Relating Reading to Experience

Both types of reading, general and specific, will be more valuable if
you have an objective in mind or can relate what you read to your
clinical experience. Experienced physicians gain the most from gen-
eral reading because they can associate much of what they read with
their clinical observations. As Gerald Plitman noted, “After a certain
time practicing medicine, you can hardly pick up a journal without
being able to relate an article to some patient you have had. I think all
physicians should try to apply the title of each article they read to a
patient they have seen.”

Screening
John Shaw Billings made an apt observation that illustrates the im-
portance of screening: “There is a vast amount of this effete and
worthless material in the literature of medicine. . . . [O]ur preparers of
compilations and compendiums, big and little, acknowledged or not,
are continually increasing the collection, and for the most part with

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material which has been characterized as ‘superlatively middling, the

quintessential extract of mediocrity.’ ”3
The Need. A primary problem has been the proliferation of publi-
cations. The 20,000 biomedical journals now published are increas-
ing by six to seven percent a year.4 To review 10 journals in internal
medicine, a physician must read about 200 articles and 70 editorials
a month.5
Physicians may receive more than 5,000 pages of journal material
each month, including advertisements and give-away journals. Much
of this contains valuable alternatives and advances in medical prac-
tice. Diagnosis is continually being refined by innovations, new drugs
provide additional therapeutic options, and newly described diseases
also demand attention.
Considerable poorly written or otherwise faulty material in-
filtrates medical publications. Unfortunately, even peer review in the
most prestigious medical journals does not preclude publication
of premature, questionably valid, or repetitious scientific reports.
DeBakey and DeBakey6 – 11 have written extensively on the invalid
themes, illogical arguments, inadequate or inaccurate data, and un-
supportable conclusions, as well as the ungrammatical prose and gen-
erally inferior writing, in some reputable peer-reviewed journals. In a
personal communication, John Williamson reported that his extensive
study of scientific publications pointed to a “misinformation explo-
sion,” in which only 20 percent of published reports today meet even
minimal criteria of scientific validity. Sir Thomas Lewis, writing in
1944, emphasized the need for critical reading: “. . . reform, to be
useful, must render the student of medicine discriminating in a world
where a disquieting proportion of what is offered him in conversation
and in the generality of journals and of books is inaccurate, slovenly,
or redundant.”12
“It is important for us to recognize that the reasons for writing
clinical articles and the reasons for reading clinical articles may have
very little in common,” cautioned David Sackett. “We read them to
find out how to manage our patients; often, however, authors may

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write them to obtain tenure. It is our responsibility to determine the

validity and applicability of what we read; and we certainly cannot
depend on the give-away magazines that provide advice but no data.”
Techniques If the busy physician is to avoid unreliable and
unintelligible articles, he must read selectively and critically. Ob-
serving certain screening techniques can make reading more effi-
cient, whether it is general reading to keep abreast of current medical
events or specific reading to solve problems in practice. “Since we
recognize that the clinician is never going to have any more time to
read than he has now,” continued Sackett, “we have formulated spe-
cific guides and, perhaps more important to the busy clinician, some
screening questions that the physician can apply as he reads scien-
tific articles.”
Screening for Relevance All physicians begin by looking at the title
and determining whether the article is potentially interesting or use-
ful to them. “Next,” advised David Sackett, “review the list of au-
thors; with experience, you will know what their professional
reputations are and whether their work has withstood the test of time.
Consider the site where the work was carried out, and note whether
the patients described are similar to those you see. Turn next to the
abstract or summary, which will tell you whether the substance of the
article, if true, would be useful to you as a clinician.”
Screening for Validity “Readers need to be much more critical
than editors, and certainly more so than authors, in determining what
is valid and what is going to help their patients,” continued Sackett.
“Some of the reasons we read, certainly those most pertinent to indi-
vidual patients, are to understand the cause of a disease, to determine
whether a new diagnostic test is worth using, to distinguish useful
from useless forms of therapy, and to find out the clinical prognosis of
a disorder.” If an article concerns etiology, the reader needs to ask
basic questions about the integrity of the study (proper selection and
prospective follow-up, or simply case reports and undocumented clin-
ical impressions).

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“If you want to find whether a diagnostic test is useful,” Sackett

explained, “you can quickly scan the methods section to see if there
is a valid basis for comparison between the proposed diagnostic test
and some established standard. Alpha-fetoprotein, for example, is the
diagnostic test that has been suggested for hepatocellular carcinoma
in patients with preexisting cirrhosis. In this instance, the established
standard would not be just the microscopic examination of the liver.
The patients with negative biopsies should be followed until they
have done well for at least two to three years, so that you can exclude
hepatoma. Thus in many conditions, we increasingly use the subse-
quent clinical course as the standard.”
If you are reading to differentiate useful from useless or harmful
therapy, the key question, Sackett pointed out, is: “Was the assign-
ment of patients and treatment randomized? That is the only way to be
sure that the groups are sufficiently comparable to draw valid conclu-
sions. If the methods section includes terms like ‘a table of random
numbers,’ or ‘a computer program of randomization,’ you can be rea-
sonably sure that it was a randomized trial. If, on the other hand, you
see statements like ‘patients were allocated at random,’ then you
should be skeptical.
“Randomized clinical trials offer the most convincing evidence
available today in the study of both therapeutic effectiveness and side
effects. We need to compare the incidence of skin rashes, photosensi-
tivity, gastrointestinal upset, headaches, weakness, or dizziness in pa-
tients on placebos with those on active drugs. Some side effects occur
so infrequently, however, that the usual randomized clinical trial
would not be large enough to disclose them. For those, we must rely
on a much less powerful design, the case-control study, in which a
group of patients with the apparent side effect is assembled and then
matched with a control group without the disorder (and that is where
we usually get into trouble). Discrepancies between the two groups in
the incidence of prior exposure to the drug or other factor would con-
stitute some evidence, although not very strong, that the factor pre-
cipitated the disorder.

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“If we are reading about the clinical course and prognosis of a

disorder, we should find out if the patient group was identified at an
early, uniform stage of the disease. If not, a host of biases may inter-
fere. For example, what exactly is the increased risk of colorectal
cancer in patients with ulcerative colitis, and does it justify a prophy-
lactic colectomy? When you search the literature to find an answer to
that question, you become frustrated because the most ‘authoritative’
studies of the risk of cancer in ulcerative colitis patients are based on
‘grab’ samples of patients, many of whom were included because they
already had cancer. As a result, the cancer risk associated with ulcer-
ative colitis is vastly overestimated in these studies. The way to an-
swer the question is to collect a group of ulcerative colitis patients at
an early, uniform point in the natural history of the disease, such as
when they develop the first unambiguous symptoms or receive the
first definitive therapy. That is the only way to determine the natural
history and clinical course of a disease.
“Critical screening of articles not only substantially increases the
validity of the conclusions the reader draws from them, but also in-
creases his efficiency considerably. By applying these basic screen-
ing principles, the reader can expeditiously identify which papers to
keep and where to file them.”
James Young describes how he reads journal articles. “I scan the
table of contents of each journal on the day I receive it and quickly
read abstracts of papers that pique my interest. I then review the ta-
bles, figures, and references cited in these papers. Sometimes I read
the entire paper; an in-depth, critical reading is usually reserved for
papers I deem particularly relevant, important, controversial, or inter-
esting. I photocopy these articles for files I maintain on subjects I am
likely to write or lecture about in the future. Interestingly, I do not leaf
page-by-page through my specialty or subspecialty journals. I reserve
this practice for general medical journals, particularly The Lancet and
The Journal of the American Medical Association, which contain many
newsworthy items, controversies, thought-provoking editorials, help-
ful book reviews, and moving literature, including poetry and per-

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sonal perspectives on the humanities as they relate to our profession.

Although the scientific content of The New England Journal of Medi-
cine may arguably be most laudable, I find an in-depth perusal of The
Lancet and the The Journal of the American Medical Association com-
pelling because of their regular features of poetry, art history, and, in
The Journal of the American Medical Association, ‘A Piece of My
Mind.’ ”

Note-taking and Mental Summaries

Note-taking is a time-honored method of crystallizing what you read.
Osler used it to great advantage. According to Cushing, Osler was “a
rapid, methodical reader with an exceptionally retentive memory, but
in addition he had formed the habit of jotting down the gist of what he
had read so that it could be drawn on when needed, and moreover he
would often augment the notes with some reflections of his own. It was
due to this habit of writing as he read that he finally acquired the
charm of style which characterized his later essays.”13
The late Alton Ochsner, Michael DeBakey’s mentor, kept a perma-
nent record of his notes. “Just by looking at those notes,” he said, “I can
recall relatively easily the thousands of references that I have read.”
Thomas Callister uses cards for note-taking, and reads them when he is
having coffee or has nothing else to do, thereafter filing them at home,
where they are easily available. “This system works well for me, even
though it has been hard on my coat pockets.” Charles Brunicardi re-
calls that Judah Folkman had a habit of recording five new facts each
day, then reviewing those facts at the end of the week. “It is truly amaz-
ing what you will remember using this simple technique.”
Some physicians use a tape recorder rather than cards or paper
for note-keeping. Mentally reviewing and summarizing the important
points of an article, in a single sentence if possible, will help fix them
in your mind. Richard O’Brien enhances his retention by mentally
devising experimental approaches to extend the state of knowledge
beyond that reported in the papers that he reads.

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A Scheduled Time for Reading

Most physicians agree that learning has to be a daily activity, in which
you discipline yourself to read at least one hour a day and adopt a
reading schedule that accommodates your lifestyle.
To keep unread journals from piling up, designate a special time
to read. Daniel Stone gets up at 4:30 a.m. and reads for one and one-
half hours every day except Christmas. “When I get home in the
evening, I am too tired to read in an active, aggressive way. I may turn
the pages, but I am not really absorbing the information. Furthermore,
I prefer spending my evenings with my wife. In the morning, on the
other hand, there are no distractions. My mind is fresh, and I can re-
ally absorb the material.” Richard Field reads from 6:00 to 6:30 a.m.,
when no phones are ringing and there are no intrusions. “In that short
time, I cover about four journals a month.”
According to Cushing, Osler read during meals: “During this first
year in Philadelphia he usually dined alone at the old Colonnade
Hotel, diagonally across the street from his rooms, always it is said
with books and manuscript on the table, and he was usually to be
seen reading and making notes during the course of the meal.”13
Allan Ebbin keeps a pile of journals beside his bed to read before
retiring: “I know of no better way to fall asleep than to read my jour-
nals. Since my wife is also a pediatrician, I can put some of them on
her pile, and she doesn’t know the difference. Seriously, my best
learning has always been at home, alone, with a book or journal.
There are only a few things that provide more entertainment for me.”
Some physicians prefer to read in brief spurts, at intervals
throughout the day—5:30 to 6:30 a.m., at work, after work, and before
bedtime. Since a set time for reading is not possible for Lawrence
Green, he leaves journals on various tables in his office and home, to
be picked up when convenient. Alton Ochsner also used any brief
free time to read. “I try to make every moment of my day count, be-
cause there is so little time to do things,” he said. “I have on my desk
journals of all types, and if I have a few spare minutes, I use that time
to read.” Norton Greenberger reads on several specific subjects in-

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Reading is as important a habit for a physician as

brushing his teeth and watching his waistline.
R OBERT H. M OSER . M.D.
Executive Vice President Emeritus
American College of Physicians

stead of concentrating for an hour on one particular topic, which he

finds soporific. “When I read, I decide in advance how much I want to
accomplish per unit time. I do not read every word; I read for compre-
hension, recognizing that I have to get through a certain amount at a
given time.”
Suzanne Knoebel considers her reading time a reward. “Saturday
afternoon or Sunday is my ‘R and R’ time. If I have problems in pa-
tient care that I need to read about, I eagerly anticipate this time. But
I caution against trying to ‘fit’ learning into an already tightly sched-
uled period; pick a convenient ‘R and R’ time and use it for that.”
Some physicians combine reading with other hobbies. David Cov-
ell, for example, can be seen every Wednesday afternoon hiking in the

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Angeles National Forest above Pasadena reading a current journal,

despite the slight risk that engrossing articles can distract attention
from tree limbs, snakes, and boulders on the trail.
Reading Retreat Frederick Ludwig and Gerald Plitman use their
vacations to catch up on their reading. Plitman created a two-day
“reading retreat” for colleagues, which evolved from the practice he
and his wife had of going away for a few days every summer, isolating
themselves from their usual routine, to read. For each retreat, they in-
vite two professors, who are asked to select topics and to send copies
of the selected publications to all others going on the retreat. Every-
one reads the material in advance and comes to the retreat ready to
discuss these topics. “It is a restful, relaxing event,” said Plitman.
Donald Switz and Dan Mohler have initiated similar reading re-
treats in Virginia. “The format of dual teachers and many papers has
worked well for Plitman, but we use a different format,” said Switz.
“We select three topics per conference and, by rotating the subject,
cover all of internal medicine every four years. A single teacher is in-
vited to put together each of the half-day sessions. The teacher selects
no more than seven original articles, which he believes are the most
important in his field since the last presentations. We ask the regis-
trants to tell us the aspects of each subject they wish to ‘catch up’ on.
We believe physicians learn best when they have a voice in what they
will read. Before the reading retreat begins, this information is re-
turned to the teacher, who then has a chance to modify his reading list
or to know what to emphasize from his selections. We do not mail the
readings in advance, but do distribute a bibliography.
“Like Plitman, we restrict the group to about 25. We retreat to a
park-like setting, and families usually come. We make time for walk-
ing, loafing, and fishing. The structure of each session is similar to
Plitman’s. The teacher spends about 30 minutes at the beginning put-
ting the subject of the articles in perspective with respect to current
knowledge. We then ask for volunteers to present the pith of each ar-
ticle, after which we retire to read for two hours. When we reassem-

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ble, the volunteers present the abstracts, which serve as a basis for
discussion by all participants. We spend about 90 minutes discussing
the articles in the order the participants desire. There is ample time
to ask the teacher for special insights related to clinical cases partic-
ipants have struggled with.
“Special benefits of the reading retreats are: (1) an opportunity to
look critically at original articles, (2) the stimulation of group discus-
sion, and (3) the opportunity to quiz the instructor about clinical mat-
ters germane to patients and the articles. We work hard to help
participants think about good study design.”

Following Specific Investigators

Irvine Page connects facts to people. “I have always been interested
in contemporary history; I follow what is going on in the world of med-
icine largely by associating events with people. History tells me how
people make discoveries or observations. My interest in history grows
as both the subject and the people grow. A classic example is DNA
research. I knew Oswald T. Avery and Colin M. Macleod, both of
whom worked on the floor below me at the Rockefeller Institute for
Medical Research. I saw the evolution of their work from the begin-
ning, with the accompanying development and skepticism. This is the
way I remember things.” Donald Seldin also tries to keep abreast of
advances by following the work of scientific leaders.

A Historical Perspective
Reading the history of science and medicine provides a good basis for
teaching or learning what has happened in the past—how people with
keen curiosities were led to important discoveries. Gastone Matioli,
however, warns readers: “Validate the historical background upon
which the experts base their views. Reviews sometimes distort origi-
nal intentions or at least phrase them poorly. Americans often ignore
history and thus miss the opportunity to identify the source of inher-

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ited errors and misunderstanding.” Osler advised physicians to “read

the original descriptions of the masters who, with crude methods of
study, saw so clearly.”14

GENERAL READING
We use the term “general reading” to refer to that not directed to spe-
cific problems in practice or patients under current care. Such reading
is enjoyable, useful, and necessary to keep abreast of the general state
of medicine. As Paul Wehrle pointed out, “General reading is helpful in
following medical progress and disease trends, especially in communi-
cable diseases and new problems.” Ian Mackay finds that “General
reading provides the opportunity to ‘think sideways.’ Often, when I
have been taxed by a difficult or puzzling clinical problem, or have
been startled by an unexpected diagnosis, I am surprised by the num-
ber of articles related to that problem that I suddenly encounter; the
clinical experience has created an interest in the subject, and I become
aware of articles that would otherwise have been overlooked.”
Every physician must develop a personal method of selection.
Most subscribe to several general journals, such as The Lancet, the
British Medical Journal, The Journal of the American Medical Associ-
ation, and The New England Journal of Medicine, as well as one or
more journals in their specialties. They usually review the table of
contents, checking off the titles that appear interesting. After scan-
ning the abstracts, and sometimes reading an entire article, they file
the most significant papers for future use.

Aids to General Reading

Editorials A physician who reads the editorials in two or three

major journals can keep fairly well informed about new develop-
ments. Of Arthur Rubenstein, Professor of Medicine at the University
of Chicago and a specialist in diabetes mellitus, Richard Byyny re-

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marked: “When we went on rounds together, I wondered how he kept

up with his busy schedule. One day I asked him how he did it, and he
said, ‘I am absolutely religious about reading the editorials in The
Lancet because they are succinct and timely.’ ”
Letters to the Editor Perusing the letters to the editor in presti-
gious journals is an enjoyable way to review and gain additional per-
spective on important medical and related issues of the day. They are
not only topical but are often more readable than the more stilted for-
mal articles.
Screening and Abstract Services The Medical Letter, a biweekly publi-
cation, and the Yearbook publications contain excellent information,
with expert commentaries. William Waters has made a habit of
keeping the Yearbook of Medicine at his bedside and reading two or
three articles in it every night. “This is the cream of the literature
reviewed by the cream of the experts.” Some physicians scan ab-
stract journals such as Excerpta Medica, whereas others peruse cur-
rent awareness newsletters, such as Medical Alert and Infectious
Disease Alert.

Self-assessment Programs
Certain specialty societies regularly publish syllabi prepared by ex-
perts in the field and containing self-assessment programs, along with
objective tests, patient-management problems, and critiques of the
questions and answers. Many physicians use the self-assessment pro-
grams, such as the Medical Knowledge Self-Assessment Program
(MKSAP) or the Surgical Education Self-Assessment Program
(SESAP), to keep abreast of new developments or to study for recerti-
fication tests. This study combined with the comparison of one’s own
answers with those of others has proved to be extremely valuable. Be-
tween editions, some textbooks offer current awareness volumes,
which include self-assessment questions and answers.

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Reading in the General Media

The media often release new information in medicine before it is pub-
lished in the medical journals. Reporters get The New England Jour-
nal of Medicine, for example, before many physicians receive it. “A
patient reads something in The Wall Street Journal and calls his
physician for an opinion about it,” said Alan Gordon. “If the physi-
cian hasn’t heard of it, he appears not to be keeping up.” James Moss
pointed out that “Many patients were better informed than their
physicians about dimethylsulfoxide (DMSO) after it was featured in a
story on ‘Sixty Minutes.’ ” David Sabiston pays attention to medical
stories in the public press primarily because he may want to look up
such topics in medical publications. “You soon recognize that there
are recurring themes in the press. This year it may be obesity, and
four years later it may be the surgical treatment of obesity. Cancer,
like various new concepts in heart disease, is always there. The sub-
jects repeat themselves in cycles, and it is just a matter of keeping
each updated.” The Harvard Medical School Health Letter and Mayo
Clinic Health Letter aid physicians in the education of patients about
their diseases and general health.
Some physicians post articles on a bulletin board in their offices
to convey medical information in the general news to patients. Such a
system encourages the physician to assess medical news items as they
appear.

R E A D I N G T O S O LV E S P E C I F I C P R O B L E M S
Full coverage of medical periodicals is not possible, and even if it
were, detailed recall is not. If it is true, as most students of adult edu-
cation believe, that learning is most effective when a specific problem
needs to be solved, overworked physicians can spend their available
time most efficiently focusing on information that will help them diag-
nose and treat the patients under their care. Robert Petersdorf con-
siders patients to be the gateway to new knowledge: “If we direct our

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reading to conditions we see in our practice, we can keep up reason-

ably well.” Practice-related reading can be classified in two cate-
gories: reading about recurring conditions seen in practice, such as
hypertension or duodenal ulcer, and reading about puzzling problems
in individual patients.

Reading on a Topic of Special Interest

Most physicians develop special interests in certain problems, dis-
eases, drugs, or laboratory studies. A record of the types of prob-
lems seen, the drugs prescribed, and the laboratory studies ordered,
can direct their reading to their personal experience and can lead to
expertise in specific medical topics. (See also Chapter 10.) Donald
Seldin explores certain subjects in great depth as they come up. “I
try to organize the material in some way, either in the form of notes
or in an oral presentation. I prepare not only a catalogue of items
but also a synthesis. If I were studying idiopathic edema of women,
for example, I would review the literature on that subject fairly thor-
oughly, and then try to assimilate the material for application to my
purposes.” Other physicians read on topics they are scheduled to
present at medical meetings, in hospital rounds, or informally to
colleagues.

Reading About Individual Patients

Eugene Braunwald considers it vital to read about a problem as soon
as it arises. “If Mrs. Jones has a mitral valve click and migraine, and
you wonder if the two are associated, look the subjects up immedi-
ately, not six months later. You will retain the information longer be-
cause you will make an association with a specific patient, and this
association will help you apply the knowledge you have acquired to
similar future problems.”
Reading on a particular patient increases retention. “What I re-
member most,” said Edward Shortliffe, “is the information related to

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specific patients. I may find an interesting article when reading ran-

domly, but it does not stick the same as if I am forced to read because
of puzzling questions I have about a patient. Somehow, that becomes
better integrated into my memory and helps me deal with similar
problems in the future.”
When a clinical problem requires additional information, framing
the precise applicable question is essential to finding the specific in-
formation needed. Rich sources of information, including textbooks,
commentaries, and journal articles are now easily accessed electroni-
cally. If you are not yet using the Internet, you can consult a recent
print edition of a standard textbook or a good review article. If more
detailed information is needed, you can consult a medical librarian to
obtain pertinent references.

*****
Reading is the most common way for physicians to gain new
knowledge and review fundamental concepts. Since there are en-
tirely too many medical publications for physicians to read, they
must develop methods of screening journal articles for relevance
and validity. As George Sarton said, “The art of reading implies the
art of non-reading, and more energy is sometimes needed in order to
skip rather than continue useless drifting. Many would-be scholars
never learn anything not only because they cannot read, but also be-
cause they cannot stop reading: they are like asses turning round
and round in a mill with blinkers on their eyes.”15 In addition to
reading to remain aware of the state of the art, physicians read about
their cases, either about individual puzzling patients or about their
aggregate experience with various conditions. Scheduling a daily
time for reading and developing related activities such as taking
notes, following specific investigators, and relating reading to expe-
rience will enhance the value and efficiency of reading. Cultivating
a historical perspective about the medical literature and disease en-
tities also enriches understanding and provides a basis for coordi-
nating and integrating new knowledge with old. Editorials in

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leading journals generally keep one alert to new developments. The

physician with limited time can maximize efficiency by concentrat-
ing on reading about puzzling individual patients and conditions
seen recurrently in practice.

REFERENCES
1. Da Costa JM. Valedictory address to the graduating class of
Jefferson Medical College, Philadelphia. Delivered 1874
Mar 11. Philadelphia: P. Madeira, Surgical Instrument
Maker; 1874:8.
2. Osler W. The student life: a farewell address to Cana-
dian and American medical students. The Medical News.
1905;87:630.
3. Billings JS. Our medical literature. In: Rogers FB, ed. Se-
lected Papers of John Shaw Billings: Compiled, with a Life of
Billings. Baltimore: Waverly; 1965:128–129.
4. Price DJdeS. The development and structure of biomedical
literature. In: Warren KS, ed. Coping with the Biomedical
Literature: A Primer for the Scientist and the Clinician. New
York: Praeger; 1981:3–16.
5. Warren KS. Selective aspects of the biomedical literature.
In: Warren KS, ed. Coping with the Biomedical Literature: A
Primer for the Scientist and the Clinician. New York:
Praeger; 1981:17–30.
6. DeBakey L. Critical reasoning: a prerequisite for clear sci-
entific writing. Int J Cardiol. 1984;5:629.
7. DeBakey L, DeBakey S. Muddy medical writing: is the cul-
prit “bad grammar,” technologic terminology, committee
authorship, or undisciplined reading? South Med J.
1976;69:1253–1254.
8. DeBakey L. The Scientific Journal: Editorial Policies and
Practices. St. Louis, MO: C. V. Mosby; 1976.

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9. DeBakey L. Releasing literary inhibitions in scientific re-

porting. Can Med Assoc J. 1968;99:360–367.
10. DeBakey L, DeBakey S. Medicant. Forum on Med. 1978;
1:38–40, 42–43, 80–81, 83–86.
11. DeBakey L, DeBakey S. The abstract: an abridged scientific
report. Int J Cardiol. 1983;3:439–445.
12. Lewis T. Reflections upon reform in medical education.
Lancet. 1944;6298(Pt 1):619.
13. Cushing H. The Life of Sir William Osler. London: Oxford
Univ. Press; 1940:242.
14. Osler W. In: Bean WB, ed. Sir William Osler: Aphorisms from
His Bedside Teachings and Writings. Springfield, IL: Charles
C Thomas; 1968:79.
15. Sarton G. Notes on the reviewing of learned books. Science.
1960;131:1183.

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 R E F L E C T I O N S / E U G E N E B R A U N WA L D , M . D .

R E F L E C T I O N S
...

If Mrs. Jones has a mitral valve click and migraine, and

you wonder if the two are associated, look the subjects
up immediately, not six months later. You will retain the
information longer because you will make an associa-
tion with a specific patient, and this association will
help you apply the knowledge you have acquired to
similar future problems.
E UGENE B RAUNWALD , M.D.

Dr. Eugene Brauwald’s research, reported in more than 1000 pub-

lications, has illuminated many aspects of cardiology. He and his
colleagues clarified the importance of Starling’s Law as a major de-
terminant of human ventricular performance, conducted some of
the earliest studies on beta-adrenergic receptor-blocking drugs,
and described an important biochemical defect in heart failure—
the depletion of norepinephrine in the hearts of patients with this

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condition. Dr. Braunwald’s description of hypertrophic cardiomy-

opathy and his work on limiting the ultimate size of myocardial in-
farction have profoundly influenced clinical cardiology. His
brilliant animal experiments demonstrated that infarct size after
coronary occlusion can be reduced by various interventions, and
the thrombolysis in myocardial infarction (TIMI) trials profoundly
influenced the care of patients with myocardial infarction world-
wide. Recipient of numerous awards and honorary degrees, Dr.
Braunwald has been influential in governmental affairs related to
cardiovascular research and practice and has served on the edito-
rial boards of several prestigious medical and scientific journals.
His work as an outstanding mentor during almost 40 years of teach-
ing—10 as Chief of Cardiology and 28 as Chairman of Medicine—
has been recognized by the American Heart Association’s
establishment of the Eugene Braunwald Mentorship Award.

*****
Dr. Braunwald is one of the foremost contemporary
scholars in the cardiovascular sciences. His contribu-
tions are prolific, and his influence is profound in both
clinical cardiology and basic research on the heart and
circulation. Intense intellectual curiosity and extraordi-
nary analytical abilities are the foundation of Dr.
Braunwald’s search for knowledge to treat patients af-
flicted with heart disease. His example has been an in-
spiration to his students; more than one-sixth of Dr.
Braunwald’s former trainees are full professors, depart-
ment heads, or directors of cardiology divisions in
major medical schools throughout the world.
W ILLIAM F. F RIEDMAN , M.D.

78
 My Three Professional Lives

Eugene Braunwald, M.D.

Distinguished Hersey Professor of Medicine
Harvard Medical School
Chief Academic Officer
Partners HealthCare Systems
Boston, Massachusetts

I lead three professional lives, each with different educational needs.

As a Faculty Dean at Harvard Medical School, I must have some
basic understanding of the broad aspects of medicine and biomedical
sciences in order to deal with recruitment and promotion of senior
faculty. My second role is that of author and editor-in-chief of two
textbooks: Harrison’s Principles of Internal Medicine and my own text,
Heart Disease. We now offer Harrison’s [textbook] OnLine. It was both
challenging and exhilarating to prepare the first textbook for this
medium. The third component of my professional life is as leader of a
clinical trials research group.
I have tried to make all three professional roles support, rather
than compete with, one another. As I have observed physicians in ac-
ademic life whose research is far removed from their clinical work, I
have noticed that these two activities are often competitive, not com-
plementary. I am always skeptical about a person who, for example, is

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a superb molecular biologist but tells me he wants to practice general

internal medicine. These two activities do not support each other. If,
on the other hand, that person were interested in research on the fun-
damental mechanisms of cell division and wished to be a clinical on-
cologist, it would make more sense to me.
For the past 30 years, I have conducted research primarily on the
myocardial ischemia. My continuing education in this field derives
from the intense association I enjoy with my own research fellows and
other colleagues in the field. To keep abreast of the field in which I con-
duct my research, I must read about 10 hours each week.

THE CASE STUDY

I am becoming more and more convinced that the case-study method,
which can be done very readily in a hospital setting, is one that we
should be pursuing. Instead of giving a lecture on unstable angina, for
example, one can select for discussion six patients who demonstrate
different aspects of the problem. Education based on the case-study
methods without any didactic lectures is different from the usual
grand rounds in which a patient with XYZ diseases is presented and
a lecture is given. The case-study method, in which the discussion is
about a series of patients, each of whom illustrates different princi-
ples, requires much more preparation, but is more effective than tra-
ditional educational methods.

M O T I VAT I O N
I have been “programmed” for the work I am doing; my parents ex-
pected me to do exactly what I am doing, and that expectation was
made clear to me even before I started school. My parents wanted me
to do something that they did not have a chance to do, and they saw
that I had the capacity to do it, so they encouraged me. I do not regret
that. My professional life gives me joy and considerable satisfaction
and rewards.

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When I began medical school, I intended to practice clinical

medicine. Bill Hubbard, then Dean of Students at New York Univer-
sity, introduced the elective system in 1951. When I went to see him,
I thought that I wanted a clinical elective—dermatology or orthope-
dics, as I recall. He said: “I expected that you would do research for
your elective,” and I said, “No, I do not want to do research. Nothing
could be further from my mind.” When I sensed that he was becoming
angry with this response, I said to myself, “If I fight this, I will get into
serious trouble.” So I said, “I will be glad to do research.” He asked,
“What kind of research do you want to do?” I responded, “Oh, no, I
am just saying this to please you, and therefore you must make that
decision. I really do not want to do any.” He called Ludwig Eichna,
who at the time was Chief of Cardiology, and said, “I have a man here
who is eager to work in your laboratory.” “Please send him over,” was
the reply. I joined Eichna’s laboratory, and within days my life was
changed forever. Not only did I become enthusiastic about research,
but I became fascinated by the cardiovascular system.
As one of the editors of Harrison’s Textbook of Medicine and Har-
rison’s OnLine, I must read all the new material in my field. Thus, my
editorial work becomes my continuing education. I also read the
major cardiac journals in some detail. This is essential to my position
as Faculty Dean, to the preparation of my textbook Heart Disease, and
to my research program. Thus, my three professional lives are mutu-
ally supportive and are built on an infrastructure of continuous updat-
ing of my own knowledge base.

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R E F L E C T I O N S
...
Dr. Philip Tumulty received his M.D. and residency training from
Johns Hopkins University. He was twice the recipient of the George
J. Stuart Award as Outstanding Clinical Teacher and received an
Honorary Doctor of Science Degree from Georgetown University.
He published The Effective Clinician1 and wrote extensively on
clinical subjects, including the treatment of pneumonia, infectious
endocarditis, recurrent malaria, the natural history of systemic
lupus, scleroderma, giant-cell arteritis, hepatic hypoglycemia, and
functional illness.
In the opinion of Sherman Mellinkoff, Philip Tumulty exempli-
fied what Francis Peabody had in mind when he said, “The secret
of the care of the patient is in caring for the patient.” Mellinkoff
noted that Tumulty, a gifted, lifelong student of medicine, radiated a
compassionate concern for all his patients, whatever their back-
grounds, their sorrows, and their fates. His devoted care of his pa-
tients, even during the search for a diagnosis, is the kind of therapy
each of us would like to have and was a lasting inspiration to his
students and his colleagues.

REFERENCE
1. Tumulty, PA. The Effective Clinician. Philadelphia: W.B.
Saunders; 1973.

83
 Preparing for a Fulfilling Career

Philip A. Tumulty, M.D. (1911 – 1989)

Former David J. Carver Professor Emeritus of Medicine
Johns Hopkins University School of Medicine
Baltimore, Maryland

S tudents and others have asked me: “Why do you find a career in gen-
eral internal medicine so completely satisfying?” My answer: Be-
cause each day that medicine is practiced properly, I find a full measure
of those fulfillments for which we all strive: intellectual enhancement,
stimulation, and excitement; an opportunity to increase and expand the
best qualities of mind and spirit; a chance to feel the thrill of bringing re-
lief to fellow human beings through the best use of one’s intellectual and
personal endowments; and finally the daily experience of seeing and un-
derstanding more clearly the depths of human nature, with its intense
complexities and eccentricities, its good and bad, its sublimity and de-
pravity, its victories and defeats. A clinician is not merely a bystander
looking at life as it flows by him; he is an active participant in it, at some
of its most crucial stages involving his fellow human beings.
To be effective in such a role, one must, of course, have a number
of requisites, including a knowledge of medical science and of the na-

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ture of man, both based on the broadest possible clinical experience.

One must be stimulated not only by scientific facts and intriguing
clinical situations, but by the very simple or exceedingly complex
problems arising from patients’ human qualities as well. To perform
superbly, one must be an eager, persistent, devoted medical scientist
whose joy of living comes largely from experiencing the positive ef-
fects one’s knowledge and talents have on patients’ problems, what-
ever their source may be.
But how does one prepare for such a totally fulfilling yet demand-
ing career, and, once embarked upon it, how does one prevent the
practical burdens involved in it from leading to boredom, intellectual
and spiritual sterility, and a gradual decline of the stimulus to excel-
lence and of pride in achievement?
Here, we come to the significance of the role of continuing educa-
tion in our clinical careers. While a proper program of continuing ed-
ucation may keep alive the essential qualities of an effective
clinician, it cannot create them. It is therefore the role of the medical
schools to select those students with the proper gifts, talents, and
abilities of mind, spirit, and character and to create a broad curricu-
lum that fertilizes their growth.
Organized lectures and demonstrations are of undisputed value,
but they are not the heart of the matter. The key remains in self-
education, and, to my way of thinking, clinical self-education has
three essential components:

• Physicians need to have as many and as varied clinical experi-

ences as possible. I see clinical conditions today that I have never
seen before, and although they are sometimes insignificant, they
may also sometimes be exciting and unusual, as with Takayasu’s
disease.
• Having had this new experience, the physician must learn more
about it. It is important that the clinical experience come first and
the reading after.

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• Discussion with others of one’s new clinical experiences is in-

valuable, not necessarily by formal consultation but perhaps by
informal conversations and exchanges.
A major concern of the clinician is involvement in matters spring-
ing from the patient’s human nature. Surely the greatest study of
mankind is man. A superbly trained scientist who is ignorant of the
classics of literature and art and who is naive about social, political,
and financial factors is not likely to use these factors positively to
ameliorate his patient’s illness. How can the physician become more
sensitive to these matters? A well-organized schedule, permitting rea-
sonable time for hobbies and interests, social and community activi-
ties, and reading, is helpful but is not enough. I recommend a
program by the local medical group such as that conceived and de-
veloped by George Udvarhelyi of the Johns Hopkins Medical Institu-
tions. In regular informal sessions, often embellished by wine and
cheese, those with experiences in widely diverse fields—basic scien-
tists, musicians, actors, clergymen, judges, psychiatrists, social work-
ers, politicans, and others—are invited to talk and to answer
questions.
Every physician, whether a specialist or a general internist,
should select some clinical condition and begin, at an early date, to
develop special knowledge and experience about its natural course
and its diagnostic and therapeutic management. Systemic lupus ery-
thematosus, bacterial endocarditis, and giant-cell arteritis, for exam-
ple, have intrigued me through the years, always as a result of my
having seen a patient with the condition. Seeing the patient was fol-
lowed by a gathering of articles, compilation of a filing index, and
slow, methodical collection of case material.
Developing subjects of special interest has several advantages.
First, it keeps the clinician intellectually stimulated instead of sub-
merged in the purely routine. Second, in examining the natural his-
tory of a disease over time, the physician will acquire a richer
knowledge of many other disorders that may simulate it. Third, such

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clinical studies, if carried out well, may lead to a clinical report, and
such a report sometimes leads to an important advance in medicine.
Finally, and from a purely practical standpoint, such studies help the
young clinician become established as a consultant in the community
and as a speaker at medical programs.
Clinicians, then, should be permanent, enthusiastic students of
disease and of human beings affected by it, so that they may acquire
the ability to cure illness or relieve discomfort and to afford compas-
sion and support to their patients. Without a practical and vital pro-
gram of continued self-education, these priest-like powers of the
superior clinician cannot be fully realized.

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 REFLECTIONS / BOBBY R. ALFORD, M.D.

R E F L E C T I O N S
...

Personal satisfaction and success as a physician de-

pend on an insatiable curiosity, constantly asking
“why,” then searching for, and finding, the answer.
B OBBY R. A LFORD , M.D.

Dr. Bobby Alford received his M.D. with honors from Baylor Uni-
versity College of Medicine in 1956. After completion of a resi-
dency in Otolaryngology—Head and Neck Surgery, he served as a
Fellow in Otology at the University of Texas Medical Branch and as
a Special NIH Fellow at Johns Hopkins University School of Medi-
cine. He holds the Olga Keith Wiess Chair and is Professor and
Chairman of the Department of Otorhinolaryngology and Commu-
nicative Sciences, now named in his honor, at Baylor College of
Medicine.
Dr. Alford has served on the Advisory Board of Johns Hopkins
University School of Medicine and on the National Advisory Coun-

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cil of the National Institute for Neurological and Communicative

Disorders and Stroke, the National Advisory Council of the Na-
tional Institute for Deafness and Other Communication Disorders,
the Advisory Council of the Lunar and Planetary Institute, the
NASA Headquarters National Advisory Council, the White House
“Blue Ribbon” Advisory Committee for the Redesign of the Space
Station, and the Aerospace Medicine Advisory Committee (Chair-
man). He has also served as Consultant to the Surgeon Generals of
the United States Army and the United States Navy. He wasCchief
Editor of the Archives of Otolaryngology for 10 years and has pub-
lished more than 140 scientific papers.
Dr. Alford is a Fellow and former President of the American
Academy of Otolaryngology—Head and Neck Surgery, a former
President and Executive Vice President of the American Board of
Otolaryngology, a Fellow and former member of the Board of Gover-
nors of the American College of Surgeons, and a former President of
the American Council of Otolaryngology—Head and Neck Surgery.
He is a member of The Johns Hopkins Society of Scholars and the
Institute of Medicine of the National Academy of Sciences. As CEO
of the newly established and NASA-funded National Space Bio-
medical Research Institute, he leads a consortium of institutions
that includes Baylor College of Medicine as the lead institution.
Dr. Alford was recently awarded the NASA Distinguished Pub-
lic Service Medal. In 1991, he received the Good Housekeeping
Award as one of the “Top 400 Best Doctors in America.”

90
 The Prepared Mind

Bobby R. Alford, M.D.

Executive Vice President and Dean of Medicine
Chairman, Department of Otorhinolaryngology
and Communicative Sciences
Baylor College of Medicine
Houston, Texas

“[C]hance only favours the mind which is prepared. . . . ”

L OUIS PASTEUR 1

A lifelong commitment to continual learning, the acquisition of

new knowledge, and expanding experience through caring for
patients are essential features of a successful physician. Several fac-
tors contribute to effective continual learning and the resultant assim-
ilation and application of the latest discoveries for the patient’s
benefit. An open mind and a learned, disciplined, enlightened ap-
proach to the prudent use of new information, technology, and
problem-solving are essential. Personal satisfaction and success as a
physician depend on an insatiable curiosity, constantly asking “why,”
then searching for, and finding, the answer. In reflecting on these
points, I believe a passage from the Daily Prayer of a Physician, at-
tributed to Maimonides, is as pertinent today as it was when he lived

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in the twelfth century A.D.: “[N]ever awaken in me the notion that I

know enough, but give me strength and leisure and zeal to enlarge my
knowledge and to attain ever . . . more. Our art is great, and the mind
of man presses forward forever.”2
There are many well-established ways to advance one’s knowl-
edge. For example, access to the latest biomedical information is
crucial to a physician’s continued development, which, in turn,
leads to optimal patient care. Numerous sources are available, but
because all are not of comparable reliability, currency, or scientific
merit, the physician must select only sources of the highest value,
relevance, and credibility. Today, emphasis on evidence-based
medicine and the availability of special analytical databases as ref-
erences provide a wealth of information that helps improve patient
outcomes. Traditional sources, such as peer-reviewed journals like
The Journal of the American Medical Association and The New En-
gland Journal of Medicine, as well as many specialty journals, are
valuable sources of reports of new discoveries in diagnosis and
treatment. Textbooks are useful general references, but quickly
become outdated as new knowledge emerges. Other valuable
sources of timely information that expand overall knowledge are the
Medical Letter (a nonprofit publication) and the U.S. Department of
Health and Human Services’ Morbidity and Mortality Weekly Report
(MMWR), which offer updates regarding drug therapy and public
health issues, respectively.
Professional meetings or courses approved by the Accreditation
Council for Continuing Medical Education, as well as a variety of clini-
cal and research symposia, also provide updates of the latest develop-
ments in the pathophysiology of disease, technology, diagnosis, and
treatment. Participation in such activities, which are required to meet
specific minimal standards, often requires travel and absence from
practice, and the content may not always justify the overall expense.
Professional organizations (academies, societies, associations) also
offer worthy continuing education materials, some of which are avail-
able through printed mailings, audio/video tapes, or electronic media.

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 REFLECTIONS / BOBBY R. ALFORD, M.D.

In general, biomedical information for physicians should be as

broadbased and convenient as possible to expand their knowledge
base; a narrow, limited input will not serve their patients well. In recent
years, electronic technology, such as the Internet, has provided access
to numerous data banks and Web sites, each of which has advantages
and disadvantages. The information is extensive, but sometimes lacks
peer review and validation. Unless stringent ethical guides are ob-
served, Web sites and e-mail can produce false impressions and border
on misrepresentation. The computer-literate public may become con-
fused or be misled by the lack of validity or clarity. Nevertheless, the
Internet and e-mail have brought the physician and the public closer to
the latest developments in medicine.
An authoritative, critically peer-reviewed, published manuscript
continues to be the gold standard in scientific communication and the
best source for expanding knowledge. Although electronic versions of
such respected scientific communications can shorten the time from
submission to accessibility, the technology is often substandard in re-
production of radiographic images and histopathologic materials.
The history of medicine is replete with examples of how learning
and the application of knowledge, coupled with astute powers of ob-
servation, have resulted in important biomedical discoveries. Some-
times discoveries have resulted from the recognition of something
missed by others. A few selected examples bring special meaning to
Pasteur’s statement that, in the fields of observation, “ . . . chance
only favours the mind which is prepared. . . .3 ”1 An experiment in
perception conducted by Bruner and Postman3 asked subjects to
identify a series of playing cards that included a few anomalous
cards, such as a red six-of-spades and a black four-of-hearts. When
these cards were shown briefly, the subjects almost always identified
them as normal. The black four-of-hearts, for example, would be seen
as either the four-of-hearts or the four-of-spades, without any aware-
ness of anomaly. When the subjects were given gradually increasing
increments of time for viewing the cards, most eventually identified
the anomalous cards correctly. A few subjects, however, never could

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identify the anomalies, even when given 40 times the average expo-
sure needed to identify normal cards.
An accidental discovery by the Dutch pathologist Christjaan
Eijkman4 illustrates the importance of recognizing an anomaly. When
the supply of rough, unmilled rice ran low, Eijkman fed table scraps
of white polished rice to the laboratory fowl, after which he noted that
they developed beriberi. When he restored their usual diet of un-
milled rice, they recovered. He repeated the experiment several times
with the same results, proving that an ingredient of the rice skin—
now known as vitamin B—prevents beriberi.
The history of surgery for thyroid disease provides yet another ex-
ample of how the prepared mind led to a significant advance in med-
icine. In the late 1800s, the famous surgeon Theodor Kocher5
observed that one of the young patients on whom he had successfully
performed a total thyroidectomy had become extremely tired and
cretinoid postoperatively. His astute observation and follow-up of his
patient’s course led him to describe the clinical picture of hypothy-
roidism (due to the absence of thyroid hormone) and thereafter to re-
frain from removing the entire gland. Kocher received the Nobel Prize
in 1909 for his outstanding work on the physiology, pathology, and
surgery of the thyroid gland. His important observation led to the de-
velopment of thyroid extract.
One other example of a presumably serendipitous discovery (but
more likely the result of a scientist’s recognition of the significance
of an anomalous occurrence) was that by Alexander Fleming, who
noticed that the colonies of mold growing on his contaminated cul-
tures had killed the staphylococci around them.6 This observation, in
combination with much painstaking research, led to the discovery of
penicillin.
Each of these discoveries owes much to accident, but each also
results from unusually astute powers of observation—the ability first
to observe an anomaly, then to recognize its importance, and finally to
make productive use of the observation.

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 REFLECTIONS / BOBBY R. ALFORD, M.D.

Teaching and sharing discoveries or experiences by publishing is

another way to learn. Preparing a lecture or a scholarly manuscript is
a stimulus for mastering the subject. Invariably, dialogue between
teacher and student or author and reader permits a beneficial ex-
change of ideas, information, and perspectives.
In addition to the formal and traditional ways of keeping abreast
of new knowledge and applying it appropriately to patients, other fac-
tors add value and success to your medical practice, contribute to
new understandings in medicine, and enhance professional growth
and development. An open mind that can accommodate an initially
radical-appearing idea should be nurtured. In Alexander Pope’s
words: “Be not the first by whom the new are tried, nor yet the last to
lay the old aside.”7 Such an open-minded philosophy is as important
in medicine as it is in other endeavors. Regrettably, “instant report-
ing” must sometimes be retracted as invalid, but that should not close
your mind to new knowledge or techniques that, after being carefully
reported, prove to have a sound biomedical basis. Indeed, Pasteur’s
counsel to young physicians (on the celebration of Pasteur’s seventi-
eth birthday, December 27, 1892, in Sorbonne) emphasized this very
point: “Whatever your career may be, do not let yourselves become
tainted by a deprecating and barren skepticism. . . . ”8 Guy de Chau-
liac (1300–1370), regarded by many as the Father of Surgery, said:
“The conditions necessary for the surgeon are four: first, he should be
learned; second, he should be expert; third, he must be ingenious,
and, fourth, he should be able to adapt himself.”9 Both statements ad-
monish against clinging tenaciously to what you already know as
though that knowledge were absolute; have an open mind.
In this past century, one example of narrow-mindedness in sur-
gery stands out as the antithesis of the admonitions of Pasteur and
Chauliac: In the late 1930s until the early 1950s, the recommended
operation for hearing impairment caused by otosclerosis (fixation of
the stapes bone in the middle ear) was the fenestration operation per-
fected by Julius Lempert. In 1952, Sam Rosen10 accidentally discov-

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ered that mobilization of the fixed stapes would improve hearing in

many patients over results from the fenestration operation. Because
most ear surgeons of that era did not know how to perform the mobi-
lization operation and because the results in some patients were tem-
porary, there was considerable skepticism about the benefit of the
operation, and many surgeons, including Lempert, openly criticized
the new procedure. It was, however, Rosen’s novel observation that
led to the highly successful stapedectomy and stapedotomy proce-
dures still used today to relieve otosclerosis.
Another factor that is important in professional growth and devel-
opment, and in “preserving the passion,” is the pursuit of excellence.
In part, it evolves from a personal commitment and discipline. Other
special concepts or principles are important to continual learning and
the pursuit of excellence:
At Morning Report at many teaching institutions, residents, espe-
cially the chief resident, report on the status of patients on a clinical
service. When multiple institutions contribute to the training pro-
gram, such meetings provide not only a review of the diagnosis, plan
of treatment, and progress of each patient, but also continuity in care
as residents rotate within the affiliated institutions. The Morning Re-
port, which extends the clinical experience of residents beyond their
assigned patients, represents shared learning.
Some directors of surgery training programs urge each resident to
think of each surgical patient as having three operations: the one the
surgeon considers ideal for the patient’s diagnosis, carried out men-
tally before the operation; the actual operation; and a third operation,
again performed mentally, that recapitulates the operation performed
and changes that may have improved the result.
At several institutions today, it is possible to do a preoperative
“virtual operation” with computer-modeling systems. In the future, if
not now, it should be feasible to reconstruct the problem or diagnosis
encountered during operation and, with virtual systems, reenact the
actual operation or design a better one. Such a disciplined approach

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 REFLECTIONS / BOBBY R. ALFORD, M.D.

to surgery, with or without computer systems, adds significantly to the

maturity and expertise of a surgeon.
Continual learning and progressive professional development, as
described here, may substantially expand the physician’s knowledge
base and skills for the optimum care of patients. No single learning pro-
cess can produce “the prepared mind,” but two critical elements that
assist in that goal are motivation and adaptation to changing times.

REFERENCES
1. Pasteur L. Inaugural lecture, University of Lille, December
7, 1854. In: Vallery-Radot R. The Life of Pasteur, Devon-
shire RL, trans. Garden City, NY: Garden City Publishing;
1923:76.
2. Bogen E. The daily prayer of a physician. JAMA.
1929;92:2128.
3. Brunner JS, Postman L. On the perception of incongruity: a
paradigm. J Pers. 1949;18:206–223. Also discussed in
Kuhn T. The Structure of Scientific Revolutions. 2nd ed.
Chicago: Univ. Chicago Press; 1970:62–64.
4. Kyle RA, Shampo MA. Christjaan Eijkman. JAMA.
1980;244:1992.
5. Kocher T. Ueber Kropfextirpation und ihre Folgen. Arch
Klin Chir. 1883;29:254–337.
6. Maurois A. The Life of Sir Alexander Fleming, Discoverer of
Penicillin. London: Jonathan Cape; 1959:123–158.
7. Pope A. An essay on criticism: part. 2, line 335. In: Dobree
B, ed. Alexander Pope’s Collected Poems. London: Dent &
Sons Ltd, Everyman’s Library; 1956:66.
8. Pasteur L. Comments on the occasion of his 70th birthday,
Sorbonne, December 27, 1892. In: Vallery-Radot R. The
Life of Pasteur, Devonshire RL, trans. Garden City, NY: Gar-
den City Publishing; 1923:451.

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9. Chauliac Guy de. On Wounds and Fractures. Brennan WA,

trans. Chicago: W.B. Brennan; 1923:xiii.
10. Rosen S. Palpation of stapes for fixation. Arch Otolaryngol.
1952;56:610–615.

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 R E F L E C T I O N S / W I L L I A M W. PA R M L E Y, M . D .

R E F L E C T I O N S
...

When I encounter a puzzling patient and the available

publications do not help, I discuss the patient with my
colleagues in the cardiology division, where the com-
bined experience of the group is extremely helpful in
reaching a diagnosis, or at least in pointing me in the
appropriate direction.
W ILLIAM W. PARMLEY, M.D.

Dr. William Parmley received his M.D. degree from Johns Hop-
kins Medical School and his internal medicine training on the Osler
service at Johns Hopkins. He then spent two years in research at
the cardiology branch of the National Heart Institute, followed by
formal training in cardiology at the Peter Bent Brigham Hospital.
He served as Associate Chief of Cardiology at Cedars-Sinai Med-
ical Center in Los Angeles for four years, before becoming Chief of

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Cardiology at the University of California at San Francisco (UCSF)

for 24 years.
Dr. Parmley has been President of the American College of
Cardiology, where he is a Distinguished Fellow and Master. Now
completing a 10-year term as Editor-in-chief of the Journal of the
American College of Cardiology, he is the author or coauthor of
more than 350 peer-reviewed publications and 300 abstracts.
He has also published four books, 140 book chapters, and 125
editorials.

100
 Keeping Up to Date:
Difficult, But Not Impossible

William W. Parmley, M.D.

Professor of Medicine
Araxe Vilensky Professor of Cardiology
University of California, San Francisco
San Francisco, California

I remember an incident as a first-year medical student at Johns Hop-

kins that greatly impressed me at the time. A lecturer in one of the
basic sciences rose one day to advise us that certain material he had
presented the previous week had been replaced by new data just pub-
lished. He carefully reviewed the new data and explained that the old
data were partly correct, but had clearly missed some of the major is-
sues. I was impressed by this change in information as a marker of the
future changes in “medical truths” that I would experience over a
lifetime of learning. At that time, the amount of information one had
to absorb and the number of newly published articles were far less
than the seemingly endless new information today, especially in car-
diovascular disease.
As I have reflected on how I learn information best in this age of
high technology, certain patterns have emerged. As third- and fourth-
year medical students, and especially during our training years and

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beyond, we always learned a lot from our patients. No book can ade-
quately describe how each patient with a particular disease is going
to present to the physician, and what the course will be. As we gain
experience over the years, this information falls into place in our un-
derstanding of the variations and long-term course of individual prob-
lems. Furthermore, we learn much by seeing individual patients as
our focal point and then reading about their problem in textbooks and
other available sources. Certainly, the first few patients with diabetes
that I saw as an intern provided me with an incentive to study this dis-
ease in more detail in textbooks and journals. Somehow, it made more
sense to tie my knowledge to individual patients, so that I had a mem-
ory bank full of faces that I could link to a given disease. For those
who continue the clinical care of patients, I believe that this model
will always serve us well. Since the nuances of each patient differ
from the one before, we can review the available information on the
subject and get a sense of the variety and spectrum of a given disease.
The interaction with patients can never be totally replaced by biblio-
graphic searches.
When I encounter a puzzling patient and the available publica-
tions do not help, I discuss the patient with my colleagues in the car-
diology division, where the combined experience of the group is
extremely helpful in reaching a diagnosis, or at least in pointing me in
the appropriate direction. The willingness of colleagues in all special-
ties to share information with one another is a particular advantage in
our collective quest for continuing medical education.
There was a time in my training when I was content to confine my
learning primarily to the revered textbooks of the day. Although I un-
derstood that, at publication, they were almost a year out of date, their
authority and the fact that many aspects in medicine do not change
gave me comfort that this was the best way to learn about a given dis-
ease. This model has served us all well. The reliance on textbooks
prompted me to edit a three-volume loose-leaf textbook of cardiology,
which, although updated 10 percent each year, was still out of date
because of the time lag in publication and the rapid advance in

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medical knowledge. I no longer buy textbooks, but physicians still

flock to “Publisher’s Row,” and selling books continues to be a brisk
business.
Special opportunities to learn about new medical information
have come through editing journals. As a previous Associate Editor of
the American Journal of Physiology, the Journal of Applied Physiol-
ogy, and Circulation, and currently as Editor-in-chief of the Journal
of the American College of Cardiology, I have had a unique opportu-
nity to review the world’s latest medical information before it is pub-
lished. This opportunity is exciting and stimulating because new
reports that are going to make a major impact in the cardiovascular
community leap out at me in advance. By reading the articles submit-
ted to a journal, including the editorials and review articles, an editor
can maintain an excellent perspective on the current state of medical
knowledge. For me, this has been an effective form of continuing
medical education.
More recently, I have preferentially used an electronic CD-ROM
product called UpToDate, which covers internal medicine, including
cardiology. The physicians on staff and the editors of UpToDate (in-
cluding me) scan the world’s new publications and important presen-
tations from national and international meetings for those deemed
worthy of inclusion on a future UpToDate CD. UpToDate is organized
to help the clinician answer specific questions about patients. Each
section is written by an expert author, then updated by the full-time
physicians employed by UpToDate. Since the CD-ROM is released
three times a year, there is a slight lag in information, but this is re-
duced considerably by the inclusion of items in prepublication form,
such as reports that appear on journal Web sites or are presented at
medical meetings.
For a scientific search of the world’s medical publications, I pri-
marily use PubMed, which quickly sorts out the important articles I
need to review and has been extremely helpful for reviews. Although
I have occasionally consulted other Web sites for appropriate up-to-
date information, the two sources just cited are my current primary

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supply of information in cardiology. With the continuing explosion of

information technology, even better ways of keeping up-to-date may
be available in the future. The volume of information, however, is
so daunting that we will have to be selective if we are not to drown in
an ocean of information when we are really looking for a river of
knowledge.
One of the current challenges of journals is the transition to elec-
tronic media. Most journals now have full contents of past articles on
a Web site usually reserved for subscribers. The NIH proposal for
PubMed Central to permit free access will probably be only gradually
embraced by publishers of the largest and most popular journals. As
one projects forward, however, a large database such as PubMed Cen-
tral may well be the wave of the future for obtaining data from scien-
tific journals. Concerns remain about the extent of peer review for
some submissions and the impact on professional societies.
One of the challenges of the future, of course, will be to determine
how continuing medical education (CME) will be offered. Large clin-
ical meetings in cardiology, such as the American Heart Association
(AHA) and American College of Cardiology (ACC) meetings, remain
popular. The attraction of CME meetings with an outstanding faculty
at desirable resort sites (and with family members present) cannot be
duplicated on the Internet. It may well be that two types of CME will
emerge: traditional CME courses attended for the foregoing reasons,
and more specific CME on the Internet, for review of specific topics
as well as for collection of appropriate credit hours. As one active in
CME over the years, however, I consider the interactive phase of any
CME course to be most important. The ability to ask questions of a
speaker or a panel and to hear the direct responses is extremely help-
ful to the practicing clinician. Thus, an attempt must be made to
maintain the interactive component of traditional CME if the Internet
is to replace it partly or wholly.
Whatever the course of medical education in the future, it will
work only if we maintain a passion for learning. Medicine must re-
main our beloved profession in a way that is stimulating and exciting

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throughout our professional lives. I remember Dr. John Sampson, past

President of the American Heart Association, attending Grand
Rounds lectures at the University of California, San Francisco, in his
nineties, when he was no longer practicing and after he had sustained
a minor stroke. He was still taking notes, reviewing them and asking
questions as if he were a new house officer. This insatiable desire to
learn is the key ingredient of a lifelong pursuit of medical knowledge
and may, in fact, be far more important than the specific method used
to satisfy that need. I saw this passion in my father, who had been a
physics professor at the University of Utah. At age 99, two days before
his death, we had a conversation about advances in astrophysics,
based on his journal reading. Fortunately, I believe I have inherited
his “desire for learning” genes.

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 REFLECTIONS / NORTON J. GREENBERGER, M.D.

R E F L E C T I O N S
...

One reason we academicians like our work is that we

learn a lot by osmosis. We go to conferences, and we
seek out people who have the answers to our questions.
So my advice to young physicians is to surround your-
self with people who can educate you.
N ORTON J. G REENBERGER , M.D.

Dr. Norton Greenberger received his M.D. degree from Case West-
ern Reserve University and his residency training in gastroenterology
at University Hospital, Cleveland, Ohio, and Massachusetts General
Hospital, Boston. He has served as President of the Central Society
for Clinical Research, the American Gastroenterological Association,
the Association of Professors of Medicine, and the American College
of Physicians, and as Secretary-treasurer of the American Board of
Internal Medicine. Past editorships have included The Journal of
Laboratory and Clinical Medicine, and the Year Book of Medicine,
and the Year Book of Digestive Diseases.

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 Reading:
Finding the Time and Place

Norton J. Greenberger, M.D.

Clinical Professor of Medicine
Harvard Medical School
Senior Physician
Brigham and Women’s Hospital
Boston, Massachusetts

P hysicians must be lifelong learners. When you consider four

years of undergraduate education, four years of medical school,
three to four years of residency training, three years of fellowship
training, and a medical career of 35 years or more, it generally
amounts to a 50-year medical experience. With the explosion in new
biomedical information, physicians must continually discard irrele-
vant or obsolete information and assimilate new biomedical knowl-
edge into their daily activities. I am reminded of a statement by C.
Sidney Burwell, a noted Harvard cardiologist, who, in addressing the
Harvard Medical School graduating class of 1956, said: “My students
are dismayed when I say to them, ‘Half of what you are taught as med-
ical students will in 10 years have been shown to be wrong. And the
trouble is, none of your teachers knows which half.’”1 This admoni-
tion is now quoted each year in many medical schools.

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Early in their careers, medical students, residents, and physi-

cians need to develop a method for continued acquisition of reliable
information that they can apply in practice. Some physicians are vi-
sual learners, some auditory learners, and some learn by both ap-
proaches. Many medical students and residents, however, have not
learned how to manage their time for reading and studying. In this re-
gard, I distribute my reading rather than concentrate it. With a list of
disorders before me that I want to read about and with available text-
books, journal articles, and selected references from my reprint file,
as well as other resource material, I will sit down to seek the answers.
My extensive reprint collection of more than 40,000 articles orga-
nized by disease system has now been largely superseded by
computer-generated information, and not a day goes by that I do not
use the computer to access information related to subjects I am inter-
ested in. I also have about 40 years of bound journals covering the
walls of a very large office. I often refer students, house staff, and fac-
ulty to classic articles written 20 to 30 years ago and not always read-
ily available from computer sources.
The average student’s attention span in the library is about two
minutes. I read in my den, where I know I will not be distracted. I
read titles, scan abstracts, tables, graphs, and diagrams and read the
introduction and first and last paragraphs of the discussion. Then I
ask myself what the message is in one sentence. If an article is poorly
written and I cannot understand it, I am not going to waste my time
with it; it impairs my efficiency.
When I finish reading an article, I often construct mnemonics and
try to reproduce the material that I want to remember. Periodically, I
also see if I can recall that information, and when I am with students
or house staff on rounds, I go through the material for teaching pur-
poses to reinforce my retention. Another trick is to talk about what
you have read. At the end of Morning Report, I will ask anyone who
may have read something interesting the night before to summarize
that reading material.

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 REFLECTIONS / NORTON J. GREENBERGER, M.D.

If we are on rounds and a question comes up that I cannot answer,

I will often assign someone to look up the answer and give a five-
minute report with references. When we have coffee during rounds, I
solicit a list of topics the house staff and students want me to discuss,
and when I finish rounds, they generate additional subjects. Such ac-
tivities stimulate me to read on a given subject and provide me an op-
portunity to recall information that I may not have used for some time.

REFERENCE
1. Burwell CS. Quoted in Pickering GW. The purpose of med-
ical education. BMJ. 1956;2:113–116.

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 REFLECTIONS / ROBERT J. LUCHI, M.D.

R E F L E C T I O N S
...

I can think of no avocation that would provide the emo-

tional and intellectual gratification that the practice of
medicine does.
R OBERT J. L UCHI , M.D.

The son of a physician, Dr. Robert J. Luchi graduated from the

University of Pennsylvania School of Medicine magna cum laude
and rose to Associate Professor, Associate Director of the Depart-
ment of Medicine Clinical Research Center, and Professor of Inter-
nal Medicine, at the University of Iowa. He arrived at Baylor
College of Medicine in Houston in 1970 as Professor and Vice
Chairman of Medicine and Chief at the Houston Veterans Affairs
(VA) Medical Center. After Dr. Luchi completed a sabbatical with
Professor Exton-Smith in London, England, in 1976, he became the
Founding Director of a new program in aging at Baylor and the VA

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Hospital with exceptional resources for the study of the mecha-

nisms of aging.
Dr. Luchi was the first to discover changes in cardiac myosin in
health and disease and the first to describe diastolic dysfunction as
a cause of heart failure in elderly people. He has published original
research articles and book chapters on geriatric topics. Dr. Luchi
has received numerous awards; most recently, the John A. Hartford,
Inc. Foundation of New York named Baylor College of Medicine’s
Huffington Center on Aging as a “Center of Excellence.” For his
many accomplishments, Dr. Luchi is listed in The Best Doctors in
America.

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 Retired Physicians:
Preserving the Passion for Medicine

Robert J. Luchi, M.D.

Professor and Chief, Section of Geriatrics, Department of Medicine
Founding Director, Huffington Center on Aging
Baylor College of Medicine
Houston, Texas

O f overriding import in maintaining the passion for medicine is the

desire to be useful by contributing to the welfare of others. The
passion for excellence is reinforced by my daily practice. As I ap-
proach retirement, I must consider how I can sustain the passion for
medicine. I can imagine a retirement in which I do not practice med-
icine in some form or another, but this image is fragmentary and fleet-
ing. I can think of no avocation that would provide the emotional and
intellectual gratification that the practice of medicine does.
In full retirement, I will find it harder to keep up. Why keep up if
one is not going to practice or teach? One reason is simple: intellec-
tual curiosity. All of our adult lives we have been interested in learn-
ing: in school, being taught; in educational institutions, teaching.
Learning for the sake of learning becomes part of our being, an in-
grained habit hard to break even when the only raison d’etre is one’s
own intellectual stimulation. Being a physician is such an integral

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part of who we are that it becomes impossible, while health remains,

to forgo drinking at the fount of medical knowledge.
But there may be other reasons. Can one fully retire from the
practice of medicine? Family and friends, from habit or for more solid
reasons, look to the retired physician for advice, direction, second
opinions, and the like. What if one were to have only out-of-date
information to offer? Most of us value our medical integrity too much
to let that happen.
With reduced access to the constant stimulation of challenges
arising from daily contact with patients and students, it becomes more
difficult to stay on top of things. Certainly, one can attend confer-
ences, chat with colleagues, read the newspapers, and listen to the
broadcast media announcing the latest medical news fed to them by
medical journals or medical institutions. E-mail and the Internet offer
other sources of medical and scientific information. Accessing infor-
mation is now easy for those with even a modicum of computer liter-
acy; all that is required is some skill in typing, use of the mouse to
point and click, and some basic knowledge of how to use a Web
browser. Although some information on the Internet is unreliable or
unproved, some sources of current medical information, in varying
detail, are accurate. Images for slide presentations, difficult to find
elsewhere, can be downloaded from some excellent Web sites.
For physicians in retirement, the Internet offers an opportunity to
remain productive and current in medical knowledge and practice.
New and existing Internet sites continue to seek experts, and the
knowledge and skills that physicians in retirement can offer will con-
tinue to be in demand, affording the retired physician an opportunity
to continue to contribute to the medical and lay communities with the
unique perspective long practice offers. And the continuing demand
for the retired physician’s expertise may well keep the passion for
medicine alive when the formal practice of medicine ceases.

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 REFLECTIONS / ANDREW I. SCHAFER, M.D.

R E F L E C T I O N S
...
Dr. Andrew Schafer received his M.D. degree from the University
of Pennsylvania School of Medicine and his internship and resi-
dency in internal medicine at the University of Chicago Hospital
and Clinics. He also had clinical and research fellowships in hema-
tology at Harvard Medical School and the Brigham and Women’s
Hospital in Boston. Dr. Schafer joined the faculty of Harvard Med-
ical School in 1979 and remained there as Associate Professor of
Medicine until 1989, when he became Chief of Medicine at the
Houston Veterans Affairs (VA) Medical Center.
Dr. Schafer’s clinical and research expertise is in thrombosis,
hemostasis, coagulation, platelet function, and vascular cell biol-
ogy. The author of more than 180 original articles, he has edited or
coedited five textbooks. He is currently the principal investigator of
two National Institutes of Health (NIH) research grants in platelet
and vascular cell biology. He has served on NIH and VA research
study sections in hematology. A member of the executive committee
of the American Heart Association, he is a former Secretary-
treasurer of the American Society for Clinical Investigation, is cur-
rently Treasurer of the American Society of Hematology, and is a
member of the Association of American Physicians. He is on the
editorial board of several major journals.

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 Integrating the Art
and Science of Medicine

Andrew I. Schafer, M.D.

The Bob and Vivian Smith Chairman of Medicine
Baylor College of Medicine
Houston, Texas

T wenty-five years after my own graduation from medical school, I

now see my son as a first-year medical student. Some colleagues
have challenged my unwillingness to discourage him from pursuing
this career path during such an unsettling and precarious time. I
argue that medicine endures as the most ennobling, spiritually re-
warding, and intellectually exhilarating calling imaginable. Yet there
is no question that we are now in the midst of perhaps the most turbu-
lent period in the history of American medicine. It is impossible to
predict the shape of medicine in general, and academic medicine in
particular, that my son will encounter in mid-career. Undoubtedly, it
will be radically different and perhaps barely recognizable to those of
previous generations.
The recent explosion of new knowledge in molecular biology and
genetics poses an intimidating challenge for today’s physicians to
keep up with the scientific basis of medicine. At the same time, the

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even more recent dramatic reorganization of medical practice, the

chaos of free-market healthcare economics, and the dizzying pace of
innovations in information technology have placed enormous new
pressures on the already overburdened time of clinicians. Indeed, I
have great concern that we are witnessing a rapidly growing schism
between clinical practice and basic biomedical research. Practition-
ers emerging from this generation appear to be abandoning much of
the scientific foundation of clinical medicine, and, conversely,
physician-investigators are losing sight of the clinical relevance and
application of their research. To erect durable bridges between med-
ical practice and medical research and thereby prevent the diver-
gence of these two groups is, I believe, one of the greatest challenges
of today’s leaders of academic medicine.
There is little opportunity during the workday to acquire any new
knowledge except by anecdotal word of mouth. Rigorous organization
of my time therefore assumes paramount importance. I continue to set
aside about two hours per night to read medical and scientific publi-
cations. I try to do this during “prime time” in the evenings and to rel-
egate to the end of the evening, by which time I am virtually
decerebrate, the task of sorting through the pile of memos and circu-
lars that invariably accumulate during the day.
My continuing education in the evenings depends on a variety of
sources. I subscribe to several journals that are delivered, by intent,
to my home; these range from clinical journals, such as The New
England Journal of Medicine and The American Journal of Medicine,
to basic science journals, such as Science and Nature. Articles in
these must be reviewed and selectively perused on the day of deliv-
ery; once placed on my desk, they almost invariably go unread. Dur-
ing the day, I jot down reminders on an index card of “things to look
up” at night; these are triggered by questions that arise in my daily
clinical activities, especially those posed by trainees on rounds, as
well as problems encountered in my research laboratory, and even
challenging issues in healthcare administration. I spend my evening

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“education time” pursuing these questions and problems. In some

cases, I use my home library, but increasingly I rely on computer bib-
liographic searches, now a more convenient and up-to-date way of
surveying publications and sometimes even of reading entire articles.
Indeed, I now keep journals only for the past two to three years, and
my home library is beginning to suffer serious disuse atrophy.
Although I must ration my commitment to writing scientific or
clinical review articles, I continue to volunteer to do these selectively
and regularly. I write most of these myself, often as sole author, be-
cause they provide me with an unparalleled opportunity for continu-
ing medical education. To the chagrin of my family, writing articles
and books is generally assigned to weekends, when I have more unin-
terrupted time.
Although the revolution in information technology is transforming
the instruments of learning and scholarship in astonishing ways, con-
tinuing education remains uncompromisingly essential throughout
one’s career in medicine. I consider it an integral part of my job, not a
pastime. The increasing prominence of technology in medicine must
continue to be balanced with a deep understanding of its scientific
underpinnings. The integration of the art and science of medicine,
with its enduring allure, is a legacy I wish my son to inherit.

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 3

Evidence-based Medicine

...
Evidence-based medicine is patient care based on a syn-
thesis of the most reliable scientific evidence available
and the physician’s own clinical experience and knowl-
edge of the individual patient under consideration.
P HIL R. M ANNING , M.D., AND L OIS D E B AKEY, P H .D.

T he basic principles of evidence-based medicine (EBM) link a

physician’s clinical experience with a systematic appraisal of
clinical evidence in medical publications. In the words of Ian
Mackay: “The report in 1992 by an Evidence-Based Working Group,1
in which the McMaster originators were well represented, was a major
impetus for evidence-based medicine. The report begins: ‘A new par-
adigm for medical practice is emerging. Evidence-based medicine
deemphasizes intuition, unsystematic clinical experience, and patho-
physiologic rationale . . . and stresses the examination of evidence
from clinical research.’ The paradigm was seen as lowering the value
of ‘authority’ (perhaps the authors meant ‘authoritarianism’), and the
‘final assumption’ was that ‘physicians whose practice is based on an
understanding of the underlying evidence will provide superior pa-
tient care.’ If a faculty member recommends a therapeutic plan that
has been handed down from one generation of physicians to another

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and the resident assigned to the case questions the basis or effec-
tiveness of that treatment, the resident may wish to perform a com-
puterized bibliographic search, find reliable articles on the subject,
discuss them with the faculty member, and proceed to outline an
action-plan based on the evidence found.
“What is the contemporary definition of evidence based-
medicine? Sackett and colleagues2 defined it as ‘the conscientious,
explicit and judicious use of current best evidence in making deci-
sions about the care of individual patients. The practice of evidence-
based medicine means integrating individual clinical expertise with
the best available external clinical evidence from systematic re-
search.’ Sackett emphasized that evidence-based medicine is not re-
stricted to randomized trials and meta-analyses, but also involves the
tracking of all the best external evidence with which to answer our
clinical questions, whether the accuracy of a diagnostic test or a
question about prognosis. The evidence needed may come from the
basic sciences, perhaps genetics or immunology. Whatever the case,
the idea of evidence-based medicine has proved so appealing that
centers have been established to study it, workshops convened to dis-
cuss it, and a journal launched to propagate it.”
John P. Geyman elaborates: “Evidence-based medicine is neither
a substitute for clinical experience and judgment nor a panacea for
the clinician’s need for knowledge. Many questions, perhaps most, in
daily clinical practice can never be studied by randomized clinical
trials. Further, as Paul Fischer recently observed, clinical guidelines
based on the highest quality evidence still cannot fully answer the
clinician’s need and responsibility to tailor the best possible care for
the individual patient. That process will always require informed
partnership decision-making, responsiveness to patient preferences,
accommodation for concurrent medical problems, and dealing with
ambiguity and uncertainty.3 Clinical experience remains an essential
springboard for clinical decision-making, but is enhanced when com-
bined with judgments based on critical review of the best available
evidence.” The McMaster group suggests that evidence-based medi-

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cine should be merged with excellent skills in history-taking, physi-

cal examination, and diagnosis and therapy.4
Ian Mackay believes that “Evidence-based medicine has cer-
tainly added a new dimension to empirical medical practice, but it
should complement, not replace, the conventional skills of the prac-
titioner. Experience-based and intuitive clinical acumen, the art of
medicine, is in part the result of a long apprenticeship traditionally
used by artisans, navigators, trackers, and others to acquire needed
skills. Such skills are required for the care of patients with different
stages and features of multiple diseases, with subtleties as infinite
as hands of bridge or moves in chess.” As an example, Mackay cited
a patient under his care, a 78-year-old man with rheumatic mitral
stenosis and mild cardiac failure who was being treated with war-
farin. In addition, the patient had advanced hemochromatosis and
possible autoimmune hepatitis and esophageal varices. Mackay
asks: “Should this patient have a liver biopsy? Should long-term ve-
nesection be instituted for the hemochromatosis? Should the patient
receive immunosuppression?” Since evidence-based medicine can-
not answer these questions, Mackay concluded that “Individually
acquired experience-based medicine and the developed algorithms
of evidence-based medicine should be practiced in unison, at least
until we have the clinical equivalents of the IBM ‘Deep Blue’ pro-
gram that can match, but not exceed, the skills of the Grand Masters
of chess.”
David Sackett and his colleagues at McMaster University and Ox-
ford deserve credit for developing systematic approaches to the prac-
tice of evidence-based medicine, but intellectuals have long known
about levels of quality in the information upon which we base deci-
sions. Sackett and coauthors traced the philosophic origins of evidence-
based medicine to the mid-19th century in Paris and earlier.4
Spinoza understood the importance of determining the quality of
information, cautioning that we must distinguish carefully the various
forms of knowledge and accept only the best. In the 17th century, he
identified levels of understanding, beginning with hearsay informa-

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tion (the date of your birth); vague experience (knowing that you are
mortal; oil feeds a flame, water extinguishes it); concluding one thing
from another (after realizing that an object looks smaller as the dis-
tance from it increases, we conclude that the moon above is larger
than it appears); and perceiving a thing from its essence alone (two
lines that are parallel to the same line will be parallel to each other).5
So far as we know, there were no randomized controlled studies in
Spinoza’s time, but conceptually it is important to understand the lim-
its and advantages of the several kinds of knowledge. No one would
contest that the best interest of the patient is served by use of the most
reliable evidence available.
“The interesting thing about evidence-based medicine,” in the
words of Jan Vleck, “is that many physicians think they have been
practicing EBM all along, so they either think EBM is nothing new
or they oppose it because they do not want to change what they are
comfortable with. It is actually easier to rely on local experts or
apply traditional treatment forever, even if such actions are not sup-
ported, or are even contradicted, by the actual evidence. Many
physicians find it difficult to change what they do or to challenge
the local experts with evidence. And, of course, convincing patients
that the evidence speaks to them is also a challenge. It does not
bother me greatly when patients reject the evidence, as long as I
have presented it clearly to them. There is always another day, at
least in a continuity practice.”
Despite some difficulties in the practice of evidence-based medi-
cine, the movement is making practitioners more aware of the need to
assess carefully the quality of evidence they use in patient care. Prac-
titioners and medical educators now realize that a systematic ap-
proach is necessary.
The classic McMaster approach emphasizes a framework of five
steps4:

• Convert information needs into answerable questions.

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• Track down, with maximum efficiency, the best evidence with

which to answer them (from the clinical examination, the diagnos-
tic laboratory, research evidence, or other sources).
• Critically appraise that evidence for its validity (closeness to the
truth) and usefulness (clinical applicability). (Also see pp. 121).
• Apply the results of this appraisal in clinical practice.
• Evaluate our performance.
David Slawson outlined his approach to assessing medical informa-
tion: “When physicians read journals, attend conferences, or consult
with colleagues, the goal is to spend the least time and energy finding
the best information. We are all busy with important aspects of life be-
sides medicine (family, friends, fun), yet we always want to do the best
possible for our patients. Useful information must have three attributes:
relevant to everyday practice, correct, and easy to obtain.
“Relevance focuses on our ultimate goal: finding information on
how to help our patients live long, functional, satisfying, pain- and
symptom-free lives. We have a plethora of information about disease:
etiology, prevalence, pathophysiology, and pharmacology. These
intermediate-level studies are crucial to medicine. We must understand
how a disease evolves before we can diagnose, treat, or prevent it. Little
of this information, however, tells how to obtain patient-oriented evi-
dence, which provides effective interventions, the ultimate goal of our
patients. Only in the past few years has this concept of real-world re-
search surfaced, a concept that focuses on interventions used in clini-
cal practice and their properly tested effects on outcomes.
“For example, an article about prostate cancer screening with the
prostate-specific antigen (PSA) assay may report the sensitivity, speci-
ficity, and predictive values for identifying men with prostate cancer.
Another article may report survival rates for different treatments and
stages of prostate cancer. Neither tells us, however, what we and our pa-
tients really want to know: whether they will live a longer, healthier,

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happier life as a result of identifying the cancer. Only a randomized

trial evaluating the overall effect of early detection on the mortality and
morbidity of prostate cancer will provide that information.
“Validity defines to what extent the knowledge gained represents
the ‘truth.’ Well-designed clinical trials that minimize bias are more
likely to provide valid conclusions. Validity assessments of research
articles are best performed by application of the excellent guides for
critical reading published by the Evidence-based Medicine Working
Group. Although this task can be delegated to an ‘expert,’ each of us
must accept responsibility for critically assessing validity. We should
not accept evidence at face value simply because it is published in a
well-known journal or is recommended by a specialist.
“Work or time spent is the negative attribute that we must con-
sider when searching for useful information. An inordinate amount of
time to establish the validity or relevance of information may be be-
yond the reach of the overworked physician. On the other hand, a cur-
sory approach may not yield totally valid or relevant information.
From the physician’s point of view, the best solution is to find highly
valuable and pertinent information with minimal effort.” A partial so-
lution is to use sources that are based entirely or almost entirely on
evidence-based medicine articles, such as the Cochrane Library col-
lection and Clinical Evidence (published by the BMJ Publishing
Group) and the ACP Journal Club. When a physician encounters a
difficult search problem, the help of a medical librarian may be es-
sential, both as a time-saver and insurance of a complete search.
Slawson continued: “Using relevance as the primary screen for
validity results in the least unnecessary effort. Answering ‘yes’ to the
following three questions will help identify relevant information
requiring validation: (1) Is the problem common in my practice?
(2) Will this information have a direct bearing on the health of my
patients? (3) If valid, will this information require me to change my
current practice? When all three answers are ‘Yes,’ we call the study
a POEM because it is Patient-Oriented Evidence that Matters. For

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research articles, the conclusion section of the abstract will usually

give all the information necessary to answer these three questions.
“We must also consider our goals for obtaining new information or
reviewing previously learned information. Different goals require dif-
ferent approaches. We can (1) search for the answer to a question re-
lated to a specific patient, (2) forage to stay informed about new
developments in our field, (3) keep up with a specific area of interest,
or (4) retrace our path by reviewing previously learned information to
compare it to new information. But gathering and evaluating patient-
oriented information is not enough; the final step is to incorporate this
new knowledge into medical practice. We may not have all the an-
swers, but we need to find and verify those available. For the rest, we
need to start asking the right questions.”
David Slawson recommends two specific tools to help physicians
efficiently identify information that is highly relevant and valid: “Clini-
cians need a first-alert method—a POEM bulletin board—for relevant
new information as it becomes available. Resources (newsletters, Web
sites, continuing education, and others) used by clinicians to update
their knowledge should carefully filter out preliminary or unverified in-
formation to facilitate keeping-up. Clinicians can purchase POEMs for
Primary Care, a database of 20–25 POEMs gleaned from more than
100 primary-care articles and delivered daily in an e-mail update
(MedicalInfoPointer: http://www.medicalinforetriever.com) or as a
monthly paper supplement to The Journal of Family Practice,
Evidence-Based Practice (www.jfponline.com). Clinicians also need a
way of rapidly retrieving the information to which they have been
alerted but that has not yet been cemented into their minds. Computer-
based resources, especially handheld portable devices, can provide in-
formation in less than 30 seconds. To be lifelong learners, physicians
have to use tools that help them forage in the jungle of information.”
Ian Mackay described a taxonomy of evidence developed by the
National Health and Medical Research Council (NHMRC) of Aus-
tralia: “Benchmarks for current best practice will vary according to

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TABLE 1
Taxonomy of Evidence (Revised 1998)

I From a systematic review of all relevant randomized controlled

trials
II From at least one properly designed randomized controlled trial
III-1 From well-designed pseudo-randomized controlled trials (alternate
allocation or some other method)
III-2 From comparative studies with concurrent controls and allocation
not randomized (cohort studies), case-control studies, or interrupted
time series with a control group
III-3 From comparative studies with historical control, two or more
single-arm studies, or interrupted time series without a parallel
control group
IV From case series, either post-test or pre-test and post-test

Source: National Health and Medical Research Council of Australia.

the circumstances in which evidence-based medicine might be ap-

plied. The taxonomy is based on earlier guidelines (Table 1).6 Thus,
when an evidence-based decision is recorded in a medical record, it
can be coded according to the quality of the evidence available, as
shown in Table 1 (modified from NHMRC’s original taxonomy).”6
Gary Kelsberg uses his desktop computer to search for answers to
clinical problems, such as “Should Type 2 diabetic patients start taking
an angiotensin converting enzyme (ACE) inhibitor before there is labo-
ratory evidence of microproteinuria?” or “Are antibiotics likely to ben-
efit a smoker with bronchitis more than the minimal or no-benefit seen
in nonsmoking patients?” One of several databases that allow rapid
searching is TRIP (Translating Research Into Practice, http://www.trip-
database. com). Kelsberg explains that “This is a metasite, containing a
search engine to comb Patient Oriented Evidence that Matters
(POEMs) from numerous sources (ACP Journal Club, Bandolier,
Evidence-Based Practice, The Journal of Family Practice, POEMs).

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More than 10,000 POEMs are available.” While he is in clinic, he

leaves his computer up and running nearby, so he can usually step out
of the room and look something up within two to three minutes.
Kelsberg describes other information sources: “InfoRetriever is
proprietary software for the desktop or handheld Windows Pocket PC™
format. It is searchable and has about 800 POEMs, along with drug in-
formation and lots of useful clinical calculators, guidelines, and handy
tools for prediction. It is updated quarterly. Another is the Cochrane Li-
brary, available by subscription on CD ROM and the Internet (or free if
you have library privileges at a nearby medical school). It has excellent
clinical trials data, analyzed by careful methods. InfoRetriever also
contains all of the abstracts from the Cochrane Database, updated quar-
terly, and allows searching through multiple databases to obtain the
highest quality answers to patient care questions. Failing these, several
print sources are incorporating evidence in their format, for example,
the American College of Obstetrics and Gynecology Guidelines now
contain references and ratings about the strength or quality of their rec-
ommendations.”
Gary Kelsberg and Jan Vleck believe that framing a searchable
and answerable question to find the best solution to a medical prob-
lem typically requires specifying four elements: population, interven-
tion, comparison intervention, and outcome:

• Population. Who is the patient, or how can the patient be de-

scribed as a member of a group of similar people? Because most
research is conducted on groups of subjects, you will be looking
for research in which the study groups included people like your
individual patient. Example: To research a question involving an
asymptomatic, 75-year-old woman with blood pressure of 160/90
mm Hg, you would look for studies examining groups of elderly
female hypertensives.
• Intervention. What are you or your patient contemplating doing
about the clinical situation? Example: What tests or treatments
might apply to your elderly female patient with hypertension?

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• Comparison intervention. There may be a choice of interventions.

How does the approach you are considering compare with other
intervention choices, or no intervention, in terms of patient out-
comes, complications, and costs? You might want to look at out-
comes comparing diuretic therapy versus placebo in elderly
women with hypertension.

• Outcomes. What are the projected outcome differences? The out-

comes can be as stark as death, or more subtle like net economic
impact. Gary Kelsberg emphasizes: “Remember, if you are going
to find evidence, the outcome must be one that can be studied,
which in most cases means that it has to be quantifiable. Many
quantifiable outcomes are not patient-oriented evidence that mat-
ters, so the answers you find may be non-answers. (Does your pa-
tient really care about a statistically significant 4 percent
improvement in Forced Expiratory Volume 1 [FEV1]?) Be aware
also that you and your patient may not value particular outcomes
in the same way, so even the best evidence can be thrown out by
the court of patient opinion.”

At the very least, evidence-based medicine caused most medical

schools to incorporate its principles into the medical curriculum, en-
couraged medical journals to adopt structured formats of abstracts, and
heightened the interest of practicing physicians in obtaining the best
information available. The definitive basic principles of evidence-
based medicine include integrating the best external clinical evidence
from systematic research into individual clinical experience.
John Geyman recommends the following concrete steps to physi-
cians desiring to incorporate evidence-based medicine into their own
continuing medical education and clinical practice7:

• Subscribe to a foraging source of new information as it becomes

available, screening for both relevance and validity. Consider

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InfoRetriever (http://www.infopoems.com) or ACP Journal Club

(1-800-523-1546).
• Increase reading of predigested information within your specialty
or interest.
• Meet with a librarian at your nearest health sciences library to
arrange a tutorial in current search tools, such as PubMed.
• Establish bookmarked Web sites on your office and/or home com-
puter for useful sources of evidence-based abstracts and reports.
• Seek consultants who value and use evidence-based approaches
in their practices.
• Reorient your CME to evidence-based courses as they become
more available.

David Slawson points out that soon CME will be based on point-
of-care learning: “You will obtain CME credit while using handheld
portable databases, answering clinical questions as you need the in-
formation. This will become possible with embedded files in the soft-
ware that keep track of usage and can then be sent once a year to
specialty organizations to obtain CME credit.
“Gathering and evaluating patient-oriented information is not
enough; the final step is to incorporate this new knowledge into med-
ical practice. We may not have all the answers, but we need to find
and verify those available. For the rest, we need to start asking the
right questions.”
Most articles written about evidence-based medicine emphasize se-
lecting the best external information sources. The methods of applying
clinical experience, even though extremely important, have received
far less attention. All physicians should study and document their clin-
ical experience by knowing their practice mix in order to direct their
study, keeping a record of what they learn from puzzling patients and
recording outcomes and procedures they perform (see Chapter 10).

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REFERENCES
1. Evidence-based Medicine Working Group. Evidence-based
medicine. A new approach to teaching the practice of medi-
cine. JAMA. 1992;268:2420–2425.
2. Sackett DL, Gray JAM, Haynes RB, Richardson WS.
Evidence-based medicine: what it is and what it isn’t. BMJ.
1996;312:71–72.
3. Fischer PM. Evidentiary medicine lacks humility. J Fam
Pract. 1999;48:345–346.
4. Sackett DL, Richardson WS, Rosenberg W, Haynes RB.
Evidence-based Medicine: How to Practice and Teach EBM.
London: Churchill Livingstone; 1997.
5. Spinoza, B de. Spinoza’s Ethics and “De Intellectus Emenda-
tione.” Boyle A, trans. New York: E. P. Dutton; 1910:
232–233.
6. National Health and Medical Research Council. A Guide to
the Development, Implementation and Evaluation of Clinical
Practice Guidelines. Canberra, Australia Capitol Territory:
NHMRC; 1999:56.
7. Geyman JP. Evidence-based medicine in primary care: an
overview. J Am Board Fam Pract. 1998;11:46–56.

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R E F L E C T I O N S
...

For many health problems, sound evidence from

research is still thin or even nonexistent.
R. B RIAN H AYNES , M.D., P H .D.

D r. Brian Haynes received his M.D. from the University of

Alberta, his Ph.D. from McMaster University, and his residency
training at Toronto General Hospital, all in Canada. He completed
his medical training at St. Thomas Hospital School of Medicine in
London. He has had a career-long interest in the methodology of
healthcare research and in the validation, distillation, dissemina-
tion, and application of healthcare knowledge. Of particular inter-
est are information problems that confront healthcare practitioners
and their potential solutions from synoptic writing and information
technology. Dr. Haynes led the development of the format for
“structured” abstracts, now used by most medical journals. He is a

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founding member of the Working Group of Evidence-Based Medi-

cine, recognized as one of the most influential ideas of 2001. The
Founding Editor for a number of evidence-based journals, includ-
ing ACP Journal Club, Evidence-Based Medicine, Evidence-Based
Mental Health, and Evidence-Based Nursing, he was also the
Founding Director of the Canadian Cochrane Network and Centre.
All these activities have been stimulated by, and have contributed
to, his passion for lifelong learning.

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 Learning from Healthcare
Research: Evidence-based Medicine

R. Brian Haynes, M.D., Ph.D.

Professor of Clinical Epidemiology and Medicine
Chair, Department of Clinical Epidemiology and Biostatistics
McMaster University Faculty of Health Sciences
Hamilton, Ontario, Canada

A lthough I was born and reared in Alberta, Canada, I must have

had some ancestral roots in Missouri (presumably from United
Empire Loyalist times), judging by my compulsion to ask people to
show me the evidence on which their pronouncements are based.
Such insistence has gotten me into trouble from time to time, notably
in my second year of medical school in 1968. My medical school
class dubbed that year “trial by lecture,” a mind-and-derriere-
numbing initiation rite that we had to endure if we were to be found fit
for the medical fraternity.
In one lecture on Freud’s theories, which mercifully ended be-
fore the bell rang, the lecturer asked if there were any questions. I
asked what the evidence was that Freud’s theories were true. The
lecturer broke from his teaching role and admitted that he did not
know of any such evidence and did not believe that the theories
were valid. He indicated that he had been assigned by the Depart-

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ment of Psychiatry Chairman, a Freudian, to give the lecture. I was

dismayed, wondering how much of my medical education to date
was similarly based. This revelation and other, if less apocryphal,
experiences led me to resolve to combine research with clinical
practice. I tried working with a professor in animal research during
the summers, but this seemed to be a rather indirect route to learn-
ing how human beings and disease interact and what might be done
to alter the balance in favor of humans.
I interned at Toronto General Hospital, thinking that the “flagship
of the Canadian hospital fleet” might be floating higher in the eviden-
tial sea of healthcare. Although there were many good basic scientists
there, more than a few would take offense if asked for the evidence
supporting their assertions about clinical practice. I realized that I
was not going to get what I needed from them and concluded that I
would have to study research methods to become a better clinician.
Fortuitously, Jack Laidlaw, then Director of the Institute of Clinical
Sciences at the University of Toronto (whose favorite question was
“What’s the evidence for that?”), invited David Sackett from the
fledgling McMaster University Faculty of Health Sciences to speak
on “Is Healthcare Researchable?” I believe that I was the only house
officer attendee, the other attendees having been in epidemiology. I
jumped ship at the end of my internship and went to McMaster to
study with Sackett and his then small Department of Clinical Epi-
demiology and Biostatistics. What an experience! In addition to Sack-
ett, I learned at the feet of Alvan Feinstein and met Archie
Cochrane—the Canadian, American, and British parents of clinical
epidemiology.
I had intended to stay a year at McMaster before returning to clin-
ical training, but stayed three, after which I returned to Toronto, then
went to England to complete my training in internal medicine. I found
that I could apply much of my training in clinical epidemiology to
asking “the right questions” in clinical practice, but the amount of
strong research evidence for clinical practice was discouraging. (How
times have changed!)

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C R I T I C A L A P P R A I S A L O F M E D I C A L P U B L I C AT I O N S
In 1978, led by Sackett, a group of us organized a series of sessions
for residents on how to appraise medical publications. We knew that
we were onto something when the attending staff began asking for
the sessions (motivated, they said, by the impertinent questions that
the house staff was asking on rounds). They wanted their sessions
separated from the residents’ sessions so as to avoid revealing their
ignorance to the residents. To support these sessions, we developed
a series of articles that were published in the Canadian Medical As-
sociation Journal on how to interpret studies on the etiology, diag-
nosis, prognosis, treatment, and economics of health problems. This
led to a textbook on clinical epidemiology, an annual international
workshop on how to teach critical appraisal, and invitations to teach
elsewhere.
Participants seemed to enjoy the curriculum and indicated that
they felt good about mastering the concepts, which they believed
would keep them up to date in their clinical work. But we soon real-
ized that even if we could teach these principles and even if some
people enjoyed learning them, the volume of publications was far too
massive for any practitioner to deal with. It took too much time to de-
termine the best evidence for a given problem. No wonder physicians
seemed more inclined to “talk the talk” of critical appraisal than to
“walk the walk.” Indeed, we ourselves had difficulty making time to
find and appraise articles in detail amid the pressure of clinical care.
We felt that we were making the approach too academic. Further,
we needed to move the focus from reading and evaluating publica-
tions to applying their lessons directly to patient care. We therefore
sought to simplify our critical appraisal and to develop resources that
facilitated finding sound evidence as it was published and, more am-
bitiously, resources that provided “current best evidence” for any
clinical problem.
To begin the work on resources, we developed a proposal that we
took to Ed Huth, then Editor of the Annals of Internal Medicine and a
devotee of critical appraisal. The proposal called for brief critiques of

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key articles in the Annals so that readers would not have to do the cri-
tiques themselves. When the proposal was presented to the Annals
Editorial Board, the members split along generational lines: the
younger Board members were keen, but the older ones feared that no
author would submit articles to the Annals if they were going to be
criticized in public.
This led to a second proposal for authors, themselves, to prepare
more informative “structured” abstracts for their articles, providing
the key details needed for critical appraisal, including the Objective
of the study, Design, Participants, and Setting; the details of any In-
tervention; the key Results; and only those Conclusions that were di-
rectly supported by the data. This proposal was eventually accepted
by the Annals,1 supported by Stephen Lock of the British Medical
Journal, and later adopted by many other clinical journals.
Although structured abstracts provide a means for journal readers
to discern studies of relevance and value more readily for their clini-
cal practice, they do not solve the basic problem of medical publica-
tions: a small number of important studies (especially from the
perspective of any one practitioner) thinly spread among a large num-
ber of journals. To overcome this needle-in-a-haystack problem, we
developed a proposal for a new breed of derivative journal, to include
summaries of articles selected from a large number of full-text med-
ical journals according to explicit principles (an abbreviated set of
those developed for critical appraisal of publications), presented in
abstracts independently prepared (by research staff and clinical epi-
demiologists) and critiqued (by a clinical expert with at least a basic
understanding of applied clinical research methods). We took this
proposal to the American College of Physicians, which accepted it, a
decision that led to the bimonthly publication for internists, ACP
Journal Club. The process of selecting only articles that met criteria
for scientific merit and direct clinical relevance clearly demonstrated
the myth of information overload: only about one article for every two
issues of even the very best journals made the grade. The real prob-

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lem is “misinformation overload”: burying evidence that practitioners

need in material inadequately tested for clinical practice but often
glittering as if it were relevant.

C R I T I C A L A P P R A I S A L O F M E D I C A L P U B L I C AT I O N S
BECOMES EVIDENCE-BASED MEDICINE DEFINITION
We needed a new term for our ultimate goal, that is, the application of
healthcare research evidence at the bedside and in the clinic. Gordon
Guyatt coined the term “evidence-based medicine.” We discussed
this and various alternatives with colleagues, including some rather
testy basic scientists who thought the term denigrated their contribu-
tions to science (animal and preliminary clinical research being
rather low in our hierarchy of “clinically relevant” evidence). The
concept was publicized in articles in the ACP Journal Club2 and The
Journal of the American Medical Association.3 This term certainly at-
tracted attention, both favorable and unfavorable, and still does. For
better or worse, the term has spread around the world, with adap-
tations for other professions (evidence-based nursing, dentistry,
pharmacy), health administration (evidence-based healthcare), and
healthy policy (evidence-based policy). In at least some ways, the
term is unfortunate. “Evidence,” for example, was intended to be
used narrowly to mean findings from healthcare research, but those
new to the term are rightly confused when they interpret it to mean all
kinds of evidence (including that from the patient, the laboratory, and
basic research). Further, the term does not translate well into some
languages; in French, for example, the term means “self-evident,” the
opposite of “based on evidence.”
To clarify the concept and spread the word, advocates published a
new series of articles on applying results of healthcare research to
practice in The Journal of the American Medical Association begin-
ning in 1993,4 as well as in numerous books, beginning with one by
Sackett and colleagues.5

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New derivative periodicals have sprung up to help clinicians

practicing in various disciplines find sound evidence, including
Evidence-Based Medicine, Evidence-Based Mental Health, Evidence-
Based Cardiovascular Medicine, and Evidence-Based Nursing. These
journals are based on a systematic review of more than 100 clinical
journals, a process that weeds out about 98 percent of medical publi-
cations. Further, resources to help clinicians find current best evi-
dence when the need arises have now become available, including
Best Evidence and the Cochrane Library, which provides electronic
access to worldwide, systematic summaries and dissemination of all
trials of healthcare interventions. An addition to this panoply of
evidence-based resources, with promise of becoming the best, is
Clinical Evidence from the BMJ Publishing Group. This regularly up-
dated publication summarizes the best evidence for treatment of a
widening array of clinical problems.

W H AT ’ S N E X T ?
The interest in evidence-based medicine has probably been prema-
ture, raising expectations that healthcare could be readily trans-
formed by this “new paradigm.” Perhaps it can, but not so quickly, for
a number of reasons. First, for many health problems, sound evidence
from research is still thin or even nonexistent. Second, evidence from
research can be but one component of a clinical decision, other com-
ponents being the individual clinical circumstances of the patient,
the available resources, and the patient’s wishes. Just how these com-
ponents should be factored in “real time” remains a black box. Con-
tinuing education remains a problem—both as to how to practice
evidence-based medicine (EBM) and how to adopt the proceeds of the
research that it attempts to transfer into practice. We need to become
as serious about continuing education as we are about undergraduate
and postgraduate education, time and money being the greatest trolls
protecting the bridge to learning how to apply new and better health-
care knowledge. Information systems that present evidence in the

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right way (in a context that fits the problem, patient, and practitioner),
in the right place, and at the right time may help, but that remains to
be shown in a way that is both powerful and practical.

WHO ARE WE?

The journey described here has been a collegial enterprise. Many
people have been involved in addition to those named here, particu-
larly faculty and staff of the McMaster’s Department of Clinical Epi-
demiology and Biostatistics, which has been my academic home for
my entire career. I would thank them all, but that would be presump-
tuous; we’re all in this together.

REFERENCES
1. Ad Hoc Working Group for Critical Appraisal of the Medical
Literature. A proposal for more informative abstracts of clin-
ical articles. Ann Intern Med. 1987;106:598–604.
2. Guyatt GH. Evidence-based medicine. ACP J Club. 1991;
114:A-16.
3. Evidence-based Medicine Working Group. Evidence-based
medicine: a new approach to teaching the practice of medi-
cine. JAMA. 1992;268:2420–2425.
4. Guyatt GH, Rennie D. Users’ guides to reading the medical
literature [Editorial]. JAMA. 1993;270:2096–2097.
5. Sackett DL, Richardson SR, Rosenberg W, Haynes RB.
Evidence-Based Medicine: How to Practice and Teach EBM.
London: Churchill Livingstone; 1997.

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 4

Medical Information Technology:

An Instrument for Learning
...
“Knowledge is power,”1 wrote Francis Bacon. In med-
ical practice, knowledge derives from the critical analy-
sis of the plethora of information now available at the
time and place needed. That knowledge, in turn, in-
forms good clinical judgment.
P HIL R. M ANNING , M.D., AND L OIS D E B AKEY, P H .D.

T he explosive growth of the Internet and the popularity of e-mail

have simplified and facilitated physicians’ lifelong learning and
their communication with colleagues and patients. Continuing med-
ical education courses no longer need to be attended in person, but
can be completed on the computer. Medical journals and textbooks
are also available online. Daily reports on recent medical advances
may be reviewed at the click of a mouse. Authoritative essays on a
broad range of current medical concepts are readily accessible. The
reality of pertinent information at the point-of-care is approaching.
Major changes in medical library services are evolving. Most medical
schools (and even high schools and colleges) provide instruction on
use of the Internet, ensuring that graduates will be prepared to use
this source to enhance their lifelong learning.

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With these advances, physicians are able to rely less on memory

and more on managing information skillfully by finding, and deter-
mining the relevance and validity of, the plethora of available med-
ical information. Advances in electronic information technology,
especially information on the Internet, are still rapidly developing.
We offer examples of only a few products, realizing that many others
exist. With the numerous company mergers and name changes, no
one can be certain what will be available in the next few months, let
alone the next few years. The only certainty is that access to useful
information is becoming easier and faster.
“Where the penetration of managed care has been high, the time
available to acquire new information or review old information has
diminished,” observed Ralph Feigin. “Busy clinicians are allowed
less time to pursue academic activities, to expand their knowledge,
and to apply new knowledge to the care of their patients. The advent
of electronic communications has come at an opportune time in the
history of medicine, since the rapid accessibility of information may
help offset some of the problems engendered by managed care.”
The physician–patient relation is being revised as patients come
to the physician’s office armed with information gleaned from the
Internet, sometimes accurate, sometimes invalid. Physicians need to
develop skills in interpreting the information and in guiding patients
to the most pertinent sources.
John Wolf cautioned: “The computer-fluent physician will be bet-
ter prepared than his peers to practice third millennium medicine,
but with caveats. First, the Internet, in its infancy, has been replete
with erroneous information, a potpourri of poorly edited ‘facts’ that
seem to have taken Mark Twain’s facetious advice seriously: ‘Get your
facts first, and then you can distort them as much as you please.’2
Furthermore, computers, at least for now, cannot think or teach us
how to think. Some insist that computers are of limited value because
they can only produce answers. Incisive questions are essential for
basic or clinical research in medicine, and only human beings can
conceive those questions now.”

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“At the touch of a button,” said Daniel Musher, “I now have ac-
cess to a plethora of important and unimportant experimental and
clinical studies published around the world. Instead of too little in-
formation, I now have too much. Moreover, it comes right off my
printer in the office, so I no longer have some of the mnemonic clues
that helped me remember the text, such as recalling where I sat in
the library when reading Beeson and Petersdorf on fever of un-
known origin. Culling the current, relevant, and accurate from the
mass of unreliable information, much less remembering or being
able to cite a reference on rounds, has become a real problem. I
have heard colleagues chastise young authors for not being meticu-
lous about bibliographic references, as if that were a new phenome-
non. Not so. Some authors have always been meticulous, and others
always careless. I have had certain sardonic enjoyment in discover-
ing an article cited out of context or used to support a point that, in
fact, it helped refute. I feel confident that my younger colleagues
will solve the burden of excessive information, but I cannot, at pres-
ent, imagine how.”

WORLD WIDE WEB

Medical informatician Michael Ackerman pointed out that: “Informa-
tion, of variable specificity and authenticity, can be found in a few
moments whenever and wherever the need arises—the teachable mo-
ment. Trips to the library or a CD-ROM purchase may no longer be
necessary. The impact that this has on traditional and more formal ed-
ucation remains to be understood. While fingertip opportunities for
lifelong learning are endless, the ability of students to recognize reli-
able sources is problematical. Web access speeds are not fast enough,
and Web search engines still do more searching than finding, but
these problems will be solved in time. Educational technology will
bring credited course material to the physician on demand, a physi-
cian’s formal progress will be tracked from a distance, and distance
learning will be accessed from any site by means of a telephone con-

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nection. Educational institutions need to develop the educational and

commercial models that will convert these visions to reality.”
Technical producer Stephen Nazarian believes that: “Practition-
ers have traditionally used various print resources (books, journal
articles) to keep current. Sources of this information on the Internet
are easier to search, accessible around the clock, and almost limitless
in quantity. That this information is sometimes valid and sometimes
misleading or inaccurate presents new challenges to the physician.
By becoming familiar with reliable Web sites, physicians will dramat-
ically reduce the time spent dispelling misleading information for
patients.”
Yoichi Satomura, President of the Japanese Association of Med-
ical Informatics, believes that formal lecture courses are best suited
for medical students, but the best lifelong learning links education to
daily practice. Japanese physicians, however, still receive most of
their continuing education by conventional means, such as lectures,
seminars, and scientific meetings. Most Japanese physicians own
computers for accounting or personal use, but accessing information
from the Internet is not yet popular. Satomura attributes this to the in-
sufficient time that clinical practice allows to obtain reliable informa-
tion through the Internet.
As the computerized patient record becomes more prevalent in
office practice, physicians will more likely access information from
the Internet. The Japanese government has introduced measures to
encourage use of the computerized patient record. Satomura believes
that, ultimately, information technology will greatly enhance lifelong
learning, but conventional methods will continue because of the ben-
efits of social interaction.

Patients: A Driving Force

Stephen Sullivan explained how patients have become a driving force
in the use of the Internet: “Today vast clinical knowledge, simple and

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complex, is available to everyone, and people are increasingly taking

advantage of it, as confirmed by the growing medical content sites on
the World Wide Web. The number of registered users and page views
per month is rising almost exponentially. Patients are reviewing infor-
mation electronically, joining chat groups or disease-specific forums,
and seeking experts, classes, or clinical trials.
“To the surprise of physicians, Personal Health Diaries (PHDs)
have gained wide consumer acceptance on the Internet.3 This patient-
controlled clinical repository allows the user to maintain a personal
inventory of medical narratives—diagnoses, treatments, events, re-
minders, and clinical contacts. The Wall Street Journal’s weekly
‘Health Journal’ column features discussions of Internet-available
clinical screening-tool questionnaires, such as the one for depression
designed by the National Mental Health Association. A San Fran-
cisco Bay Area hospital group encourages residents to check their
cardiac health by completing similar online screening for coronary
artery disease. And on a Web site, http://www.partners.org/healthon-
line, Internet users can effortlessly find clinical trials related to per-
sonal conditions and diseases. Patients not only want more clinical
information, but also wish to manage it.
“How are physicians responding? Despite all the new Web-based
consumer brands in clinical healthcare, research verifies that pa-
tients now believe first and foremost in their local physicians’ clinical
knowledge and advice. The physician’s goal is to use this technology
to improve care and enhance the relationship of trust with patients.
Besides learning how to respond to patients armed with Web-based
general health information and printouts of recent readings, physi-
cians are devising strategies to communicate better with patients. Im-
proved communication between clinicians and patients will be
integrated with robust sharing of appropriate, specific clinical infor-
mation: relevant articles or videos; details about newly prescribed
medication from an array of pharmacy databases, textbooks, and even
pharmaceutical manufacturers; annotated clinical results linked to

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personalized explanatory notes; reminders to complete a previously

ordered screening or diagnostic study; or even alerts with new genetic
information about their condition.
“Patients will be able to review subsets of the clinical information
present in their physician’s online medical record. This capability
will allow patients to submit additions, revisions, and comments for
inclusion in their records. This two-way communication should lead
to greater efficiency in the physician’s office as changes mirror the
expectations of Web-literate patients. Routine transactions, like
laboratory orders and prescription refills, will become automatic
through the Internet, leaving time for more valued communications.
“The clinician will be expected to interpret the complex medical
information gathered by the patient as such information continues to
explode and patients’ unquenchable thirst for it expands. The more
medically informed the patients, the healthier they will be as they
seek earlier and more effective care.
“The exponential growth of clinical knowledge and of patient ex-
pectations for the physicians’ mastery of it will lead to more specializa-
tion. Routine clinical problems may become the purview of nurse
practitioners and physicians’ assistants, physicians concentrating on
more complex medical issues. The likelihood is real that the patient–
physician partnership, based on shared knowledge, will strengthen.
“Yet how can individual physicians manage the knowledge on-
slaught, even with the best reminder systems? Once a patient’s diag-
nosis has been made, won’t the physician insist on consulting an
expert to answer the most arcane question that might have arisen dur-
ing the clinical investigation? Paradoxically, an internist or family
physician may have detailed knowledge about an array of maladies,
but the patients may be treated by subspecialists, the ‘real’ experts.”

Electronic Services
No longer is there any question about the role of the computer in the
physician’s daily routine. The Internet offers scores of information re-

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sources, but with the frequent mergers and name changes, it is diffi-
cult to predict how long services and products will be available in
their present state. As more physicians rely on electronic services for
current medical information, however, the products will become more
sophisticated, efficient, and useful. Two currently popular informa-
tion resources are Medscape and WebMD. In addition to providing
up-to-date information daily, they permit accessing MEDLINE and
other databases that are more convenient because they are restricted
to key journals. Category 1 continuing medical education (CME)
credit is usually available if the physician is willing to take a brief ob-
jective test after reviewing written material. Most services also keep
records of CME credit earned by the physician.
Medscape (http://www.medscape.com) offers a wide array of in-
formation for physicians, other health professionals, and the general
public. On the physician’s site, each registrant is invited to designate
a special area of interest or expertise. Thereafter, the computer will
automatically match that registrant with the designated specialty and
provide pertinent journal articles.
Once on the personalized home page, the user may choose among
many options to obtain desired information. A popular use is to enter
a specific search term, upon which nine different databases may be
searched without further entry. The usual MEDLINE search produces
many citations, sometimes from obscure journals. Medscape Select
includes only the 269 journals in MEDLINE chosen as “best” by 77
different criteria. By searching Medscape Select, the user finds fewer
articles on any one subject, but all are from the most respected jour-
nals, which improves the likelihood of finding reliable and useful in-
formation in the shortest time.
Conference summaries are among the most popular Medscape
features. Medscape covers many of the best international medical
conferences each year. Expert physicians function as medical re-
porters who create abstracts from the meeting program, decide which
presentations to attend, and that evening summarize the presenta-
tions, giving full credit to the presenters. After being edited, the re-

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ports are posted the next day instead of six to 24 months later, as in
standard medical journals.
Medscape provides its own “Medscape Wire” news service.
Trained medical reporters scan the best medical journals and write
short, readable news stories from them. Medscape publishes Treat-
ment Updates, written by experts, based on well-established litera-
ture, and couched in language that is easily understood by practicing
physicians. This service is free to physicians.
MEDLINE is easily accessed through Ovid. Medical Updates
provides 600 – 800-word summaries of the current understanding of
specific diseases, a question-and-answer section, a biographical
sketch of the author, and a listing of pertinent guidelines, with hy-
perlinks to the Web. Quick Facts includes short essays on current
topics. Physicians may click onto another version designed for pa-
tients. Graphic displays are available to help physicians explain to
patients the mechanisms of diseases and how treatments work.
Physicians may also access lay medical information by clicking on
brief news summaries from such sources as CNN and The New York
Times, as well as finding tips on wines, travel, and other topics of
general interest.

Other Electronic Resources

Standard lecture courses abound on the Internet. Many medical
schools are putting lectures and panel discussions online from live
CME courses, with speaker and slides, as in traditional CME pro-
grams. Each year World Medical Leaders (http://www.wml.com)
broadcast at least 250 hours of original lectures by highly distin-
guished medical educators. Detailed information is provided for all
drugs mentioned in any lecture, and samples may be ordered directly
through the Internet. Other special features include discussion
boards that allow physicians to interact with their colleagues regard-
ing lectures or topics of interest, physician-to-physician-only e-mail
service for communication with colleagues around the world, and

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consultation boards to permit physicians to pose difficult diagnostic

dilemmas to the medical community.
The Encyclopaedia Britannica (http://www.britannica.com)
offers free general information on medicine, disease, human anatomy,
and physiology at its Web site. The comprehensive information will
be updated regularly and is written primarily for the lay public. This
service will not recommend particular treatments or cures, but should
prove useful to physicians by helping patients understand basic infor-
mation about their diseases and helping build an information partner-
ship among physicians and patients.
Several electronic editions of The Merck Manual are available
for purchase, but the 17th edition (1999) is available free online
(http://www.merck.com/pubs/mmanual/). The Merck Manual of Geri-
atrics and part of The Merck Manual of Medical Information—Home
Edition are also available on the Web site.
Again, the electronic services described are mentioned as exam-
ples of what is available. Name changes occur often with mergers, and
some services go out of business. Since, therefore, our examples may
have changed names or addresses, or may not exist when the reader is
ready to investigate them, we recommend that physicians consult a li-
brarian at a medical school or academic hospital to determine what is
available. Nevertheless, we are certain that electronic resources will
expand and become more valuable each year.

Finding Significant Web Sites

Edward Shortliffe suggested these Web sites and CD services: “The
American College of Physicians (ACP) maintains a listing of perti-
nent Web sites at http://www.acponline.org/computer/ccp/bookmark
/index.html?idx. They also maintain a directory of all the Observer ar-
ticles on computing topics: http://www.acponline.org/journals/news
/compmed.htm?idx.
“I consider the best general medical sites for searching the Web
to be Cliniweb and Medical Matrix. Cliniweb (http://www.ohsu.edu

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/cliniweb/), a resource from Oregon Health Sciences University, is a

high quality search interface that helps clinicians find information on
the Internet. Medical Matrix (http://www.medmatrix.org/index.asp)
offers free registration for physicians and a comprehensive portal for
medical topics.”
Thomas Lincoln pointed out that many professional societies have
their own Web sites and that some Web sites dedicated to particular
diseases are run by their nonprofit organizations. These not only offer
information for physicians but also organize electronic support groups
for patients and their families.

P E R S O N A L D I G I TA L A S S I S TA N T S
The handheld digital personal assistant (PDA) has enabled physi-
cians to carry large amounts of data in their pockets. According to
Oscar Streeter, “The issue for most physicians in practice, at least for
the foreseeable future, is not whether you are going to use a personal
digital assistant, but whether you are going to use the Palm OS™ or
the competing Microsoft Windows CE™ or Pocket PC™ platform.
Millions of palm-based devices have been purchased since they ap-
peared on the market in 1996.”4 Many hospitals are providing palm
devices for their interns and residents. Wireless palm devices are
available and in the future will dominate PDA connectivity with com-
puter networks. They can be connected with a cellular phone or be
used as a stand-alone device with a radio antenna. In the August
2000, issue of Hippocrates (http://www.hippocrates.com), Leo Burnett
listed a compendium of free or inexpensive medical software applica-
tions for the Palm™ on the Healthy PalmPilot Web site (http://www.
healthypalmpilot.com).6
Streeter uses his PDA to get weather reports, stock information, and
driving directions using Mapquest™, and to send and receive e-mail
anytime, any place. “When I pull the Palm™, out of my pocket and
raise the antenna, it connects to an internal transmitter, enabling it to
transmit and receive information over the airwaves. To use this feature,

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however, you must activate the Palm.Net™ wireless communication ser-

vice, which, like an Internet connection, requires a monthly user fee.
Medical software developers, following the lead of physicians, have de-
veloped hundreds of medical resources in patient tracking, procedure
billing, medical references, and prescription writing for the Palm™.
“Of particular use to physicians is ePocrates.com™ (http://www.
ePocrates.com/), a free drug-database, as opposed to the PDR™ ver-
sion that you must purchase. The PDR™ version is more complete, but
for most of us the ePocrates listing of more than 1,500 prescription
drugs is adequate. The Windows version automatically updates itself
whenever the Palm™ is HotSynced with your computer. You can
search by generic or trade names. PatientKeeper™ (http://www.
patientkeeper.com) is a patient-tracking software program that allows
storage of the patient’s history, physical examination, laboratory tests
completed, and reminders. The information on each patient can be
beamed between PDA infrared ports. You can sign out a patient to an-
other physician electronically, with alerts on when to check other labo-
ratory tests or x-rays ordered. This is a boon when you are going out of
town and have inpatients or are changing services as a resident. An-
other patient-tracking software program that serves as a to-do list is
WardWatch™ (http://www.torlesse.com/pilot/wardwatch/). Both of
these patient software programs offer a demonstration before you pur-
chase. Harrison’s Principles of Internal Medicine: Companion
Handbook™, which contains the entire companion edition of Harri-
son’s Principles of Internal Medicine, and other medical titles are avail-
able at http://handheldmed.com. Software is also available for writing
accurate, legible prescriptions at the point-of-care.”
For those who wish to learn the latest on handheld computers, the
magazine Pen Computing has excellent reviews and news.

A H O S P I TA L D ATA B A S E
Lawrence Cohn described a hospital database that can help in estimat-
ing patient outcome: “Brigham has a cardiac surgical database of some

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30,000 patients dating from 1972. Such databases are extremely valu-
able and provide a constant stimulus for faculty and trainees to write of
their experience. Analysis of this information allows a better under-
standing of what we are doing. I may not consult a database at the time
I am seeing a patient, but I will have database information at my finger-
tips about the general disease, procedure, and operation related to the
patient. For example, many young candidates for a valve replacement
want to know about the results of surgical experience with a homograft
or a pulmonary autograft. The constantly updated database allows me to
provide patients with numbers and risk/reward ratios, which, in turn,
allow the patients to reach an informed decision.”

REMINDER SYSTEMS
Many problems that arise in medical care are due not to a lack of
medical knowledge but to oversight. The computerized medical
record will deliver reminders to physicians while they are seeing
patients.
In 1972, Clement McDonald and his collaborators began to con-
struct an electronic medical record system, the Regenstrief Medical
Records System (RMRS), which has grown in coverage and scope
over the intervening years. At Wishard Hospital, the RMRS now car-
ries coded and computer-readable information about all diagnoses,
patient encounters, orders (including prescriptions), and diagnostic
studies, as well as all narrative dictations, electrocardiograms, and
radiographic images. Some venues, for example, obstetrics, dermatol-
ogy, and medicine, contain much more clinical detail.6 The RMRS
also includes laboratory and other patient information from four other
major Indianapolis hospital systems.7 The goals of this medical
record system have been: (1) to solve the availability and legibility
problems of the paper medical record, (2) to facilitate clinical re-
search, for example, the identification of candidate patients for clini-
cal trials and retrieval of patient data for epidemiologic research, and
(3) to provide automated guidance to healthcare.

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The physician is faced with torrential information flows, random

interruptions, and high pressure. Such circumstances are setups for
errors due to oversights and omissions.8 In Samuel Johnson’s apt
words: “[M]en more frequently require to be reminded than in-
formed,9” that is, most errors are due to oversights rather than igno-
rance. If the computer could check for, and remind the physician
about, patient conditions that need attention without requiring the
physician to initiate the checking process or (with rare exceptions)
feed data into it, the computer could improve patient care. The com-
puter would have to depend on its own content (the electronic medical
record) for data needed to generate these reminders.
The computer uses rules to relate patient states to required clinical
actions such as treatments or tests. The Regenstrief policy is to imple-
ment only rules that are well supported by published scientific evi-
dence and can be sharply defined by computer-stored clinical data. For
example, the rule about screening mammograms depends on only three
variables: the patient’s age (⬎50), gender (F), and date of previous
mammogram (⬎1 year ago). The rule about the use of angiotensin con-
verting enzyme (ACE) inhibitors depends on echo evidence of left ven-
tricular ejection fraction ⬍40 percent, a normal creatinine clearance,
and confirmation that the patient is not yet taking an ACE inhibitor.
The computer must have rules with carefully defined criteria if it is to
avoid vague and repetitive reminders.
In the 1970s and 1980s, the RMRS rules were delivered to physi-
cians as paper reports. The computer reviewed the patient’s elec-
tronic medical record for conditions that needed reminders according
to pre-defined reminder rules and produced a paper reminder report.
The clinic staff delivered the report to the physician by placing it on
top of the patient’s chart. This method of delivering reminders had
powerful positive effects on care, especially preventive care.10,11
The paper method continues to be used, but another mechanism
has been added that delivers reminders to physicians as they write
orders in the hospital, emergency room, and clinics. These re-
minders are based on a new language called G-care.12 G-care re-

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minders can deliver simple text reminders or more sophisticated

messages that contain preformed orders. The rules can also be used
to disagree with certain kinds of physician-written orders before
they are completed. Indeed, the computer can suggest an alternative
that the ordering physician can accept with one or two keystrokes.
Order-related G-care reminders have also had positive effects on
patient care.13 G-care reminders are used for research purposes; for
example, physicians can be reminded that a patient with “back
pain” might be a candidate for an ongoing clinical trial. If the physi-
cian responds online that the patient is an appropriate candidate,
the computer will send “e-mail” to the digital pager of the study
manager, who can invite the patient to join the study while the pa-
tient is still in the clinic.
Physicians receive more than one reminder a day for each hospi-
talized patient, and an average of two for each outpatient visit. Physi-
cians are free to accept or ignore reminders, as the computer never
knows as much about the patient as the physician does. The physi-
cian is always the final arbiter.

I N F O R M AT I O N AT T H E P O I N T- O F - C A R E
A long-time dream of physicians has been to ask a specific question
and receive a valid and pertinent answer quickly while seeing a pa-
tient. Several systems approach this goal.

Systems That Provide Information at the Point-of-Care

MDConsult offers a selection of current textbooks online, a few
clicks bringing specific information on a desired topic. Easily ac-
cessed are full-text articles from more than 50 clinical journals, as
well as MEDLINE. A click or two will access clinical guidelines, in-
formation on specific drugs, and written material suitable for patient
education. Daily reports of medical news appear with hyperlinks to

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related current journal articles, along with drug updates and brief dis-
cussions of clinical topics.
SKOLAR, M.D. is an integrated information system for learning
and decision-making that includes electronic textbooks, drug data,
bibliographic information, guidelines, consensus statements, and
primary-care teaching modules. Some physicians use the system in
the presence of patients. In 1999, in its underdeveloped form, the
program could answer, within four minutes, about 80 percent of ques-
tions related to patient management that were generated by primary-
care physicians. With further development, the percentage of
questions answered is increasing.
Scientific American Medicine (SAM), which began as a re-
placeable text in three-ring binders, is now available on the Internet
through WebMD, making it a widely available and frequently updated
medical text.
UpToDate is a compact disk product often used for point-of-care
information (see page 101).
UPCMD (http://www.upcmd.com), a system developed by the Uni-
versity Pathology Consortium to aid in laboratory diagnosis, is de-
scribed by Clive Taylor: “This interactive Internet service deals
specifically with selection, interpretation, and follow-up of diagnostic
and laboratory tests. The Disease Diagnosis section of the site currently
contains about 15,000 pages of information designed to assist physi-
cians in selection of diagnostic tests for a wide variety of diseases.
“A physician or other healthcare provider logging onto UPCMD
will be able to type in the name of the disease under consideration
and within seconds will have a full description of the clinical charac-
teristics of the disease, together with detailed information about test-
ordering procedures to explore further the diagnosis. There are also
hyperlinks to recent journal articles. In this way, physicians will be
able to obtain the most up-to-date information about any disease,
even an uncommon disease, encountered in daily practice without
leaving their office desk or their handheld wireless PC.”

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Problem Knowledge Couplers

A pervasive design flaw in advanced health care systems
is their unnecessary dependence on fallible, idiosyn-
cratic inputs from clinical workers. . . . Medical deci-
sions are still based largely on the recall and processing
of complex information by highly trained physicians. Yet,
their cognitive inputs fall short of what medicine re-
quires, too often producing decisions that are deficient in
quality and resistant to organized improvement.
L AWRENCE AND L INCOLN W EED 14

Lawrence Weed believes that the information retrieval, recall, and

synthesis of facts necessary to determine the best care for patients
is beyond the unaided mind, even with the help of existing clinical
guidelines and computers that deliver knowledge on request. To
help solve this problem, he has developed Problem Knowledge Cou-
plers, a computer tool that retrieves and processes information by
linking or matching patients’ specific data with up-to-date medical
knowledge. The Coupler then provides logically organized diag-
noses and management options. It is difficult to disagree with
Weed’s philosophy, but can it work in the real world of clinical
practice?
Charles Burger’s practice of about 4000 active patients is orga-
nized on the Knowledge Coupler concept. The practice consists of
one physician, two nurse practitioners, two medical assistants, one
registered nurse, and 7.5 full-time-equivalent support staff. Before
incorporating the Knowledge Couplers into his practice, Burger
conducted an intensive staff-training program in total quality man-
agement. For example, medical assistants were trained to gather in-
formation from the patient and perform physical examinations. As a
first step, Burger employed the triage coupler, which permits the re-
ceptionists to perform a triage of the patient’s medical complaints to
determine if, and how urgently, the patient should be seen by a
physician or nurse practitioner, how much time should be allocated

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for the office visit, and whether any testing should be done before
the office visit. Burger found that analyzing a patient’s complaint by
this method requires 3.9 minutes versus 3.0 minutes for the usual
interview by the receptionist, but the results warranted the extra
time.
The practice works thus: with the help of the medical assistant,
if necessary, patient completes a questionnaire. The completed
questionnaire, physical findings, and laboratory findings are keyed
into the Coupler system. The paper questionnaire can be replaced
by a handheld device that downloads responses directly into the
computer. This information, including history, physical findings,
and laboratory data, is matched or coupled by the computer with in-
formation from current medical publications. The Coupler then pro-
vides logically organized diagnoses and management options.
Secondary options may suggest further studies to confirm a given
diagnosis and comment on the sensitivity, specificity, and costs of
the studies. The pros and cons for management options are pre-
sented. The clinician’s judgment and patient’s preferences deter-
mine the final management options. The physician or nurse
practitioner will spend most of the time clarifying and annotating
the history, checking physical findings, and reviewing the results
with the patient.
Burger conducted a study indicating that the Coupler-centered
practice is successful by measures of patient satisfaction, panel
growth (his practice increased from 3554 patients in 1998 to 3991 in
mid-1999), provider productivity, satisfaction, and profitability.
Burger believes the quality of care has improved without any diminu-
tion in empathy or compassion with the use of Couplers. With less
time devoted to memorization, he can spend more time developing
communication and listening skills. He emphasizes, however, that
users should not rely on Couplers or any other single source in mak-
ing decisions; physicians cannot function competently without their
minds actively engaged.

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Potential Informatics Approaches

Other systems are being developed in research laboratories. One re-
searcher, Robert Greenes, pointed to the complexity in creating an ideal
system: “We need a framework for integrating knowledge and decision
support that will provide the physician with access to specific, authorita-
tive, problem-focused information during a patient visit. It should also
accommodate the physician’s personal notes and observations, as well as
offer links to other relevant information that can be pursued more
leisurely. Thus, the framework needs to be tailored and updated by both
authoritative sources and personal notes and references.
“In seeking ways to provide specific information, we have been
pursuing ‘Clinical Management State’ (CMS), which will address the
dual tasks of (1) information access and decision support in the care of
specific patients and (2) more general learning needed to stay abreast of
medical advances. Each CMS may represent a subclass of patients with
a particular disease or problem. Consider, for example, patients with
hypertension or diabetes: patients will be in one or another CMS (new
onset, workup, treatment, steady-state management, treatment of com-
plications). Knowing a patient’s CMS, the physician can predict the
kinds of clinical information likely to be needed, decisions to be made,
actions to be carried out, and other potentially useful resources relating
to that CMS. Questions that arise in practice will be answerable by in-
formation resources already linked to the CMS or will be added to the
CMS framework. Automatic search tools will use the knowledge model
of the CMS, including ‘eligibility criteria’ for a patient being assigned to
a CMS. These criteria will identify appropriate external resources and
will update the available information.
“For this approach to succeed, the CMS must be defined for most
key problems. We envision that the knowledge models defining a
CMS would be reviewed by disease-specific editorial boards. The in-
formation will need to be categorized by disease or problem, intended
audience, and quality rating, and further categorized by identification
of its uses (clinical, biochemical, epidemiologic, diagnostic, thera-
peutic, or prognostic). The system should also specify the type of in-

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formation as evidence, opinion, review, clinical guideline, risk as-

sessment, or other decision support tools.” While waiting for such a
service, physicians can use the principles outlined by Greenes in
conceptualizing their approach to medical information.

TOOL TO PROMOTE PRACTICE-BASED LEARNING

An educational program sponsored by the Royal College of Physicians
and Surgeons of Canada (RCPSC) encourages physicians to seek infor-
mation triggered by real problems arising in practice. The Maintenance
of Competence Program15 (MOCOMP) provides a paper diary and com-
puter software (PCDiary®) to facilitate practice-based learning. A
principle feature provides physicians an opportunity to record a ques-
tion. John Parboosingh credits the system with assisting physicians in
moving efficiently through the learning cycle, beginning with deciding
what they need to learn, formulating a question that best describes it
(see pp. 164–168), seeking assistance from peers and mentors in the
selection of learning resources, and making a commitment to integrate
the new learning into their practice. “At a click of the mouse, the diary
user may access a searchable Internet database of questions posed by
other diary users (the Question Library) and connect anonymously with
a physician working on a similar question. The software keeps a record
of the learning resources used to complete the task and asks physicians
how they intend to use their newly acquired learning. For instance, if
the user assigns as the outcome code ‘I will modify my practice,’ the
diary requests a description of how the physician intends to do this.
“PCDiary® encourages physicians to focus on the purpose of the
learning and to specify its potential impact on their expertise. These
two features are reported to increase the likelihood of a change in be-
havior. Users can search and sort items by topic, stimulus, and as-
signed outcome. For instance, one may print a list of items for the
assigned outcome code ‘I will modify my practice’ to ensure that
necessary changes are made. The search-and-sort capabilities of
PCDiary® provide feedback, engender ownership, and produce feel-

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ings of accomplishment, all of which are reported to motivate inde-

pendent learners.
“Thus the PCDiary®, using the integration of computer and
telecommunications technology in the design of personal learning
portfolios, will produce a new generation of learning tools that will
stimulate learner interaction. Using critical thinking questions, ex-
perts will communicate with peers and mentors electronically.
PCDiary® users contribute entries (the question, the stimulus, the
learning resources, and the intended outcome) anonymously by
modem transfer of data to the Question Library. It is the first library to
house questions rather than answers. As our medical knowledge base
rapidly expands and the shelf-life of clinically applicable information
falls, answers will inevitably change more often than previously, and
the question will likely be the more stable component. Experts will be
judged by the quality of the questions they ask and their ability to
produce the most accurate and current answers.”
The importance of asking circumscribed questions and seeking
answers about patients cannot be overemphasized. “In clinical prac-
tice, questions always arise that require an evaluation of both the ‘old’
and the ‘new’ in published reports,” said Stephen Greenberg. “When
I am taking care of a puzzling patient, I try to formulate the most crit-
ical questions in the case.” Of equal importance is the brief recording
of results of a search to address the question. If you do not have ac-
cess to a computer system like MOCOMP, you can keep a paper diary
or record your experience on other software.

The Learning Diary

Physicians [trainees] are ready to leave the fold when
they ask searching questions about their patients and
vigorously pursue the answers.
E UGENE A. S TEAD , J R . 16

John Toews uses MOCOMP thus: “Although I graduated from medical

school three decades ago, only in the past decade have I found a

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method of lifelong learning that suits my particular style. I enjoy shorter

learning activities to solve clearly circumscribed problems, but I thrive
on learning in depth. As a psychiatrist, I tend to be more of a concep-
tual person than one whose first impulse is to fix through action.
“MOCOMP, with its emphasis on lifelong learning, provided a
fine avenue to conceptualize and organize my learning through an
electronic learning diary (PCDiary®). MOCOMP stimulated record-
ing of continuing professional development available to RCPSC Fel-
lows.17 Two major aspects were participation in group learning
activities, such as conferences and rounds, and a diary for recording
self-directed learning. Both paper and electronic learning diaries are
key features, but it was the electronic diary that facilitated my own
learning. Although I have attended my share of conferences and
rounds, the PCDiary® encouraged me to direct my education to re-
flect more on my questions and convert them to learning projects. My
learning diary now consists of two major types of projects, short ones
that arise from immediate practice needs and long-term developmen-
tal programs.
“My first step is to frame a question based on the problem I am
facing. Framing a question is more effective for me than assigning a
title to what I want to learn. Why? Because questions circumscribe
the focus more tightly than statements or topics. The questions I ask
encourage me to reflect rather than simply describe or list. And my
curiosity often keeps me working on the question long after I have
adopted an immediate course of action in treating a patient.
“Questions induce a state of tension in the questioner, but the an-
swers provide satisfaction and an enhanced sense of competence. The
resulting improved treatment for the patient reinforces the sense of
competence, which is a major behavioral motivator.
“Many of my questions are simple: Which antipsychotic medica-
tion is safest to use in pregnancy, and what is the evidence for this? I
seek and find answers through databases or bibliographic reviews.
The questions are duly recorded in my PCDiary®. I note the esti-
mated time spent on the problem, the sources used, and the intention,

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or lack thereof, to change my practice. All this information is for-

warded to the RCPSC for my MOCOMP record. I keep the best part,
the second electronic page that contains my findings, observations,
thoughts, and key references addressing the question, a rich source
when I forget something or when I simply page through the questions,
remembering fondly past learning experiences.
“When I am not as interested in retrieving specific information as
in understanding a more complex process and thus augmenting my
knowledge and skill, I select a particular patient as a basis for both a
review of knowledge and new learning projects. Such patients become
my best teachers as they spur my major learning projects. For example,
I had a patient with severe Generalized Anxiety Disorder (GAD). Hav-
ing had few such patients, I was not sure of the latest medications. I did
a MEDLINE search of reviews for the past five years, then framed ques-
tions to guide my analysis of the search results: What advances have
occurred in the pharmacologic treatment of GAD, and how do they re-
late to, or change, my previous knowledge? Those questions allowed me
to test my previous knowledge against the new information. Since not
much had changed, my initial plans for medication were in order. In the
process, I also learned about drugs of second and third choice.
“My next questions were: Is there current evidence of advantages
from a combination of medication and psychotherapy in GAD? If so,
what is the best combination, and what skills do I need to acquire for
the psychotherapy? These questions led me to review basic differen-
tial therapeutics, a rapidly growing field of psychotherapy research.
As I read and attended a workshop on the selected therapy, I con-
stantly reviewed skills, discovering parts in which I was competent
and some in which I needed to learn more.
“The final question capped the learning project: What is the ev-
idence for the benefits of combined treatment with antidepressants
and cognitive behavioral therapy for GAD, and how will this help
my patient? I tied together the symptoms of the patient with a bio-
logical and psychological understanding of ways in which this inte-
grative treatment can work. All these questions were recorded and

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answered as separate, although related, learning projects. This

study on GAD required 15 hours over two months. I used a number
of sources: published reviews, colleagues, and workshops. What’s
more, I now have a mental hook; when I think of this patient, I re-
member my learning and more readily apply it to the next patient.
During this project, of course, I saw other patients who presented
learning opportunities. I asked initial questions to provide better
treatment, but I sought the quickest solution. I recorded in the diary
only the questions and solutions that required some time or ad-
vanced my knowledge.
“During our experience with MOCOMP, we taught others how to
record self-directed learning projects. Many colleagues have diffi-
culty deciding what to enter in learning diaries. Some stated that they
were learning so much all the time that they had no time for the diary.
A participant in a MOCOMP diary user’s focus group found that this
system solved this problem. Because he thought he had to know
everything, he felt guilty and his learning was diffuse and anxious.
With the introduction of the diary, he became more focused in his
learning; he entered his projects and systematically worked on them.
He saw them as evidence of his continuing learning and resisted
chasing every learning impulse. Both the use of the diary and the use
of questions gave direction and intention to his learning.
“One further innovation was included in the PCDiary®: all the
questions submitted electronically became part of a Question Library,
which permitted me to see what my colleagues were asking, and to
become aware of the leading edge of my field. Further, hot-links were
attached to each question, allowing me to be anonymous if I wished
and yet have my colleagues interact with me. I received a note from a
colleague about one of my question entries, and we had an e-mail ex-
change about it. This experience illustrated graphically the potential
of technology that allows learners to further one another’s education.
Knowledge is only of half use if it is not shared with a colleague.
“MOCOMP became the official Maintenance of Certification Pro-
gram of the RCPSC in 2000, and various learning categories are cred-

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ited. To my great delight, the PCDiary® remains, and I continue

framing questions because there is no better way for me to learn.”
Stephen Sullivan discussed other ways the computer facilitates
learning from your practice: “Clinical software will help by inventory-
ing a physician’s habits and developing a ‘clinical interest profile.’
Where does the physician spend most time when resolving a question
about a specific disease? Which Web sites or reference sources are
used? Which questions are asked? What disease information is
sought for a specific patient or in general reading? Based on these
cues, the computer will then develop, maintain, and update a person-
alized library for the clinician. Upon the clinician’s request and from
that database, the computer will automatically submit questions
about material the clinician has read. Continuing medical education
will no longer consist primarily of attendance at seminars and random
reading, but will be a byproduct of caring for patients and self-
teaching about clinical problems.”

ELECTRONIC MAIL
The use of electronic mail (e-mail) in the healthcare setting has ex-
ploded and continues to expand. Some physicians are using it to com-
municate with colleagues, to request referrals, to render consultation
reports, and to receive laboratory data and follow-up information about
their patients.
With practice now increasingly regulated by cost-containment,
physicians are becoming ever more pressed for time. Some say time
strictures are even jeopardizing their informal consultations with
medical colleagues, such as discussions in the doctors’ lounge. In
such a climate, can e-mail substitute for face-to-face discussions with
colleagues about puzzling patients? Can the nuances of a patient’s
problem be described clearly enough in e-mail to elicit a useful an-
swer? Research is sparse, but physicians will probably need to hone
their written communication skills in order to frame questions that
will elicit accurate and pertinent responses. E-mail interactions may

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prove valuable for informal discussions on simple issues of patient

care, but they cannot and should not replace personal discussions on
more complex issues. An asynchronous method of communicating,
e-mail is well suited for some tasks but is not ideal for all.
Stephen Greenberg follows up his e-mail communications with
colleagues about patient management issues with a telephone con-
versation if nuances of a case are difficult to transmit by e-mail.
Even so, he considers e-mail more time-efficient and more produc-
tive than the telephone or postal mail. Greenberg believes that both
written (computer) and oral communication skills will become even
more critical for the practicing physician in the future, as teaching
and mentoring functions of physicians will be central activities in
the 21st century.
A Netherlands study showed that postal mail of admission-
discharge reports to general practitioners required a median of two
days at one hospital and four days at another. E-mail and electronic
data exchange, however, allowed such delivery usually within one
hour of being generated. In one hospital, 32 percent of all laboratory
reports, and in another 52 percent, were available electronically on
the day the samples were collected. Twenty of 27 physicians rated e-
mail usefulness as a 4 or 5 (0 ⫽ useless, 5 ⫽ very useful).18
The use of e-mail to communicate with patients is evolving more
slowly. (See also pp. 329–331) After an extensive review of publica-
tions, Moyer and coauthors19 concluded that patients between the ages
of 20 and 50 years, who represent most subscribers to managed-care or-
ganizations, are more likely than older patients to use e-mail to com-
municate with their physicians. Although the telephone is still their
primary means of such communication, they also consider e-mail satis-
factory for certain communications, and believe that it increases speed,
convenience, and access to medical care. In most cases, a nurse will
triage the messages. The medical center staff sees e-mail as competi-
tive with other forms of communication in response rates, value, cost-
effectiveness, and communication style, and does not consider reading
and responding to patient e-mail to be overly time-consuming. Further-

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more, e-mail is ideal for nonurgent problems, such as routine prescrip-

tion refills, certain laboratory results, and making appointments, and it
is well suited to patient follow-up, staff education and training, and
patient-care assignments. E-mail prevents interruptions by telephone
calls, limits “telephone tag” or long waits on “hold,” and thus saves
time for physicians, patients, and nurses.
Using e-mail to communicate with patients, however, can get out
of hand, and the physician can spend a great deal of uncompensated
time answering questions in this way. Methods must be determined to
compensate for costs and office staff time required for e-mail. Ac-
cording to Thomas Lincoln, since Frequently Asked Questions
(FAQs) comprise almost 90 percent of patients’ questions, the physi-
cian’s investment of time could be reduced by use of a Web site with
advice categories or by a list of standard e-mail responses that may be
modified to suit specific circumstances.
Other concerns about e-mail communication with patients are the
inability to ensure confidentiality, potential medicolegal issues, and
the difficulty of authenticating identity (possible impersonation of a
patient). These issues are being addressed and should eventually be
resolved. Physicians should, of course, not use e-mail to discuss com-
plex issues or to convey negative reports to patients. Face-to-face
communication is not only desirable, but is an essential ingredient of
the physician–patient relationship.

P R A C T I C I N G S K I L L S B Y S I M U L AT I O N
Not only is technology providing information and advancing the study
of practice, but it is expanding the use of simulators that permit
physicians to learn procedures and other clinical skills. Michael
Fordis offered the following observations.
“Information technologies offer opportunities to learn and prac-
tice skills in simulated and interactive environments. Future learning
and training centers may have simulators and virtual reality stations
for such training. The office or home may also have learning sites over

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the Web, particularly as the bandwidth (or movement of information)

increases. Additionally, some such technologies will provide notifica-
tions, information, and education at the point of care to enhance
learning and patient services.
“Simulation technology for CME can range from interactive case
presentations offered on computer networks, CD-ROMs, or the Web to
highly sophisticated training with the learner on-site, working with
mannequins, haptic devices, and virtual reality.20–23 Issenberg and
colleagues pointed to these advantages of high-fidelity simulations of
human conditions: ‘Unlike patients, simulators do not become embar-
rassed or stressed; have predictable behavior; are available at any
time to fit curriculum needs; can be programmed to simulate selected
findings, conditions, situations, and complications; allow standard-
ized experiences for all trainees; can be used repeatedly with fidelity
and reproducibility; and can be used to train both for procedures and
difficult management situations.’24
“Educators are increasingly applying simulation technology in
various medical disciplines, including laparoscopic surgery, anesthe-
sia, cardiology, and emergency medicine, sometimes in continuing
medical education.24 Consider, for example, a sophisticated simulator
for endoscopic sinus surgery (ESS) in a virtual reality environment.
Because ESS can involve risk to the patient, an effective training tool
without patients would be attractive. Furthermore, the relevant
anatomic structures lend themselves to a virtual environment. The
structures are firm and do not easily become deformed, as soft tissue
organs do with contact and pressure. Moreover, imaging datasets are
available for creating the virtual environment.
“The ESS simulator uses the head of a mannequin into whose
nose surgical instruments can be inserted. The haptic or force-
feedback display simulates the resistance that the surgeon experi-
ences in manipulating instruments, such as the endoscope, or in
injecting substances into the tissues. The three-dimensional model of
human nasal sinus anatomy, developed from the Visible Human Data-
base at the National Library of Medicine,25 is rendered in real time at

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15 to 30 frames per second. The displays are compelling. In addition

to the endoscope, the student can use various instruments, including
scalpel, injection needle, and forceps. Visualization through the en-
doscope deteriorates as blood and secretions cloud the tip, requiring
the trainee to remove and clean the instrument. When impaling the
tissue with the injection needle, the trainee feels the resistance, and
the tissue blanches as the injection is made. With inattention to he-
mostasis, inexperienced surgeons can find their operating field
quickly obscured by blood. Different training levels are engineered
into the simulator, providing instructional aids to enable the novice
and intermediate trainee to accomplish navigation, injection, and dis-
section. No aids are provided at the advanced level.26
“In a formal evaluation of the ESS simulator, non-physicians,
non-otolaryngologist physicians, and otolaryngologists with varying
levels of experience (second-year residents to senior staff) performed
‘clinical’ procedures. Participants were evaluated with scoring algo-
rithms based on time, completeness, and accuracy. Performance on
the ESS simulator correlated strongly with the degree of prior ESS ex-
perience consistent with procedural validity of the simulation model,
findings that were supported by subjective evaluations conducted
with experienced ESS surgeons.26,27
“Whole-body simulators with mannequins have been developed
for training in anesthesia and are also being used in continuing edu-
cation for practitioners; in the training of residents and students in
surgery, radiology, obstetrics, and emergency medicine; and in the
training of critical care nurses and respiratory technicians.24,28 The
simulation of the cardiovascular and respiratory systems of human
subjects allows evaluation of fluid status, acid-base status, pharmaco-
dynamic responses, and temperature.28
“Examples of available whole-body simulators include the Eagle
Patient Simulator from MEDSIM29 and the METI simulator from Med-
ical Education Technologies.30 MEDSIM’s vision is ‘To create a vir-
tual patient for every medical procedure.’29 As early as 1999, systems
had been developed to simulate problems and treatment in gynecol-

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ogy, obstetrics, vascular disease, cardiology, surgery, and anesthesiol-

ogy. The METI allows simulation of more than 50 clinical scenarios.
The user interacts with a mannequin in which the eyelids open and
close; the pupils dilate or constrict in response to light or drugs; the
pharynx and tongue can swell; the thumb twitches (the twitches dis-
appear with paralysis); limbs swell to mimic trauma; and urine output
can be monitored, as can a variety of pulses and heart and breath
sounds. Monitoring also includes electrocardiography, blood pres-
sure, oximetry, Swan–Ganz pressure, central venous pressure,
capnography, and inspired and expired concentration of gases.
Modeling simulates the injection of drugs, precipitating the appropri-
ate physiologic response for a particular clinical situation. The man-
nequins can be manipulated and instrumented for intubation,
placement of cannulas, cricothyrotomy, chest-tube placement, peri-
cardicentesis, needle decompression for a tension pneumothorax, and
defibrillation.28
“Whole-body simulators lend themselves most easily to teaching
in small groups where participants acclimate to the simulation. De-
velopers of the METI simulator, however, have demonstrated that,
with the proper set-up, a large number of persons can participate in
such CME during a scientific meeting.31
“If the experience of the airline industry and the military is any
guide, deployment of whole-body simulators might well expand
throughout healthcare training institutions. Some evidence of this al-
ready exists.24,32 Beyond training, whole-body simulators are being
considered for assessment and certification of clinical competence.
Such considerations invite additional research regarding not only
their efficacy in training, but also their validity and predictive power
in assessment of performance.”32
The American Board of Family Practice is revolutionizing
physician recertification procedures by developing an online, patient-
centered, problem-solving test. A patient simulator provides
patient-care scenarios that include multiple questions about the case,
employing a branching technique that requires physicians to make

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clinical decisions at certain points. The patient simulator is designed

to ensure that no two cases are identical, removing the possibility that
a physician taking a test can use another physician’s simulated pa-
tients to avoid thinking through a problem himself. An advantage of
this program is its focus on clinical decision-making. Instead of tak-
ing a single examination every seven years for recertification, the
physician can be recertified in steps by completing one or two cases
every week or so from the office or home. The program thus serves a
dual function as an educational tool, as well as a recertification tool.
The test is open-book so that as a physician identifies deficiencies, he
may look up appropriate material. Ultimately, the system will provide
access to pertinent references and offer educational feedback to the
physicians.

S U M M A RY
Constant improvement in electronic information is notably changing
the way physicians learn and practice. Physicians may communicate
with colleagues and patients by e-mail, and they may take courses on-
line. Each morning, their computers may greet them with a summary
of breaking medical developments. They may click onto a service that
provides a list of published titles suited to their practice, and, with
another click, they may be hyperlinked to an abstract or a full-text ar-
ticle. They may also review summaries of major conferences.
Already available are systems that produce prompt, pertinent in-
formation at the point-of-care. More rapid, user-friendly, and authori-
tative sources at the point-of-care are being developed. The recording
of specific questions about problems arising in practice is fostering
self-directed, practice-related education, and the storage of brief
notes on lessons learned on puzzling patients will further enhance
learning from experience.
Patients are visiting their physicians with sheets of information
from the Internet, valid and invalid, and physicians must acquire spe-
cial skills to interpret such data. With such easy access to informa-

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tion, memory of detailed facts becomes less important, and the acces-
sion and interpretation of pertinent authoritative information becomes
paramount.
Since many problems in medical care are due to oversights rather
than a lack of knowledge, reminders built into a computerized medical
record help physicians avoid errors of omission or memory while they
are seeing a patient. The concept of the Knowledge Coupler, which
matches information about a specific patient with information in med-
ical publications, is an effort to help physicians retrieve and process in-
formation rather than require them to request or process it unaided. The
startling scientific advances produced by medical research, coupled
with the amazing developments in information technology, make this a
challenging and exciting time to practice medicine.

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7. Overhage JM, Tierney WM, McDonald CJ. Design and im-
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8. McDonald CJ. Protocol-based computer reminders, the

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9. Johnson S. The Rambler. London: Thomas Tegg; Dublin:
R. M. Tims;1826:11.
10. McDonald CJ, Hui SL, Smith DM, Tierney WM, Cohen SJ,
Weinberger M. Reminders to physicians from an intro-
spective computer medical record. Ann Intern Med.
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11. Tierney WM, Miller ME, Hui SL, McDonald CJ. Practice
randomization and clinical research. The Indiana experi-
ence. Med Care. 1991;29:JS57–JS64.
12. Overage JM, Mamlin B, Warvel J, Warvel J, Tierney WM,
McDonald CJ. A tool for provider interaction during patient
care: G-CARE. In: Gardner RM, ed. Proceedings of the 19th
Annual Symposium on Computer Applications in Medical
Care, Oct 28–Nov 1, 1995, New Orleans, LA. Philadelphia:
Hanley & Belfus; 1995 (JAMIA Suppl.) 78–182.
13. Overhage TM, Tierney WM, Zhou XH, McDonald CJ. A ran-
domized trial of “corollary orders” to prevent errors of omis-
sion. JAMIA. 1997;4:364–375.
14. Weed LL, Weed L. Opening the black box of clinical
judgment. Part I: A micro perspective on medical deci-
sion making. eBMJ. 1999 Nov. 13. Available at: http://
www.bmj.com/cgi/content/full/319/7220/1279/ DC2/1.
15. Parboosingh JT, Gondocz ST. The Maintenance of Compe-
tence Program of the Royal College of Physicians and Sur-
geons of Canada. JAMA. 1993;270:1093.
16. Stead EA Jr. A Way of Thinking. A Primer on the Art of Being
a Doctor. Haynes BF, ed. Durham, NC: Carolina Academic
Press; 1995:1.
17. Parboosingh J. Learning portfolios: potential to assist health
professionals with self-directed learning. J Contin Educ
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18. Branger PJ, van der Wouden JC, Schudel BR, et al. Elec-
tronic communication between providers of primary and
secondary care. BMJ. 1992;305:1068–1070.
19. Moyer CA, Stern DT, Katz SJ, Fendrick AM. “We got mail”:
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20. Friedman CP. Anatomy of the clinical simulation. Acad Med.
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21. Waugh RA, Mayer JW, Ewy GA, et al. Multimedia computer-
assisted instruction in cardiology. Arch Intern Med.
1995;155:197–203.
22. Elliott S, Gordon JA. Integration of self-directed computer-
ized patient simulations into the internal medicine ambula-
tory clerkship. Acad Med. 1998;73:611.
23. Human Interface Technology Lab. Surgery simulator evalu-
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edu/projects/sinus/. Accessed 1999 Oct. 22.
24. Issenberg SB, McGaghie WC, Hart IR, et al. Simulation
technology for health care professional skills training and
assessment. JAMA. 1999;282:861–866.
25. National Library of Medicine. The Visible Human Project.
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visible_human.html. Accessed 1999 Oct. 22.
26. Weghorst S, Airola C, Oppenheimer P, et al. Validation of the
Madigan ESS Simulator. In: Westwood JD, Hoffman HM,
Stredney D, Weghorst S, eds. Medicine Meets Virtual Reality.
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1998:399–405.
27. Weghorst S, Airola C, Oppenheimer P. Formal Evaluation of
the Madigan Endoscopic Sinus Surgery Simulator (Septem-
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28. Forrest F, Taylor M. High level simulators in medical educa-

tion. Hosp Med. 1998;59:653–655.
29. MEDSIM. Eagle Patient Simulator Description. Available
at:http://www.eaglesim.com/products/patsim/description
.html. Accessed 1999 Oct 12.
30. Medical Education Technologies, Inc. METI. Available at:
http://www.meti.com. Accessed 1999 Oct. 12.
31. Lampotang S, Good ML, Westhorpe R, Hardcastle J,
Carovano RG. Logistics of conducting a large number of in-
dividual sessions with a full-scale patient simulator at a sci-
entific meeting. J Clin Monit Comput. 1997;13:399–407.
32. Kapur PA, Steadman RH. Patient simulator competency
testing: ready for takeoff? Anaesth Analg. 1998; 86:
1157–1159.

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 REFLECTIONS / JOSHUA LEDERBERG, PH.D.

R E F L E C T I O N S
...

When I approach a problem, I usually immerse myself

in it.
J OSHUA L EDERBERG , P H .D.

Dr. Joshua Lederberg received the Nobel Prize in Physiology or

Medicine for his work on genetic material in bacteria. His discov-
ery of the mechanism of genetic recombination in bacteria and his
career-long work in bacterial genetics provided a principal founda-
tion for contemporary research and biotechnology on gene manipu-
lation in bacteria. Conducting research in artificial intelligence in
the 1970s with E. A. Feigenbaum, he spawned one of the first ex-
pert systems (DENDRAL), a prototype for practical applications of
artificial intelligence. With G. Nossal, he contributed to the con-
ceptual development of monoclonal antibodies by showing that in-
dividual immune cells produce single types of antibodies. Dr.

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Lederberg played an active role in the National Aeronautics and

Space Administration Mariner and Viking missions to Mars. His in-
terest in improving communications among scientists, the general
public, and government policymakers has led him to write exten-
sively for lay audiences on the social impact of scientific progress.

*****
I have never known anyone who exemplifies lifelong
learning more fully than Joshua Lederberg. Throughout
his life he has displayed an insatiable curiosity, wide-
ranging interests, an extraordinary capacity to integrate
information from diverse sources, and unfailing gen-
erosity in exchanging information with his colleagues.
In addition, he is extremely well organized, highly ener-
getic, and capable of making optimal use of computer
technology. One of his trademarks is to send notes with
information and ideas highly pertinent to our own inter-
est based on his monitoring of research publications.
He is always helpful to his students, friends, and col-
leagues. Joshua Lederberg is always keenly aware of
moving frontiers and is constantly searching for ways to
improve the constructive uses of existing knowledge.
D AVID A. H AMBURG , M.D.

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 The Rapid Changes
in Medical Technology

Joshua Lederberg, Ph.D.

Former President and Sackler Foundation Scholar
The Rockefeller University
New York, New York

A s the director of a laboratory in molecular genetics and a con-

sultant on infectious diseases for the government, foundations,
the National Academy of Sciences, and the biotechnology industry, I
have somewhat focused informational needs. All these responsibil-
ities require currency in mechanisms of pathogenesis, innovative ap-
proaches to diagnosis and treatment, drug discovery, and interfaces of
scientific advance with public policy. The changing informational
needs of my various roles have been outpaced by the rapid changes in
communication technology. I have been involved with that technology
for the past 40 years,1,2 but in the past decade it has leaped from the
academic Arpanet to the now-universal Internet.
We are still in the early stages of that transformation and can but
dimly guess its ultimate form. Moore’s law,3 that computer capability
will grow at about 60 percent per year, shows no signs of slackening.
For example, today’s laptop computer far exceeds the mainframe

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“supercomputer” that powered the entire Stanford University campus

40 years ago. And there is every reason to expect a comparable expan-
sion for the next generation. The entire literary content of the world’s
libraries can now be stored in an affordable electronic database and
can be transported and searched globally within the attention span of
human users. It may be some time before the corpus of our technical
data and cultural documents is actually converted to electronic bytes;
that process would be about as cumbersome as scanning documents
through a photocopier. Moreover, many of those documents are on
crumbling acidified paper that will demand special preventive mea-
sures against disintegration.
Electronic preservation carries certain hazards, the byproduct of
rapid technological change. The bytes are not particularly volatile, al-
though perils exist at that level, the more so because of malicious
hackers planting computer viruses. More parlous is the rapidly obso-
lescent hardware for electronic storage. Although everyone was anx-
ious about the Y2K crisis in 1999, few have considered the future
problem of reading the 5-inch floppy disks that were the standard a
decade ago or the stacks of IBM magtapes that were once the status
symbols of electronic sophistication. These concerns, and the ques-
tion of who will pay for assured sustainability, affect most medical
users only indirectly. They become urgent when you are collecting
statistics from patient records of a certain vintage, which, if you are
fortunate, were protected from deterioration and maintained in a for-
mat you can still access.
Of even broader immediate import are the changes in how knowl-
edge is being processed. Starting in the laboratory, bioinformatics
plays an indispensable role in the initial generation and processing of
laboratory data, most dramatically in the burgeoning of genomics.
Every day, new evidence emerges of the association of disease sus-
ceptibility with inherited DNA sequences and of the recognition of
biodiversification of pathogens like human immunodeficiency virus
and Escherichia coli O:157. Authors and readers are impatient if they
must wait months for new findings to appear in print journals, with

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further delays in access to index sources. This problem is somewhat

mitigated now that MEDLINE appears on the Web only a few weeks
after print publications appear. More and more journals are offering
near-simultaneous access to their print and Web versions. Print pub-
lishers have a natural conservatism toward these alternatives because
they jeopardize cost recovery and sometimes substantial profit. The
initiative from the National Library of Medicine to make its PubMed
Central, PMC (http://www.pubmedcentral.nih.gov/), available as a
canonical site to receive Web-based primary papers, opens a new
chapter in this challenge. As Chairman of the National Advisory
Committee to PMC, I am in the crossfire of publishers’ and profes-
sional societies’ demands to protect their financial stability through
copyright monopoly and the scientists’ demands for prompt and unen-
cumbered access to any new scientific knowledge.
There are also contentious disputes about the essentiality of peer
review, although it is mainly high-energy physicists who consider
such a filter dispensable; most biomedical scientists demand such as-
surance before they expend time and energy reading. The open ques-
tion is the extent to which immediate access will compromise quality
and reliability. We will inevitably see many races for priority—au-
thors rushing onto the Web at the first hint of positive data, hoping
that any false starts will be forgotten. Readers will adapt; since they
can scan only a tiny fraction of the overall publications, they will rely
ever more on their agents—reviewers, interpreters, critical experts—
who, themselves, may bear watching. All in all, however, the most im-
portant aspect of peer review is critical discourse after publication,
which should be enhanced by the Web. Such discussions may be ex-
pected to flow from postings on personal Web pages, like http://
profiles.nlm.nih.gov/BB. A hazard here is the author’s ability to erase
yesterday’s allegations, confusing everyone and making authorial re-
sponsibility a requisite for a reliable archive.
If primary professional publication is just making its way onto the
Web, it has been preceded by a tide of didactic material, course out-
lines, bibliographies, news items, and review material, much of it from

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reputable academic sources. One of the best of these is the Ency-

clopaedia Britannica (http://www.britannica.com), which does not
blink at providing pointers to innumerable Web sites and thus ex-
panding its utility as a first stopping place. Similar resources are
being developed in support of clinicians, for example, http://www.
Medscape.com and http://www.pdr.com, both of which provide ancil-
lary connections. Professional societies in general medicine (http://
www.ama-assn.org), as well as specialties (http://www.geron.org), pro-
vide invaluable services with links to many other sites. Users should
evaluate these critically, including the reputation of the sponsors.
These sites are easily found with the search button on the standard
browsers, and journals occasionally publish such lists.
The torrent of commercial peddling (gingko, hypericum, DHEA), is
turning more and more patients toward alternative medicine, although
verifiable evidence of efficacy remains lacking. An urgent task for the
profession is therefore to provide reliable quality control on behalf of
the public. To deal with their patients’ information and misinformation,
primary physicians and specialists will need to familiarize themselves
with this cyber-information, encourage critical discourse, and exercise
judgment regarding reliability, just as medical societies have done for
the flow of print. The volume grows inexorably, but we have powerful
tools to separate the valid from the worthless, and it is our responsibil-
ity to apply them.

REFERENCES:
1. Lederberg J. Digital communications and the conduct of sci-
ence: the new literacy. Proc IEEE. 1978;66:1314–1319.
2. Lederberg J. Options for the future. D-Lib Mag. May 1996.
Available at: http://www.dlib.org/delib/may96/05lederberg.
html. Accessed 2001 Jul 30.
3. Moore GE. Cramming more components onto integrated cir-
cuits. Electronics. 1965;38:114–117.

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 REFLECTIONS / GEORGE D. LUNDBERG, M.D.

R E F L E C T I O N S
...
Dr. George Lundberg received his M.D. degree from the Medical
College of Ohio and completed his residency in pathology in San
Antonio, Texas. He served 11 years in the U.S. Army during the
Vietnam War, after which he was Professor of Pathology and Asso-
ciate Director of Laboratories at the Los Angeles County/University
of Southern California Medical Center, and then Professor and
Chairman of Pathology at the University of California–Davis. From
1982 to 1999, Dr. Lundberg was Editor-in-chief, Scientific Infor-
mation and Multimedia at the American Medical Association. In
1999, he became Editor-in-chief of Medscape on the Internet and
in 2002, Editor-in-chief Emeritus. He was founding Editor-in-chief
of both Medscape General Medicine and CBS Health Watch.com.
Dr. Lundberg’s major professional interests are toxicology, vio-
lence, communication, physician behavior, strategic management,
and health system reform. He is Past President of the American So-
ciety of Clinical Pathologists. A frequent lecturer and radio and tel-
evision guest, and a member of the Institute of Medicine of the
National Academy of Sciences, Dr. Lundberg holds professorships
at Northwestern and Harvard Universities and has received a num-
ber of honorary degrees. In 2000, the Industry Standard dubbed Dr.
Lundberg “Online Health Care’s Medicine Man.”

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 Computers, the Internet,
and Continuing Medical Education

George D. Lundberg, M.D.

Editor-in-Chief Emeritus, Medscape, Inc.
New York, New York
Special Healthcare Advisor
WebMD
Elmwood Park, New Jersey

I n 1966, the U.S. Army sent me to the IBM Education Center in

Poughkeepsie, New York, for a full-week course called Computing
for Physicians. It changed my life. One of my teachers was Donald
A. B. Lindberg, M.D., then an Assistant Professor of Pathology at the
University of Missouri. We became colleagues and lifelong friends.
(Later, when I became Editor of The Journal of the American Medical
Association [JAMA] in 1982, Don became Director of the National Li-
brary of Medicine.) In 1968, I began the Laboratory Automation Proj-
ect at the Los Angeles County–University of Southern California
Medical Center, later extended to the entire nine-hospital system of
Los Angeles County.
Throughout many of these years, I chaired the Computer Commit-
tee of the College of American Pathologists. We held continuing
medical education (CME) workshops all over the country, teaching
pathologists how to automate the data-processing aspects of their

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laboratories and, more important, how to organize the systems flow of

the operations efficiently, whether or not they installed actual com-
puter equipment.
Today, we speak of electronic medical journalism; some of us
even earn our living practicing it. But it is important to remember that
the first fully electronic scientific journal was operational at the Mas-
sachusetts Institute of Technology in 1967. Sometimes it takes a long
time for technology to transfer. In the mid-1980s, the American
Medical Association (AMA) contracted with Mead Data Central in
Dayton, Ohio, to put all the AMA journals onto its computer system—
random access, full-text articles (except for charts, graphs, tables,
and color)—as a product called MEDIS, intended to complement the
existing and successful products LEXIS and NEXUS. This was highly
successful technically, but it failed utterly, as did its competitor, to
create a sustaining market. Then around 1990 came CD-ROM, and I
thought it was terrific, providing quick, cheap, compact, voluminous,
interactive, fully searchable information. We at the AMA put all our
best material onto CD-ROM. It was a technical tour de force, but a
marketing disaster—already a transitional technology whose time has
gone.
The Internet has changed everything in the delivery of informa-
tion and has opened the door to all types of communication. When the
World Wide Web was introduced for medical use in 1994, virtually no
U.S. physicians accessed the Internet, according to my personal sur-
vey, but by 1995, 3 percent of U.S. physicians did; by 1996, 15 per-
cent; by 1997, 30 percent; by 1998, 60 precent; and by 1999, 80
percent. Computers for physician use have finally arrived. The Inter-
net has been described as an entirely new medium, built on many
others, but likely to change all aspects of how we live, just as elec-
tricity did. And that includes CME.
We know that physicians change their practice habits over time,
but that they are generally skeptical of, and resistant to, change. We
know that traditional programmatic CME is popular (even required),
but existing data demonstrate no resulting improvement in quality of

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practice or patient outcomes.1 Why should it be any different if the

CME experience is by way of the Internet? We can only speculate
about this, but there is reason to believe that the Internet could be-
come the most effective means of CME. We know that physicians fol-
low recognized physician leaders,2 and we can take advantage of that
leadership on the Internet easily and inexpensively. In addition, the
Internet can be accessed from almost anywhere there is a telephone,
so physicians can conserve travel time by using the Web for CME.
The Internet is interactive; participation produces active involve-
ment, which is a predictor of behavior change. Of course, the Internet
knows no geographic, political, or cultural boundaries, so we can
teach globally and efficiently. And where certificates of participation
or completion are desired, we can generate them instantly and inex-
pensively for the learner after all proper steps have been met. Now we
need studies to see whether positive behavioral change, and even im-
proved patient outcomes, can follow proper Internet CME.

REFERENCES
1. Davis D, O’Brien MA, Freemantle N, Wolf FM, Mazmanian
P, Taylor-Vaisey A. Impact of formal continuing medical
education: do conferences, workshops, rounds, and other
traditional continuing education activities change physician
behavior or health care outcomes? JAMA. 1999;282:
867–874.
2. Lomas J, Enkin M, Anderson GM, Hannah WJ, Vayda E,
Singer J. Opinion leaders vs audit and feedback to imple-
ment practice guidelines. Delivery after caeserian section.
JAMA. 1991;265:2002–2207.

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 5

The Medical Library

...
The medical library of the 21st century is no longer a
structure housing a collection of print books, journals,
and multifarious documents, but a resource accessible
electronically from distant sites and capable of provid-
ing pertinent information at the point of need.
P HIL R. M ANNING , M.D., AND L OIS D E B AKEY, P H .D.

“E ven more dramatic changes in library services and informa-

tion management are occurring and will occur in the next de-
cade.” This statement concluded the chapter on “The Institutional
Medical Library” in the first edition of Medicine: Preserving the Pas-
sion published in 1987, and its prescience for the revolutionary
changes over the past 16 years cannot be disputed. Both availability
and ease of access to medical information have dramatically in-
creased during that period, providing clinicians with new and power-
ful options for continuing the process of lifelong learning and
expanding the important role of librarians in healthcare.
Medical librarian William Clintworth explained: “Technology has
affected the operation and resources of libraries and is the driving
force in transforming the current concept of the library from a cen-
tralized physical source of information to a resource for information at

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any time or place. Technology has made the rapid dissemination of re-
search and clinical data possible, and users demand its accessibility
at the point-of-care or where needed most.” In the words of Clarence
P. Alfrey, “A major event has been the essential transfer of the library
into each user’s office so that we can rapidly retrieve, from a multi-
tude of sources, a wide variety of information on almost any conceiv-
able medical problem. The Internet offers a remarkable opportunity
to look at the interactions of multiple factors, one upon another, since
we can so easily search using a variety of different criteria.”
Several milestones in information management have contributed
to the evolution of the medical library, according to Clintworth: “In
the mid-1960s, the National Library of Medicine (NLM) pioneered
the development of MEDLINE, one of the world’s most sophisticated
and comprehensive on-line bibliographic databases. No longer was it
necessary for physicians to search the printed Index Medicus manu-
ally for relevant journal articles on topics of interest. For the following
two decades, physicians relied on librarians to act as intermediaries
between them and the MEDLINE database. The physician described
the information needs, and the medical librarian constructed a search
strategy to retrieve the relevant citations and abstracts.
“In the late 1980s and early 1990s, MEDLINE and related bio-
medical databases became more widely available through a variety of
sources, both commercial and academic, and in different formats, in-
cluding CD-ROM. It became commonplace for physicians to do their
own searches by interacting directly with the database. As a result,
the role of the medical librarian shifted from a search intermediary to
an educator who designed classes, workshops, and tutorials to in-
struct physicians in retrieval techniques and in understanding the
structure and complexity of the databases to be searched.
“The rapid expansion of the Internet and the development of the
World Wide Web in the mid-1990s further fueled the physician’s in-
terest in online searching. As a result, dozens of search systems were
developed to meet the growing need and to provide more user-friendly
bibliographic searching strategies. One such effort by the National

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Like everyone else, physicians will need to know where

to find the latest information, rather than try to store an
avalanche of data in their heads. And they will have to
use the computer to find the articles they really need.
D ONALD A. B. L INDBERG , M.D.
Director, National Library of Medicine

Library of Medicine was Grateful Med, later developed into the Web
version, Internet Grateful Med. The National Center for Biotechnol-
ogy Information at NLM developed PubMed, employing a different in-
terface and incorporating additional features. It, too, was directed
primarily to the novice searcher.”
In 1997, the National Library of Medicine’s announcement that
access to their databases through either PubMed or Internet Grateful
Med would be free resulted in an explosion in the number of searches
on the NLM system by health professionals, as well as patients and
their families. According to National Library of Medicine Director

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Donald Lindberg, physicians and librarians, who had primary access

to the NLM databases before 1997, conducted about seven million
searches a year. In 1998, when NLM’s largest database, MEDLINE,
could be accessed at no charge on the World Wide Web, the searches
rose to 75 million and have continued upward. According to NLM es-
timates, the public alone conducted 51 million searches of the NLM
databases during the year 2000.
Medical librarian David Morse pointed out that some librarians
have sounded a note of caution regarding the new accessibility of in-
formation: “The availability of more tools is good news, but, like any
other form of medical instrumentation, powerful professional tools
must be properly used, and even physicians who are relatively confi-
dent of their searching skills would do well to consult a librarian oc-
casionally to ensure proper usage or to enlist help designing specific
search strategies. It is all too easy to get an apparently satisfying re-
trieval of information from a database when that may actually repre-
sent only a small percentage of the relevant information.”
Recognizing the intense public interest in accessing consumer
health information, librarians are focusing on the development of col-
lections and Web sites that provide patients and their families with im-
proved methods of accessing relevant, up-to-date information to meet
their healthcare needs. Robert Beck believes that physicians may even
direct patients to the medical library for help in sifting through the
available information. Patients who want to research clinical topics in
depth may receive guidance in distinguishing between relatively con-
clusive and more questionable clinical studies and in finding other pa-
tient health information resources. Patient health information, some
reliable, some not, is now flooding onto the Internet, presented by spe-
cialty organizations, patient advocacy groups, the government
(http://www.healthfinder.gov), and a multitude of new business entities.
In Donald Lindberg’s words, “Having access to timely and critical
health information is important not only to healthcare professionals
and faculty, but also to patients, their families, and the public. Li-
braries need to create that link for all their customers.” If patients are

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to take greater initiative in maintaining their health, access to health

information is vital.
William Clintworth believes that perhaps the most significant de-
velopment in the initiation of remote use of library services was the
advent of digital full-text journal content: “Beginning in the mid-
1990s, not only could physicians search electronically for relevant ci-
tations from medical publications, but they could also link to full-text
journal articles, including accompanying tables and graphics. Users
began accessing online journals at an astounding rate, and continue
to do so primarily because electronic access has now become integral
to the daily work of clinicians and academic physicians. This demand
will only accelerate. Researchers, clinicians, faculty, and students
will expect to access journal articles from any remote site. To keep
pace with the demand for, and the proliferation of, information in the
next decade, libraries will have to increase electronic access to addi-
tional journals. Just as libraries currently pay for and manage institu-
tional print subscriptions, one of their key roles will be to finance and
arrange access to electronic resources for their users. In most cases,
access is available through the institutional Internet Protocol (IP) ad-
dress of the computer being used or through authenticated user
names and passwords issued and maintained by the institution.”
“Even if the library of the future houses fewer print information
resources,” added David Morse, “the library as an organizational unit
will continue to play a critical role in selecting, licensing, organizing,
and publicizing resources not necessarily housed in the library. The
library’s critical mission will be to maximize the benefits of the insti-
tution’s information resources budget.” Although physicians may sub-
scribe individually to commercial electronic resources, they may also
have access to their parent institution’s library through site license
agreements. Licensed resources include not only electronic journals,
but also databases and electronic books.
The Internet has also spawned an endless variety of medical Web
sites for health professionals. Sponsorship includes professional
organizations, medical societies, commercial firms, publishers, foun-

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dations, governmental agencies, and nonprofit organizations. “Al-

though these sites focus on the specific needs of the medical commu-
nity,” explained Clintworth, “the content of these sites varies
considerably. Many incorporate up-to-the-minute medical news and
developments regarding a specific disease condition or medical spe-
cialty or simply general information about drugs, treatments, high-
lights from recent publications, practice management, CME
opportunities, medical meetings, and links to other key sites in medi-
cine. Many, such as Medical Matrix (http://www.medmatrix.org) or
Medscape (http://www .medscape.com), have editorial boards and on-
site peer review. Medical libraries maintain Web sites to publicize the
electronic resources licensed for use by their clientele, to provide ac-
cess to locally developed information, and to link to selected Web
sites of interest to their users. They also provide training in the use of
the Web and teach Web page development skills to help their institu-
tions create such sites.
“Once again, the introduction of mobile computing within the
past two years is quickly changing how physicians obtain and use in-
formation in clinical practice and teaching. Already students, resi-
dents, and physicians in hospitals and clinics are using portable
personal digital assistants (PDAs) to access drug information, elec-
tronic books, and medical calculators and to record and organize clin-
ical notes and patient data. Web sites devoted to medical applications
of PDAs have proliferated, two of which are pdaMD (http://www.
pdamd.com) and Handheldmed (http://www.handheldmed.com). As
wireless networks become ubiquitous in the next decade, the use of
information tools at the point-of-care will accelerate.” Libraries will
need to continue expanding the information formats to provide physi-
cians and students with new and efficient technologic applications.
In Clintworth’s view, “In addition to disseminating information
more widely during the next 10 years, libraries in academic medical
centers will also significantly broaden their responsibilities within
their parent institutions. Information management will no longer be
narrowly restricted to traditional library services, but will extend to

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organization and management of the plethora of research and clinical

data generated within a healthcare enterprise. This invaluable insti-
tutional asset, unfortunately, is vastly underused in most complex ac-
ademic medical environments. Currently, massive amounts of data
are created and used through a myriad of independent systems to
meet specific clinical and research needs, but because of lack of inte-
gration among these systems, data remain isolated in the unit in
which they were created and are, therefore, unusable in multiple con-
texts. Sacrificed are opportunities for collaboration; data mining for
research, patient care, and educational applications; and efficiency
gained through non-redundant data collection and management. Li-
brarians, as information specialists skilled in database use and de-
sign issues, can be effective partners in solving these problems.”
Robert Beck thinks that “The rise of powerful computers, an em-
powered patient population, and Internet technologies are leading to
the development of Web-enabled electronic medical records (EMRs)
for ambulatory care. The next wave in access to health information
will be the integration of electronic information resources with the
electronic medical record.” Morse added: “Presumably, many of the
important links from the EMRs will be to databases of possible drug
interactions, normal and pathologic laboratory values, diagnostic al-
gorithms, and the like, which will then be secondarily linked to the
pertinent journal articles. The computerized patient-problem list and
the list of drugs the patient is taking will link automatically to rele-
vant publications, and searching will be an option on the EMR
browser.”
Will print collections still be necessary given the proliferation of
digital information? “Absolutely,” according to Clintworth. “Digital
and print formats have different characteristics, each format serving
specific functions and critical needs. Digital information offers sev-
eral key advantages, including rapid access and search capabilities,
inherent flexibility of format options, adaptability for integration in
different software applications, and instant linkage to other informa-
tion sources. Digital information is an extremely useful tool, but it

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cannot in the foreseeable future ensure permanence. Compared to

paper, digital information is highly vulnerable to physical degradation
and obsolescence as a result of superseded technologies. Paper can
be preserved in a usable form for hundreds of years, whereas the
lifespan of magnetic data is only of 10 to 30 years. Optical storage for-
mats have a longer physical lifespan but, as with magnetic data, are
unreliable for long-term storage and usability because of no accepted
standard for guaranteeing continued access. Furthermore, publishers
of electronic content often only lease access to the data, such access
terminating once the lease terminates. It is crucial for academic li-
braries not only to provide current access to materials but also to pre-
serve the scholarly record for future users. Until libraries can be
assured that digital information can meet the archival standards nec-
essary for continuity, they will need to maintain print, as well as digi-
tal, collections.”
As Morse pointed out: “Few electronic versions of journals offer
backfiles of more than five years, so much clinically relevant infor-
mation must still be sought in the library stacks. As libraries begin to
drop their print subscriptions in favor of strictly electronic ones,
archiving will become critical. Publishers may not find it economi-
cally advantageous to maintain online files for more than 10 or 15
years, and publishers have a bad habit of going out of business. It is
not clear which institution(s) will bear the ultimate responsibility of
ensuring the permanence of the electronic record, but academic li-
braries, national libraries, publishers, and scientific societies should
work together closely to avoid catastrophic gaps in the scientific
record.”
“The next 10 years,” Clintworth predicted, “will bring enormous
opportunities for health sciences libraries as a result of the unprece-
dented new technologic tools being spawned and the rapidly chang-
ing healthcare environment in which information has a pivotal role.
Even the traditional medical school curriculum is currently shifting
from lecture-based formats to problem- and case-based approaches to
foster analytical and lifelong learning skills. In the coming decade,

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this shift in emphasis will see the integration of health sciences li-
braries into the formal curricula for instruction of medical students in
the informatics skills needed to use information resources effectively
throughout their careers.”
Lindberg emphasized the need for physicians to become com-
puter literate in order to keep abreast of the latest medical informa-
tion: “Like everyone else, physicians will need to know where to find
the latest information, rather than try to store an avalanche of data in
their heads. And they will have to use the computer to find the arti-
cles they really need.”
In the words of Morse: “Librarians of the 21st century are no more
defined by the physical building in which their offices are housed
than physicians are defined by the hospital at which they have privi-
leges. As the role of electronics increases, the walls of the library will
gradually become transparent, but the need for information profes-
sionals to manage, navigate, and explicate the electronic library will
only become more pressing as the universe of available information
continues to expand.”

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The Collegial Network

...
To hold him who has taught me this art as equal to my
parents and to live my life in partnership with him, and
if he is in need of money to give him a share of mine,
and to regard his offspring as equal to my brothers in
male lineage and to teach them this art—if they desire
to learn it—without fee and covenant; to give a share of
precepts and oral instruction and all the other learning
to my sons and to the sons of him who has instructed me
and to pupils who have signed the covenant and have
taken an oath according to the medical law, but to no
one else.
H IPPOCRATES 1

W hen one of us (P. M.) visited Timbuktu, Mali, the native physi-
cian, upon learning that a visiting physician was in town, went
to the hotel. Although he spoke no English, the conversation, through
an interpreter, immediately turned to medicine, lasted six hours, and
included discussions of patients, practice, and medical education.
A major advantage of being in the medical profession is the warm
spirit of fraternity among physicians the world over. After the intro-
ductions, it does not take long for two physicians who have never met
to become deeply engaged in conversation about the differences and

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similarities in their practices. This camaraderie is often most dra-

matic when physicians are visiting foreign lands, but physicians in of-
fices and hospitals have similar educational discussions daily about
patients and practice.
Social interaction can promote intellectual stimulation and satis-
faction from learning and can enhance memory. “The current ava-
lanche of information threatens to overwhelm me,” confessed Irvine
Page. “What to do about it? I learn by associating facts with people.
For example, in 1935, at a meeting of the Central Society in Chicago,
I had lunch in the Cape Cod Room of the Drake Hotel with Dr. W. W.
Herrick. Two things I have never forgotten: first, we had red snapper
soup with a small cruet of sherry on the side—a new experience for
me; second, Dr. Herrick told me that when he first described coronary
thrombosis, the presentation fell like a lead balloon. The result: after
nearly 50 years, I have forgotten neither red snapper soup with sherry
nor Herrick and his experience in introducing a new idea.”
Studies have documented the strength of the information network
among physicians, which, although informal, provides mutual support
for lifelong learning.2 – 5 Physicians are constantly providing informa-
tion to, and receiving it from, their colleagues to help resolve clinical
problems. Thomas Wood believes that his greatest source of learning
probably comes from interaction with his colleagues in consultations
and informal discussions, as well as in a journal club. “Receiving
current medical information from a trusted medical colleague,” he
finds, “is often as persuasive and useful as the physician’s own de-
tailed statistics on a particular subject.”
The lifelong student of medicine becomes eligible to join a so-
phisticated information network by associating with excellent clini-
cians who are also excellent teachers. You must, of course, uphold
your own responsibility in such relations by willingly providing accu-
rate information and contributing your own medical experiences, as
well as asking thoughtful questions and listening attentively. It does
not pay to be a leech or to try to dominate the relationship. As Francis
Moore pointed out, “The more you have to contribute to the education

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of others, the more welcome you will be in an informal network and

the more mutual benefit you and the group will receive.”
“As you grow older, it becomes more and more important to asso-
ciate with young physicians,” said Alvin Schultz. “They keep you
from withering. They don’t accept your answers easily; you have to
document what you say. And they have a lot of new ideas.” Con-
versely, young physicians can also profit from the rich experience of
older physicians, who are usually anxious to extend a helping hand.
Although you will want to associate with the best informed physi-
cians, you can learn from any colleague. “Even though you may have
been the top student at the best medical school and the best resident
at the best hospital,” counseled James Moss, “every physician you
meet will probably know more than you about some aspect of medi-
cine. If you watch him and listen to him, you will discover much that
you didn’t learn in medical school, and you will then be able to share
these new ideas with others.”

LEARNING WITH COLLEAGUES

“I really don’t begin to think until I am in a situation where there is an
exchange of ideas, where my opinion is sought, considered, and per-
haps challenged, and where some conclusion is reached,” said Jack
Tetirick. “The stimulation and the satisfaction of learning come only
through social interaction. Maintaining skills in the practice of medi-
cine requires the opportunity to demonstrate those skills to col-
leagues, with the attendant reinforcement and bolstering of the ego,
and then that gentle dangling hook of the fear of losing the circle of
approving peers.”

Group Practice
Richard Treiman enjoys the advantage of sharing common problems
that group practice affords. “It is nice,” he finds, “to be able to talk
over a clinical problem with an associate who is intimately interested

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and who will see the patient without a formal consultation or charges.
When you run into difficult problems, sharing responsibility relieves
the anxiety about whether you are doing the right thing. Every physi-
cian should have someone available to share his experiences with.”
The stimulus of association with a group helps physicians maintain
their academic interests and expertise.
Wallace Chambers described the advantages of his group practice
thus: “In addition to having discussions almost every hour of the day,
we have occasional lunches, and we usually go to breakfast on Fri-
days, after which we have rounds and see all the group’s patients to-
gether.” Neil Elgee also values the support he receives in group
practice: “With 14 of us practicing together, I have an expert on just
about everything at my beck and call. I can reach for the phone and
pick my colleagues’ brains. It is amazing how that takes care of my
needs.”
Some groups schedule a specific time weekly or biweekly to dis-
cuss particular problems of patients under care, an immediately re-
warding practice because the discussion is tied to existing problems.
In Robert Volpe’s clinic, at the end of the day, several patients are
kept—provided they are willing—and their problems are discussed
with the staff. “The patients have a chance to speak, and seem to ap-
preciate this. It is one of the highlights of our practice.” The late
Lorin Stephens belonged to a group of eight orthopedists who closed
their offices for two and a half hours Monday mornings to discuss
their problem patients. When they felt they needed outside help, they
called on an expert, usually a faculty member from a nearby medical
school, whom they would pay an honorarium. Sadahiro Yamamoto de-
scribed a practice in Japan: “Groups of private physicians in Japan
organize their practice in a way that allows them to invite specialists
from the larger hospitals to speak periodically at their offices.”
Desmond Julian considers it crucial to go outside a close-knit
group from time to time: “The little conferences among members of
group practices are sometimes reinforcements for one another’s igno-
rance. One thinks somebody is a specialist in a certain subject

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whereas, in fact, he may really be a subspecialist who is considered to

have a degree of expertise he doesn’t possess. In this kind of contact,
the specialists must understand their own limitations.”
Some practice groups, such as Jean Creek’s, have established
sabbatical policies similar to those in universities. The younger mem-
bers of his group have used the sabbatical to finish subspecialty cer-
tification, whereas Creek has used it to expand his knowledge of
specific diseases. He spent six months of a sabbatical in rheumatol-
ogy, for example, at Hammersmith Hospital in London and the other
six months in the rheumatology service at the University Center in In-
dianapolis. Although he does not plan to announce himself as a
rheumatologist, he found the experience most helpful because there
is no rheumatologist in town.

Solo Practice
Although physicians in group practice may have the edge in develop-
ing relations with colleagues, the individual practitioner also has
ample opportunities to develop collegial relations through his hospi-
tal, local medical society, and even medical centers where he has
trained or visited.

Academia
Physicians in academia learn by going to conferences and seeking out
people who have answers to their questions. Richard Byyny, for exam-
ple, can walk down the hall and find an oncologist, immunologist, or
dermatologist with whom to discuss a problem. Manuel Martinez-
Maldonado has established a practice in a Veterans Administration
hospital that would also work in group practice and even with nonaffil-
iated physicians. “Every Friday afternoon I hold a session at which
house staff members can present any case they want. I encourage the
staff to bring me cases outside my specialty of nephrology. We develop
a working list of no more than four or five possibilities according to the

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history and physical examination of the patient, and then rearrange the
list in the most logical, time-saving, and economical way of determin-
ing the diagnosis or excluding the one we have entertained. This tech-
nique has been extremely effective because it has helped the house
staff think about the tests that are essential for diagnosis.”
When Lawrence Cohn has puzzling patients, he turns to standard
textbooks for a quick survey, to a reprint file, and, most important, to
his colleagues on the cardiac surgical service. For a truly unusual
case involving something that he and his colleagues have never seen
and about which little has been published, he calls a colleague in an-
other city or country.

Curbstone Conferences
Impromptu encounters among colleagues are a useful adjunct to life-
long learning. At such “curbstone” conferences, one physician will
question another about a clinical problem or about a new drug or di-
agnostic procedure. Curbstone consultations offer advantages for both
parties. The inquiring physician often receives an answer or is di-
rected to a pertinent reference. The consulting physician, through
this opportunity to teach, is required to review personal experience
and thus strengthens an understanding of the problem. In addition to
practical education, the impromptu encounter provides a brief period
of relaxation from the physician’s busy routine.
A physician should not hesitate to ask colleagues appropriate
questions, but also should not become overly dependent on others.
Such dependence is not likely if we organize our thoughts carefully,
study the published information on the subject, and then ask appro-
priate questions. Kenneth Berge recognized this problem: “I work
hard at solving problems rather than ask for help prematurely; that is
a particular temptation in subspecialty and superspecialty institu-
tions. There is always someone around who knows more about a cer-
tain subject than I do. I have found that the best way for me to learn is
not to call that person immediately, but to bring the problem to a little

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better state of resolution in my own mind first, and then ask the ques-
tions when I am really backed up to the wall. This procedure estab-
lishes whether I really do not know the answer—that after having
taken the time to search for it, I have been unable to find it myself.”

The Telephone
Francis Moore advocated wider use of the telephone for consultations.
“One of the advantages of going to a meeting is that you hear someone
talk about a difficult case of intestinal obstruction, for example, and
later are able to call him and see how he would handle the patient you
now have. Many of us have developed close relations with peers
around the country and freely discuss our patient problems with them
by telephone.”
Frederick Ludwig, the sole surgeon in a rural institution with
eight other physicians, calls various consultants around the country
when a problem arises in the operating room. “When I am in a tough
situation in the operating room, I simply pick up the phone and call a
consultant. Using the telephone freely has greatly enhanced my abil-
ity to care for my patients.” Don’t be bashful about calling a colleague
for an opinion: most are flattered by such a call. Medical school fac-
ulties are almost always willing to answer questions.
R. J. Williamson belongs to a telephone network: “In the commu-
nication system of our hospital, we all have telephone lines in our of-
fices tied into the hospital with a three-digit number. Through my
extensions in my office and at home, I can dial any extension in the
hospital. I can dictate from any one of those extensions into the hos-
pital, or I can do it by long distance.”
The University of Alabama has established an excellent tele-
phone consultation service for physicians in the state, Medical Infor-
mation Service via Telephone (MIST). Using a toll-free number to dial
the MIST office, the physician states his problem, which is then
immediately referred to the proper faculty member for his advice.
Although few medical schools have such a formal telephone

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consultation service, most faculty members, especially those most

highly regarded, receive calls regularly from former students, resi-
dents, fellows, and other physicians. Thus, the telephone provides
quick access to information and expert clinical judgment.

Correspondence
Some physicians develop teaching/learning associations through cor-
respondence. Andrew Dale, for example, maintains a sizable corre-
spondence. “When I read an article of special interest about which I
have questions, I dictate a letter to ask the author about it or state why
I disagree with him. Then he will respond with what he thinks. The
exchange is always profitable.” Correspondence may be especially
useful for communicating with fellow physicians in other countries,
and today e-mail expedites communication.

S I T E S O F C O L L E G I A L C O N V E R S AT I O N S

The Lunch Table

Paul Beeson stated the case clearly: “I have always been impressed by
the value of the lunch table, where you can sit down and discuss an in-
teresting case. Our profession, after all, deals partly with guess work;
we do not deal in absolutes. A solo practitioner is at a terrible disad-
vantage because he does not have other people to bounce ideas off, and
so the lunch table can be a particularly valuable tool for him. Medical
students learn a great deal from other students and from informal con-
versations and contacts. This is the knowledge that sticks; it is study in
connection with a case rather than study in isolation, reading in books.”
Too often, however, conversation at lunch drifts to automobiles, the
stock market, and golf. With just a little effort, physicians can derive
greater benefit and enjoyment through discussion of medical topics.
H. Ralph Haymond finds that immediately after reviewing a topic is a
good time to start conversations on the subject with your colleagues at
lunch or elsewhere. “Not only will they be impressed with your knowl-

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edge, but they may fill you in on some aspects of the topic that you
have overlooked. Even chance encounters can prove valuable.”

The Bedside of Other Physicians’ Patients

Gustavo Kuster described the cooperative spirit among the surgeons
at his hospital: “Every week the general surgeons make rounds on all
the patients we have in the hospital. We do not fully examine every
patient unless one of our colleagues needs an opinion. Instead, we are
simply overseeing what is happening within our division. An ex-
change of opinions ensues. If I do a certain operation, I have to justify
it to my colleagues.”
Ian Mackay advocates inviting specialists, like pathologists and ra-
diologists, on hospital rounds and clinical conferences. “They make ex-
cellent contributions. Someone on the service should make sure,
however, that they are well briefed on the problem to be discussed. It is
unfair to throw a strange laboratory result at them and ask them why the
laboratory data do not agree with the clinical impression, with the im-
plication that something went wrong in the laboratory.”
Bedside rounds with colleagues are most common in teaching
hospitals, but all physicians will find the exercise an opportunity for
broadening their clinical outlook.

Study and Discussion Groups

. . . I had form’d most of my ingenious Acquaintances
into a Club for mutual Improvement, which we called
the Junto. We met on Friday Evening . . . . Our Debates
were to be under the Direction of a President, and to be
conducted in the sincere Spirit of Enquiry after Truth,
without Fondness for Dispute, or Desire of Victory. . . .
B ENJAMIN F RANKLIN 6

In 1911, because Winston Churchill was denied membership in a

dining club originally founded by Sir Joshua Reynolds and Samuel

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Johnson, he established, with Mr. F. E. Smith, a club of his own,

called “The Other Club.” The membership included such prominent
men as Generals Kitchener and Montgomery and H. G. Wells.
Churchill invited only those whom he considered both estimable and
entertaining. “The Other Club” had such significance for Churchill
that he insisted on attending even at the height of the Blitz in 1940
and 1941.7 For this group, politics was the main topic of conversation,
but physicians can also profit from medical discussion groups, and,
as with Churchill’s group, the sessions are most effective when the
members are both estimable and entertaining.
Medical colleagues with similar practice problems can profit
from discussing individual experiences related to a current clinical
problem.
David Covell reflects: “The study group at Huntington Hospital is
nearing its twenty-fifth year of 7:30 a.m. Tuesday meetings. Through
all this time, from five to nine internists have met weekly to review
cases. The continued pleasure we experience is due partly to sharing
our individual experiences with similar cases (and noting how diag-
nosis and treatment of common entities have changed over the long
careers of most of us), and partly to the collegiality and lack of one-
upmanship the group has fostered. At present, three of the group of
seven are retired. Four are in active practice, and one is a young
woman in her first year of private practice who brings us a wealth of
information about new procedures and devices. Surely the love of
learning medicine is the glue that holds the group together.
“We decide what we would like to study, make assignments for
each of us to present material, informally discuss the material, and
thus learn from one another’s experiences. Usually we choose patient-
related self-study programs, such as the ACP–ASIM Medical Knowl-
edge Self-Assessment Program (MKSAP) or similar material from
major textbooks or medical centers, but the primary value of our
group lies in the discussions generated and their relation to our own
practice. It is not all serious, however; we enjoy one another’s jokes
and gripes. Of course, the group would not have lasted so long if we

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did not all get along. Combining the fun of learning something useful
with the fun of a bull session has helped to keep the study group going
all this time.”
Kunio Okuda of Chiba, Japan, who endorses weekly study ses-
sions to discuss puzzling patients, believes that occasionally inviting
young, academically oriented physicians to join the group enhances
the discussions.
John Premi and others have developed the Practice Based
Small-Group (PBSG) program, which was launched in 1992 as a
community-based, peer-led educational program. Groups of physi-
cians are organized in their own communities, and one of their mem-
bers is a trained educational facilitator. They meet at a time and place
of their choosing to discuss PBSG-developed educational modules
with or without their own clinical cases. The program has grown rap-
idly, with a current enrollment of 2700 physician participants orga-
nized in more than 400 groups representing all 10 Canadian
provinces and both national territories. The concept of practice-based
learning is also being adopted by residency programs in family medi-
cine, with 12 to 16 residency programs in Canada participating. (Four
peer-led groups and two residency programs in the United States are
also involved in the PBSG program at this time.)
A typical module starts with one or more case histories designed
to reflect common family-medicine practice problems, each case
accompanied by questions to stimulate reflection on the key issues.
The second part of the module contains a critically appraised sum-
mary of relevant medical publications, followed by an educational
commentary outlining application of the published material to the
clinical case, specifically addressing issues arising from the ques-
tions posed. The commentaries also identify and suggest ap-
proaches for the management of barriers to change that may arise
when the proposed solutions are applied to practice. Modules are
written by practicing family physicians, with support from experi-
enced educators. Educational materials are reviewed by one or
more specialists in the relevant field.

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Initial evaluation of the program showed an increase in the knowl-

edge of participants as compared to a control group.8 In the year
2000, a randomized controlled trial involving four cohorts of PBSG
groups compared the effectiveness of the PBSG process with that of
personal audits on the prescribing behavior of the participants.9 Of
the four possible group interventions (PBSG module alone, PBSG
module plus personal prescribing profile, personal prescribing profile
alone, and control), all active interventions resulted in statistically
significant changes, the combined intervention of prescribing profile
and PBSG modules leading to the greatest change.

Visits to Hospital Departments of Pathology and Radiology

and the Clinical Laboratory
Pathologists, radiologists, and the clinical laboratory staff are often
major teachers in a community hospital. Sir John McMichael, for ex-
ample, profited greatly from his visits to the pathology department.
“Every day I was on duty at Hammersmith, I went to the postmortem
room, and never came away without having learned something; often I
was a bit humiliated.” Ian Mackay confirmed these visits: “Sir John
says he visited the postmortem room every day, and he did. He never
missed. Unfortunately, at our postmortem room the presence of a con-
sultant is a rare event.”
The radiologist should be consulted personally to help with the
choice of radiologic studies needed in difficult cases. Oscar Balchum
stressed the value of personal communication: “I learn a great deal
from the radiologist. I personally review with him the results for every
patient rather than depend on written reports. Often, the radiologist
may suggest pertinent articles to read.” Edward Shapiro and his part-
ners start their rounds with a visit to the radiology file room. “We go
over the files with the radiologists, an experience that has shown the
variation in interpretations and opinions among individuals.”
“Forming a close relation with the staff of the hospital clinical
laboratory, to discuss the indications and outcomes of certain labo-

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ratory studies, new tests, and unusual results, is an easy way to ac-
quire surprisingly useful bits of knowledge,” in Joseph Lydon’s ex-
perience. “From my earliest days I sought out peers whose interests
were somewhat different from mine. I made it a practice to ‘pick
them clean.’ I would lunch, lounge, loiter, or take advantage of any
contact. As a surgical resident, for example, I would lunch with
those who were working in the forefront of hypertension. On slow
evenings I would go through the x-ray teaching file with radiology
residents who were studying for their Boards. I would hang around
the pathology laboratory and look at any specimen that came in. I
continued this practice with ophthalmologists, orthopedic surgeons,
and cardiologists.”

Visits to Other Medical Centers

Will and Charles Mayo made a practice of visiting medical centers in
the United States and around the world to learn different surgical
techniques and policies. One brother would travel while the other
maintained the practice. This arrangement was highly successful for
the Mayos, who soon developed a leading medical center that at-
tracted, and welcomed, visiting physicians from all over the world.10
Today, many physicians, especially surgeons, visit medical cen-
ters regularly. Occasionally, Frederick Ludwig will visit a medical
center with a patient he is referring. Frederick O’Dell, who practices
in a small community, takes off a week or two every two years to go to
Ann Arbor, to Boston, or to Houston, where he observes in the operat-
ing room, speaks with the residents, and makes rounds with surgeons.
“You can get a lot of useful hints from residents and junior members
of the faculty. Not only is the experience enlightening, but it also al-
lows me to form close relationships with many people.”
Gustavo Kuster also finds traveling beneficial. “I try to spend one
or two weeks every couple of years in centers outside my immediate
area—the Midwest or Europe. The instruments and techniques used
are considerably different.” Additionally, in learning a new surgical

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technique, he has found it useful to invite a guest surgeon to assist

him when he cannot master the technique simply by reading.
A more formal visit may be desired by some physicians. “Unless
a physician is in a teaching institution,” explained David Sabiston,
“he may continue to practice about the same kind of medicine as
when he finished his residency. We have mini-residencies at Duke for
graduates from outlying areas who can spend two weeks or longer
making daily rounds with a particular specialist. These are much bet-
ter than courses because they allow participation in actual practice,
where there is give and take and not just presentations with a stiff
question-and-answer period.”
Some medical centers are better equipped to receive visitors than
others. To avoid inconvenience and disappointment, a prospective
physician should have specific goals in mind and make arrangements
well in advance of the visit.

Recreational Sites
Fred Turrill likes not only to work with colleagues but to play with
them as well—at golf, tennis, fishing, or hunting—and finds that such
relaxation with colleagues is a pleasant way to learn. “Not only do you
get to know your colleagues better, but you also learn from the med-
ical discussions.”
“Perhaps the greatest learning method of all,” according to
Desmond Julian, “is to be sharing a ski lift with a distinguished col-
league who can pass on his expertise to you. He is trapped with you,
he is probably in a very good mood, he is preparing for the onslaught
of the ski slopes, and he is prepared to speak to you very honestly
about what he does. One of the problems about many formal presenta-
tions is that we speak in generalities and not about specific problems
we encounter or about our shortcomings. We miss physical signs. We
misinterpret investigations. Until you talk to someone very frankly, as
you can on a ski lift, you really don’t find the truth.”

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L E A R N I N G F R O M O T H E R H E A LT H P R O F E S S I O N A L S
A mutually beneficial collegial relationship can also be developed
with other members of the health team. Brian Goodell advocates hav-
ing office staff involved in its own and the physician’s continuing ed-
ucation: “If it is a small office staff, you can assign tasks for the
collection of relevant information. If someone in our office has read a
particularly good article, he will have it copied, distribute it to every-
one else who might be interested, and then label and file it for every-
one’s future reference. Nurses are particularly important resources for
this purpose.” Desmond Julian thinks he has probably learned more
about his patients and practical nursing problems from informal dis-
cussions with nurses and other health personnel at coffee and lunch
than from the formal sessions.
Joseph Gonnella regrets that physicians do not take full advan-
tage of pharmacists’ knowledge: “We still visualize that profession to
be the old-time druggist, but in many hospitals there is someone who
knows the side effects of drugs better than the doctors, and that is the
clinical pharmacist. Some of us, in fact, have graduate students in
pharmacy making rounds with us. The director of our pharmacy is a
good friend, and since I know he is interested in evaluation of drugs,
he and I are always asking each other questions.”

*****

This section has highlighted informal learning methods that

physicians use each day. These methods may seem self-evident and
unsophisticated, but they exemplify the multitude of possibilities
available to physicians to profit from the experience of others, to
weave education into social and recreational events, and to organize
and test thoughts on medical problems. The collegial network in med-
icine is real and extremely active. It is one of the dividends of being a
physician and, if nurtured, will enhance not only the physician’s
knowledge but his enjoyment of practice.

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REFERENCES
1. Edelstein L. The Hippocratic oath: text, translation and in-
terpretation. Bull Hist Med. 1943;(Suppl 1):3.
2. Manning PR, Denson TA. How cardiologists learn about
echocardiography. Ann Intern Med. 1979;91:469–471.
3. Manning PR, Denson TA. How internists learned about
cimetidine. Ann Intern Med. 1980;92:690–692.
4. Stross JK, Harlan WR. Dissemination of relevant informa-
tion on hypertension. JAMA. 1981;246:360–362.
5. Stross JK, Harlan WR. The dissemination of new medical
information. JAMA. 1979;241:2622–2624.
6. Franklin B. In Farrand M, ed. Benjamin Franklin’s Memoirs.
Berkeley: Univ California Press; 1949:152.
7. Colville J. Winston Churchill and His Inner Circle. New
York: Wyndham; 1981.
8. Premi J, Shannon S, Hartwick, et al. Practice-based small-
group CME. Acad Med. 1994;69:800–802
9. Herbert C, Wright J, Maclure M, Dormuth C, Wakefield J,
Premi J, et al. the better “prescribing” project—a random-
ized controlled trial of an educatkional feedback interven-
tion to support evidence-based practice. Family Practice
Forum 2000, Ottawa, Ont., Canada, 2000 Oct. 20.
10. Clapesattle H. The Doctors Mayo. Minneapolis, MN: Univ
Minnesota Press; 1941.

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 7

Learning from
Formal Consultations
...
When thou arte callde at anye time,
A patient to see;
And doste perceave the cure to greate,
And ponderous for thee: . . .
Gette one or two of experte men,
To helpe thee in that nede;
And make them partakers wyth thee,
In that worke to procede.
J OHN H ALLE , 1565 1

“C onsultation, coupled with a brief bibliographic review on the

specific subject, benefits the patient, the referring physician,
and the consultant,” said Paul Wehrle. “Information is always better
retained when associated with specific problems.” Consultations also
promote interaction among colleagues—the basis for much continu-
ing education in medicine. When a consultation is indicated, it is, of
course, necessary for the physician to discuss its purpose with the pa-
tient beforehand.

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R E A S O N S F O R T H E C O N S U LTAT I O N
Conventionally, referring physicians request consultations because
they need assistance in diagnosis or treatment or because the patient
requires a special procedure, such as liver biopsy. Occasionally, it is
because the patient or the family is unduly anxious or apprehensive.
Determining the precise purpose of the consultation before request-
ing it will expand the knowledge gained and save valuable time.

R E Q U E S T I N G T H E C O N S U LTAT I O N

Seeking Consultation
George Thorn warned against two extremes in consultations: “At one
extreme is the physician who balks at a consultation, as though his
own knowledge were being challenged. Patients appreciate the physi-
cian who agrees to obtaining a second opinion even when he thinks he
knows the answer. Every good clinician realizes this, but some, par-
ticularly young physicians, may feel that they are expected to know
all the answers. At the other extreme is the physician who gives up too
easily, hardly ever solving a problem alone and complicating the situ-
ation by involving too many others.”

Profiting Most from a Consultation

First Study the Problem Yourself When the referring physician and
consultant have a common specialty, the referring physician will usu-
ally study the case thoroughly before requesting the consultation.
When, however, the consultation is outside the referring physician’s
specialty, as, for example, when an orthopedist seeks advice from an
otolaryngologist, the referring physician may not do a comprehensive
study of the condition and may therefore not learn as much as possi-
ble for application to future patients, especially since the consultant
often proceeds with the patient’s treatment.

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To obtain the most from a consultation in your field of interest,

first look up the subject in a standard textbook or in your personal in-
formation file. That will help reduce the scope of the consultation to a
few specific questions. Delineation of the problem by one or more ex-
plicit questions and a brief review of an authoritative publication on
the subject can, in fact, sometimes clarify the problem enough to
make a consultation unnecessary.
Summarize the Records All data, including patient records,
roentgenograms, and laboratory reports, should be summarized and
made accessible to the consultant. While summarizing his data,
James Dooley assesses his own performance with the patient, whom
he may have observed for 10–20 years, by carefully reviewing all the
clinical material accumulated during this time, including his notes.
When the patient is to be seen in the consultant’s office, the refer-
ring physician may summarize the clinical information in a letter. For
hospitalized patients, the summarizing note is made on the chart.
Preparation of either summary, when preceded by a careful review, is
educational for the referring physician. Regardless of the type of sum-
mary used, it is helpful for the referring physician and consultant to dis-
cuss the problem in person or by telephone before the consultation.
Ask Specific Questions William Parmley deplores the vagueness of
many consultation requests and stresses the importance of informing
the consultant of the explicit purpose of the request. The more spe-
cific the questions, the more the patient and the referring physician
will profit from the consultation.
Example:

This 23-year-old woman with rheumatoid arthritis continues to have sig-

nificant symptoms while taking three aspirin tablets four times a day. A
dosage of 14 tablets per day produces tinnitus. Should treatment be
changed? Are nonsteroidal anti-inflammatory agents indicated? Should
we go directly to gold?

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Ask the consultant for a listing of the phenomena that should be

monitored.
Example:

What signs, symptoms, and laboratory tests should be monitored and at

what intervals? For example, joint symptoms, swelling, fever, and sedi-
mentation rate.

The consultant may also be asked to identify the criteria (signs, symp-
toms, and laboratory tests) that will require additional consultations.
Warren Williams tests the specificity of his questions by writing
his own responses to his consultation requests, outlining diagnostic
and therapeutic plans. He then compares his plans with those of the
consultant, and they discuss any differences. Consultations thus be-
come a personal and active educational tool.
When R. D. Richards was a young faculty member, he saw a cer-
tain patient and decided what he thought should be done. He then
asked a senior faculty member to look at the patient and give his rec-
ommendation. “To my surprise,” said Richards, “he recommended
something quite different from my approach, although I still felt my
approach was preferable. At that time, I realized that I had not com-
municated properly with him, and should have specifically stated
what I wished to know. Since then, I have never asked for a consulta-
tion unless I really wanted it and have always specified precisely
what I wished the consultant to do.”

Who Is Present During the Consultation?

Some referring physicians like to be present during the consultation.
“I call the consultant,” said Edward Shapiro, “outline the problem,
and make a date to meet with him at the bedside. I watch him exam-
ine the patient, I supply additional information if needed, and I inter-
rogate the consultant. In this way, I learn a great deal. One consultant
said I cross-examined him, and I don’t deny the accusation.” Aaron

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Feder will not perform a consultation unless the referring physician is

there, and will not make such a request himself unless he is present
to hear what the consultant has to say.
Most physicians think, however, that the consultant does better
without the presence and influence of the referring physician, which
may interfere with the consultant’s establishing rapport with the patient
or may inhibit the patient’s responses. Most consultants prefer to have
time to organize their thoughts without feeling that they are “on stage.”

P R O V I D I N G T H E C O N S U LTAT I O N
“A physician conducts a patient consultation under two different cir-
cumstances,” said Walter Somerville. “In the teaching hospital, he
may be attended by junior staff and students eager to learn and imi-
tate, and by hand-picked senior residents and fellows, critical and
watchful for a false move or clinical slip. With such continuous audit,
the physician is in the ideal environment to bring out the best in him-
self as teacher and physician.
“The procedure is different when the physician is alone in his of-
fice or face-to-face with the patient in a nonteaching hospital. Two
techniques are beneficial to the patient and invaluable to the isolated
physician. The first is patient transposition, in which the physician
imagines the patient’s thoughts and feelings: ‘I am sensitive and terri-
fied. I am overawed by the doctor, writing down my anxieties, intimate
disclosures, and sexual indiscretions, to be read by goodness knows
whom? And that tape recorder? No wonder I feel like running away,
screaming, from this horrible experience.’ Considering the patient’s
point of view goes a long way toward creating the proper environment
for easy doctor–patient communication.
“The second technique is the invisible audit. I surround myself
with an imaginary audit-jury, drawn from the most constructive critics
in my experience. Closest to me, breathing down my neck, is Paul
Wood, then Sam Levine, and beside him my most stringent critic, my
wife, Jane, whispering emphatically what I’m doing wrong. With my

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pomposity deflated, affectations minimized, and extempore guess-

work challenged, I’m ever aware of my watchful friends. And the pa-
tient gets the best service I can give,” concludes Somerville.

The Consultant as a Learner

Paul Harvey cited another advantage of consultations: “The consult-
ant has the chance to examine a patient and think over a clinical
problem without doing the basic work and with most of the tests com-
pleted. This review of the work of others is a unique opportunity to see
how others approach problems.”
The questions asked by the referring physician may offer a useful
perspective. The request may stimulate the consultant to review a recent
specialty textbook or personal information file or even do medical li-
brary research. If the specific reason for the consultation is not clear, the
consultant should ask the referring physician for further information.

Teaching What Not to Order

To promote cost-containment, consultants should point out unneces-
sary studies that were ordered before they came on the scene, even
though such disclosures may be ticklish. In Desmond Julian’s opin-
ion, “Consultants don’t do enough teaching about when certain tests
are not needed. Every time you order a test, even an electrocardio-
gram or roentgenogram, let alone an invasive procedure, you should
ask yourself if the information will improve the care of that particular
patient. The consultant can often diplomatically point out the limita-
tions of some laboratory work that is ordered.”

The Consultant’s Report

On completion of the evaluation, the consultant will write a letter or
make a consultation report on the hospital chart. Restricting the

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length of the report forces the consultant to summarize and communi-

cate better. Writing succinctly also reinforces retention. Within 24
hours of the consultation, the consultant should call the referring
physician.
Daniel Stone pointed to the instructional value of consultations:
“The teaching in my consultation is largely through the letters I write
afterwards, in which I review my thinking with the referring physi-
cian. I also cite references, and if the physician does not have access
to a good medical library, I photocopy relevant articles and append
them to the letter.”
The inclusion of references must be handled delicately, since
some referring physicians may consider such citations to be conde-
scending. On the other hand, many physicians turn to consultants
who are known to be outstanding teachers and who often provide use-
ful references in diagnostic workups and treatment.
“The report sent from the consultant to the referring physician
upon discharge of the patient,” noted Julian “doesn’t convey much to
the referring physician if the diagnosis or treatment is buried among a
mass of data representing the results of tests that he does not under-
stand. I recommend a brief letter, which outlines the diagnosis, the
basis for the diagnosis, the treatment selected and its rationale, or, in
a complicated case, a more detailed letter further explaining these
points.” Even the most effective letter does not eliminate the need for
a personal discussion after the consultation, whether face-to-face or
by telephone.

Discussing the Consultation

Almost all referring physicians arrange for a personal meeting or a
telephone conversation with the consultant afterward to discuss
details or to ask further questions. Sherman Mellinkoff cautioned:
“Physicians sometimes forget the value of conversation. We habitu-
ally write notes to consultants in the chart, which is fine—it was pre-

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scribed by Hippocrates and remains a good idea today—but I don’t

think you learn as much or help the patient as much if you rely exclu-
sively on notes in the chart by the attending physician, consultant, or
others caring for the patient. If something important develops regard-
ing the patient, it is a good idea to discuss it directly with the consult-
ant. Then both the consultant and referring physician will understand
the problem better.”

Reporting to the Patient

“The patient often has high expectations of the consultation, and al-
though the consultant may try to withdraw and say he will discuss the
case with the patient’s doctor, the patient usually wants to hear the
consultant’s opinion directly,” Ian Mackay pointed out. “Consultants
should be given an opportunity to express an opinion and perhaps
offer a little reassurance to the patient, but this is a delicate issue in
the referring physician–consultant relationship.”
Desmond Julian added: “The consultant and referring physician
should see the patient together after the consultation. It’s remarkable
how often patients see as major discrepancies the minimal differ-
ences in what two physicians tell them. If, for example, I recommend
a 1,000-calorie diet and another physician recommends 800 calories,
the patient may think: ‘These doctors can’t agree.’ Joint decisions are
desirable regarding matters that may seem inconsequential to us but
very important to the patient.”

The Follow-up
The formal consultation should not end with the consultant’s written
or verbal communication. When the referring physician remains
responsible for the patient’s primary care, the consulting physician
should be kept posted on the patient’s progress. Follow-up telephone
calls to review the case or clarify points benefit the patient as well as
the referring physician and consultant.

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“Whether the consultant should see the patient again is,” in Ian
Mackay’s words, “often a touchy matter in hospital practice when a
good relationship develops between the consultant and the patient.”
If the consultant considers it advisable to see the patient again, that
should be stated, to avoid disturbing the referring physician–consult-
ant relationship.

T H E I D E A L C O N S U LTAT I O N
To learn the most and ensure the best advice for the patient, the refer-
ring physician should delineate the precise reasons for requesting the
consultation. Unless the problem is in a totally different specialty, it is
desirable to read about the subject in a current textbook or other publi-
cation, collect all existing data on the patient, summarize the records in
a letter or note on the hospital chart, and formulate specific questions
for the consultant.
“In the ideal consultation, the referring physician is present on
my arrival, describes the problem he wishes to consult me about, and
introduces me to the patient,” said Desmond Julian. “That’s important
because it shows a collaboration of colleagues rather than a physician
giving up and having to pass the problem to someone else. After he
introduces me to the patient, he leaves while I talk to the patient pri-
vately. In this way, the patient is not fearful of telling a different story
to one physician from that told to another or of contradicting himself.
I take the history and do the physical examination myself. Then I
meet the referring physician again and discuss the problem with him.
Sometimes something emerges that requires action or further elucida-
tion, or some contradiction in the story may need to be resolved. I like
to go back to the patient with the referring physician and explain our
joint opinion about diagnosis or treatment.”
Even when the patient’s problem is discussed in person or by tele-
phone, it is still necessary to write a letter or consultation report. The
consultant’s report should be clear and concise, providing specific
advice on diagnostic and therapeutic plans, along with the rationale

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on which that advice is based. The consultant should be notified of

any significant changes in the patient. Each of these steps offers op-
portunities for active participation and enlightenment.

REFERENCE
1. Halle J. An Historiall Expostulation: Against the beastlye
Abusers, bothe of Chyrurgerie, and Physyke, in oure tyme:
with a goodlye Doctrine and Instruction, necessarye to be
marked and folowed, of all true Chirurgiens. London:
Thomas Marshe; 1565. Edited by T.J. Pettigrew, London:
Percy Society; 1844:31–32.

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Formal Courses
and Conferences
...
[Lectures] are a temptation to the more contemplative
mind to learn diseases by the study of models, rather
than of the things themselves. They tend to divorce him
from the workshop and the chips and fragments and
rude designs that lie about within it, and introduce him
into a room swept and garnished and hung round with
masterpieces for his contemplation. This may be all
very well for gentlemen who patronise the arts; but this
is not the way to make the artist.
P ETER M ERE L ATHAM 1

F ormal courses and conferences are the second most popular method
of continuing medical education, after reading.2–4 Numerous stud-
ies have shown that physicians learn facts from such formal instruc-
tion.5,6 Courses that focus on physician performance in specific clinical
situations, however, can not only transfer facts but can also alter that
performance, even though such changes are difficult to measure.
Critics have focused on the limitations of courses and confer-
ences, which are memory based. Because knowledge so acquired may
not be used for weeks or months in the care of patients, it may be for-
gotten by that time. The educational needs of physicians may also
vary widely, and yet courses and conferences, which are group enter-

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prises, emphasize common needs, not individual needs. Jesse Rising,

who spent decades organizing courses, said: “After retiring as the As-
sociate Dean of Continuing Education, I became a volunteer in the
Department of Family Practice at the University of Kansas Medical
School, where I have been learning general medicine again. From that
experience I am convinced that the critical factor in CME is to take
care of patients. Courses are interesting, but learning comes from
studying patients.”
To Claude Organ, conferences are often simply dull. “To inspire
the participants, the course director must create a spirit of learning.
This sounds trite, I know, and it is easier said than done.”
Despite their limitations, formal courses and conferences can
keep physicians aware of current knowledge and new developments,
can broaden understanding, and can put the practicing physician in
touch with experts and peers. Physicians who gain the most from
courses are able to relate course material to their own clinical experi-
ence. The fact that these gains are difficult to measure after standard
courses or conferences does not vitiate such instruction in a compre-
hensive lifelong educational program.

R E A S O N S F O R AT T E N D I N G F O R M A L C O U R S E S A N D C O N F E R E N C E S
Physicians are motivated to attend formal courses and conferences by
both inner standards and extrinsic forces, such as peer pressure and
licensing regulations.7 – 12 The motivations varied slightly in different
studies conducted, depending on the phrasing of questions, but can
be grouped into several broad categories. Physicians frequently cited
as motivating factors the opportunity to review and increase medical
knowledge by becoming more aware of the general state-of-the-art
(with the assumption that the knowledge will make the physician
more competent) and by acquiring information pertinent to specific
patient problems. Physicians also use courses for self-assessment, to
compare their knowledge to that of experts in the field, and to com-
pare their work to accepted standards of practice. Continuing medical

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education is also seen as an integral part of professionalism by society

and the medical community. Professionals are expected to sharpen
their knowledge and skills continually. A change of pace from prac-
tice and contact with colleagues and faculty are also cited as motiva-
tions to attend courses.

Expected Benefits
For Patrick Storey, the single most important benefit of attending a
conference or CME short course is a recognition of what the registrant
does not know and what he cannot do. As Oliver Wendell Holmes
bluntly stated, “The best part of our knowledge is that which teaches
us where knowledge leaves off and ignorance begins. Nothing more
clearly separates a vulgar from a superior mind, than the confusion in
the first between the little that it truly knows, on the one hand, and
what it half knows and what it thinks it knows on the other.”13
Reinforcement of the physician’s past knowledge is more valuable
to Richard Caplan than the slight new information he may acquire.
“Nor must we forget the attitudinal advantages—the re-ignition of
languishing fires, the recharging of batteries, the renewal of excite-
ment. Further, a course or conference allows us to place ourselves in
the fertile mode of an active learner, free from daily professional re-
sponsibilities and interruptions.” Even if a physician’s knowledge is
up-to-date, as Jack Lein said, “attending a course will reinforce the
assurance that he is doing his best.”
For George Race, the ripple effect is the primary benefit from for-
mal courses. “When physicians hear something new, their interest is
piqued, and they will then consult journals, books, or experts to learn
more about the subject. Furthermore, the contacts that participants
make with course faculty often allow them to identify consultants with
whom they can establish ready communication.”
“A continuing education course is a wonderful, legitimate excuse to
leave behind the responsibilities for children, spouse, and patient
care,” said Karin Jamison. “The setting is usually some elegant hotel in

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It is important for physicians to summarize and docu-

ment their clinical experiences, and to remain current
with medical progress through reading and attending
conferences.
P ROFESSOR W U J IEPING
Honorary President
Chinese Academy of Medical Sciences
Beijing, China

a different environment. It is fun to meet people from all over the coun-
try and share experiences, joys, and problems, and to discover that
what is difficult for one may be difficult for all. Such recognition gives a
sense of relief. Even though the meetings are intense, they are still a
restful experience. It is an unusual opportunity to laugh at oneself with
trusted colleagues who understand. Finally, it is very gratifying to take
back home some information that is helpful to one or more patients.”
Surveys of registrants in courses given by the University of South-
ern California illustrate the benefits derived from them:

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“It is regenerating to be away from any distractions at home and

thus be able to concentrate on the course. I expect to feel more stim-
ulation from the renewal of academic knowledge and to gain more
clinical confidence.” (Peter Best)
“I want to update my concept of patient care and reassure myself
that I am maintaining a high standard of medical practice.” (Gerald
Farinola)
“Courses give me an opportunity to coordinate the material I read
in the literature, and to hear directly from the people in the forefront
of their specialties.” (Unsigned)
“I expect to get the most advanced knowledge in the field from the
course, since I can find the day-to-day knowledge and information in
textbooks.” (Ragheb Sawires)
“Courses make reading more meaningful, placing the importance of
the material in better perspective. Often the writer of an article has
spent much of his life doing research on a particular subject and is
therefore somewhat biased about the significance of his work.” (Wenzel
A. Leff)
“I compare what I hear at the course with what is currently in the
literature. I expect to come away with a summary of what is new on a
subject that will be clinically useful to me.” (Daniel Hoffman)
“I want to learn how medicine is practiced in different places and
review important developments that I may have missed or do not have
in proper perspective.” (Unsigned)
“I get the opportunity to compare my method of practice to what is
taught in the university hospitals.” (Rokay Kamyar)
“I want to increase my medical knowledge and demonstrate to
myself how much I don’t know, as a stimulus to read.” (G.E. Wiebe)
“Courses offer a more provocative approach than sitting at home
and reading.” (P. B. Jorgensen)
“Attending courses permits me to dilute parochialism a bit—to
get views on medical subjects other than those prevalent in my lo-
cale.” (Donald Jacobs)

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SELECTING A COURSE OR CONFERENCE

Content
In deciding whether to take a particular course, Donald Petit sug-
gested that physicians ask themselves: “Do I want a board review? Do
I want to find out what’s new on a given subject? Do I want to learn
something because I think it might be good for me, for example, basic
science for clinicians? Courses or conferences for physicians should
have a clear statement of content so that the physician will know in ad-
vance what to expect.” More specifically, Edward Rubenstein advised:
“The scope and the level of sophistication should be explicitly stated.
For instance, does the program deal in depth with a subject, or does it
consist of a number of compressed sessions highlighting the most im-
portant or most timely points? Does it emphasize basic science, or
does it focus on practical clinical matters? Is it intended
for specialists or subspecialists or physicians with other primary
interests?”
Lawrence Highman chooses courses that provide current informa-
tion on problems that arise in practice at his small rural hospital. “I
want to find out what changes I can make or what equipment is
needed to improve my care of my patients.” It is, of course, the physi-
cian’s responsibility to determine whether the content will make a dif-
ference in clinical practice. Richard Caplan suspects that most
physicians “respond with a somewhat more visceral than intellectual
awareness of what they need. Furthermore, the present methods used
by educators to demonstrate needs leave much to be desired. Who is
to say that ‘visceral wisdom’ is not a reasonably good measure of what
we need to learn?”

Faculty and Sponsor

The reputation of the sponsor is a fairly reliable index of the compe-
tence of the faculty and the value of a medical education conference.
“An outstanding course,” in Donald Petit’s opinion, “depends first on

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the quality of the faculty—its ability to impart knowledge, its enthu-

siasm, and its style. Does the faculty stimulate me to learn? Is the ex-
perience really enjoyable?”

Course Design
A program that promotes active participation is most beneficial, with
ample opportunity for questions or concerns of the participating
physicians through direct question-and-answer periods or discussion
forums. Programs are enriched by multiple formats such as lectures,
panel discussions, and problem-solving sessions. Informal periods at
lunch and coffee breaks are useful for discussion among participants.

Facilities and Site

Are the chairs comfortable, and are the tables convenient for writing?
Is the lighting good? Are the audiovisual facilities adequate? Is the
temperature comfortable? These may seem like minor factors before
one attends a conference, but once the sessions are under way, their
absence can become a major detriment.
National or regional courses or conferences are held at medical
schools, hospitals, hotels, convention centers, or popular vacation
sites. “With tuition, air travel, and the practice of conducting courses
in posh resort areas, not to mention the expense of maintaining the of-
fice and staff while the physician is away, cost is becoming a tremen-
dous factor,” noted Wenzel Leff.
On the other hand, a relaxed setting is important because it re-
moves physicians from the tensions and distractions of practice and
thus allows better concentration. A relaxed setting may also lower the
barriers between faculty and participants and permit interaction to
continue at the beach, poolside, or dinner table. Because a vacation
setting is also pleasant for the faculty, it may attract superior teachers.
In our view, a combined course and vacation will enhance educa-
tional activities rather than detract from them, provided that the spon-

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sor plans a superior course that leaves no question that the prime pur-
pose is learning. Recreational activities should be scheduled outside
of course hours. Courses that appear to be simple tax dodges, with lit-
tle or no educational value, are deplorable. That such courses exist
does not argue against the superior programs set in vacation sur-
roundings. Participants must be particularly alert in assessing the
quality of the faculty and suitability of topics to ensure the legitimacy
of the program and the applicability to their needs.

Fruitful and Worthless Courses

Some interviewees gave examples of fruitful as well as worthless
courses. Cited most often as worthwhile were courses with informa-
tion for practical clinical application, with opportunity for interaction
with an outstanding faculty, and with emphasis on new information
and skills rather than overviews. The most useful courses, in Robert
Palmer’s view, are those that apply directly to the physician’s own
practice, whereas the most worthless are those that suggest that the
only proper care of patients is given in a large medical center or
“Ivory Tower” setting. In J. Young’s opinion, controversy and discus-
sion are crucial components of a good course. “Passive didactic in-
struction does not really encourage intellectual growth. A great
number of panel discussions are worthless, the ‘professors’ merely
scratching one another’s backs.”

ENSURING OPTIMAL BENEFIT

Preparing for a Course or Conference

When Frederick Ludwig goes to a meeting, he has a specific goal in
mind. “A day or two in advance of the meeting, I will study what I am
going to be dealing with. Then at the meeting, I take notes, and when
I get home, I organize my thoughts and dictate a summary for my sec-
retary to transcribe so that I have a record of it. Later I can go back

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and consult those notes.” Donald Feinstein also reads the abstracts
the night before. “It is extremely inefficient if I do not prepare.” Try-
ing to think in advance of something worthwhile to contribute makes
Kenneth Berge much more attentive to the content.

Being Active During the Course

Most interviewees take notes during the sessions, and some rewrite
them the same evening to reinforce the concepts. Summarizing your
notes while the presentation is still fresh in your mind gives “double
exposure” to important ideas. Some physicians corral the speaker
after the presentation to ask questions not answered during the ses-
sions; others discuss particular cases with other participants. A good
course syllabus is a great help but, unfortunately, is rare.

Follow-up Study
After a course, some physicians summarize their notes or the pro-
vided syllabus and file the material under the appropriate heading in
their files. New information can be condensed into a few basic state-
ments, written on one sheet of paper, and reviewed periodically over
the next few days. To disseminate new information, as well as to help
retain it, the physician can dictate and distribute to interested col-
leagues a summary of the meeting. Also, a presentation based on the
subject can be given to the hospital staff. Many physicians probe fur-
ther into subjects that engage their interest or that they do not fully
understand, looking for articles to compare, refute, or reinforce what
was covered at a conference.
Daniel Bird uses his active learning participation in courses to
improve patient understanding. “As an aid in patient education, I
have typed short summaries of lectures I’ve attended and have placed
them in a special corner of my waiting room or occasionally mailed
them to certain patients. This ensures the wide dissemination of ac-
curate and timely medical information and strongly underlines the

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concern of physicians for the welfare of their patients. Patients take

these sheets of information home, discuss them with family and
friends, and thus introduce the physician to many persons as one who
both knows and cares.”

C O N F E R E N C E S O F F E R E D B Y H O S P I TA L S A N D S P E C I A LT Y S O C I E T I E S
The general principles discussed under formal courses and confer-
ences are applicable to all such programs, although hospital confer-
ences and annual sessions sponsored by specialty groups may present
a different orientation from courses offered by medical schools.

H O S P I TA L C O N F E R E N C E S
All hospitals have staff meetings, many have section or departmental
meetings, and some have general educational meetings. Hospital con-
ferences are convenient for physicians and can be designed to solve
specific medical problems in the hospital. They also promote interac-
tion with peers and may enhance the physician’s visibility while im-
proving cooperation among physicians, nurses, pharmacists, and
other health professionals.
In place of medical grand rounds consisting only of a clinical lec-
ture, Samuel Rapaport prefers a case presentation to serve as the spring-
board for more generalized comments on mechanisms or treatment. Paul
Beeson favors morbidity and mortality rounds, along with case reviews
and medical pathology reviews. “These sessions permit physicians to re-
view frankly what happened and where the treatment went wrong. Noth-
ing sticks with you like a mistake. Having someone looking over your
shoulder and saying ‘No, it is not what you think it is, but it is this,’ gives
you a healthy humility. I have had just enough experience in private
practice to know that no matter what you do, 90 percent of your patients
are going to get well, and unless someone points this out to you, you may
begin to feel that what you are doing is responsible.”

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Hugh Lawrence also lauded the review of morbidity data, with

open discussion of cases, followed by an audit. “The audit report sug-
gests a plan of action, and a later audit indicates if there has been any
progress. When I came to our hospital about seven years ago, several
different bowel preparations were used by the 20 surgeons. We dis-
cussed this and found the infection rate in intestinal surgery to be
about 18 percent. We narrowed the protocols to four, and the infection
rate dropped to 5.8 percent. The new practice was presented at a mor-
bidity and mortality conference, which led other surgeons to refine
the protocol, with a further reduction in infection rate to 1.8 percent.
We found, however, that some surgeons were having a higher infection
rate than this. At first we thought that the nurses were not carrying out
the procedures, but an audit showed that certain doctors had not been
writing orders satisfactorily.”
Analysis of hospital patient care data can be used beyond confer-
ence planning, extending into direct conversation about quality as-
surance. If a physician is having a high complication rate for a given
disorder, Hugh Lawrence will approach the physician privately. “I
will not communicate with him by memorandum or letter, but will go
to him personally, solicit his help with the problem, and ask him how
he would approach it. I will pick the physician with the next worse
complication rate and say, ‘You are one of two people here who are
having a problem, and I just wonder how we can eliminate it.’ In this
way, I encourage him to produce the action himself.”
Death conferences and clinicopathologic conferences, which
have been important educational tools in the past, have declined in
popularity because they focus on exotic diseases and rare diagnoses.
James Moss would like to see these conferences directed toward pa-
tients with avoidable deaths. Unfortunately, the litigious atmosphere
today makes discussions of this kind very difficult.
Morbidity and mortality rounds can be inordinately dull, “a slow
unfolding of the inevitable, ending with a pathology demonstration,”
according to Ian Mackay. “In addition, although an outcome may be

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unfavorable and the criticism severe, there may have been, in retro-
spect, no other course to follow, or the course followed may not have
been at all unreasonable at the time.”
Francis Moore encouraged the staffs of small hospitals to review
their own experiences. “The average surgeon or internist or pediatri-
cian probably does not analyze his practice data. The purpose of staff
committees and staff review groups in small hospitals should be to en-
courage that kind of review of one’s own work.”
Desmond Julian advocates a switch from mortality to morbidity.
“Whereas the postmortem room used to be the main learning area,
with all the tests we have today on living patients, the biopsies and
the radiologic investigations, we learn more from morbidity confer-
ences than mortality conferences, that is, from what goes wrong in pa-
tients who survive.”
Discussions of medical care in which the physician should have
acted differently are essential, but some physicians may have a ten-
dency to cover up their actions, as Paul Wehrle explained: “Facilitat-
ing discussions with medical colleagues is an interesting art and
requires a certain amount of understanding. Some practicing physi-
cians in small rural private hospitals are unwilling to discuss can-
didly patients who have been mismanaged. Each staff member knows
precisely which physician treated which patient and must use special
tact to make constructive criticisms and suggest alternate diagnostic
or therapeutic approaches. Unless the discussion leader is experi-
enced and diplomatic, the atmosphere can become tense and painful
for those responsible for the medical decisions under scrutiny.” It is
best to relate these meetings to educational activities, lest overly
harsh punitive measures drive the errors underground.
Claude Organ considers the best hospital meetings to be those di-
rected at deficiencies disclosed by a properly designed audit. He ad-
vises physicians to resist wasting time at hospital staff meetings about
administrative and statistical reports that lead to no conclusions. The
primary purpose, after all, is to improve patient care through educa-
tion. Charles Brunicardi agrees: “If you take an active approach, con-
ferences can help you remain current. I choose several conferences
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relevant to my needs and attend them weekly. Taking notes at these

conferences requires discipline, but is well worth the effort, since it
helps me to concentrate and process information.”

Annual Sessions
Annual sessions of specialty and state societies and associations can
provide excellent opportunities for learning and reviewing the state of
knowledge. As in any other educational event, preparation and par-
ticipation make attendance more productive.
Advantages Programs sponsored by a subspecialty society, which
usually give an in-depth view of the latest research and clinical infor-
mation, differ from the formal course given by a medical school,
which is often a review of a topic. The formal course or conference
generally entails broad coverage, whereas annual sessions often spot-
light recognized authorities on given subjects.
Because of its many concurrent sessions, an annual meeting may
have a wider appeal than a three- or four-day postgraduate course and
may provide better opportunities for division of groups by special in-
terest. Unlike most postgraduate courses, it usually also has commer-
cial and scientific exhibits, which may include teaching media, such
as computer-based or audiovisual programs. The commercial exhibits
usually alert the practitioner to new drugs and devices.
Discussions with fellow physicians from different areas of the
country are enlightening. As William Davis has found, “You learn as
much or more in the halls between sessions as you do from listening
to the presentations.” The “Meet the Professor” sessions with infor-
mal discussion of clinical problems provide divergent views.
Limitations Not only do annual out-of-town sessions require a
protracted absence from one’s practice, but large meetings do not al-
ways offer the best opportunities for fellowship and may be dominated
by political rather than professional issues. The large audience can
also be an obstacle to learning, with less opportunity for face-to-face
interchanges. There may also be housing problems, and less choice of
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scheduling. On the other hand, the physician can choose the month
and general location desired for a postgraduate course.
Of little value are prolonged discussions of rare diseases and syn-
dromes that few physicians will ever see, as well as presentations of
new diagnostic procedures or therapeutic measures that have not
been studied adequately and that may subsequently prove to be of no
benefit. For Marsha Wallace, it is a mistake to design information for
everyone from country doctors to those in urban centers, each with
vastly different needs. “By the time basics are rehashed, there is often
little time left for what is new.”

*****
Courses and conferences are traditional and remain popular.
When most physicians think of continuing education, they think of a
classroom presentation. Courses and conferences may define to the
physician directions for further study, reinforce past knowledge, ac-
quaint the physician with experts in the field, and provide opportuni-
ties for informal discussions with peers, as well as present new
information and developments. Such group teaching and learning
help keep the profession aware of the current state of knowledge and
of contemporary standards, but cannot provide all the detail a physi-
cian needs for daily practice. Courses are therefore no substitute for
reading or for colleague consultations on specific problems. Physi-
cians who have developed methods for reviewing their practice ac-
cording to problems seen, drugs prescribed, and studies ordered may
profit most from courses and conferences because they can compare
their experience and performance with those of the instructors.

REFERENCES
1. Latham PM. A word or two on medical education. In: Martin
R, ed. The Collected Works of Dr. P. M. Latham. London:
New Sydenham Society; 1878:562.
2. Manning PR, Denson TA. How cardiologists learn about
echocardiography. Ann Intern Med. 1979;91:469–471.

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 8 / FORMAL COURSES AND CONFERENCES

3. Manning PR, Denson TA. How internists learned about

cimetidine. Ann Intern Med. 1980;92:690–692.
4. Vollan DD. Scope and extent of postgraduate medical edu-
cation in the United States. JAMA. 1955;157:703–708.
5. Manning PR, Abrahamson S, Dennis DA. Comparison of
four teaching techniques: programmed text, textbook,
lecture-demonstration, and lecture workshop. J Med Educ.
1968;43:356–359.
6. Manning PR. Pre- and post-course testing as a teaching aid.
The Mayo Alumnus. 1966;2:18–20.
7. Stein LS. The effectiveness of continuing medical educa-
tion: eight research reports. J Med Educ. 1981;56:103–110.
8. Richards RK, Cohen RM. The value and limitations of
physician participation in traditional forms of continuing
medical education, Part II. Kalamazoo, MI: Educational
Service Department, Upjohn; 1983.
9. Houle CO. Continuing Learning in the Professions. San
Francisco: Jossey–Bass; 1980.
10. Schuknecht HF. The risks and limitations of the course as
providing competent training. Trans Am Acad Ophthal Oto-
laryngol. 1976;82:640–641.
11. Meighan SS. Continuing medical education: philosophy in
search of a plan. Northwest Med. 1966;65:925–929.
12. Cervero RM. A factor analytic study of physicians’ reasons
for participating in continuing education. J Med Educ.
1981;56:29–34.
13. Holmes OW. Border lines of knowledge in some provinces of
medical science. In: Medical Essays: 1842–1882. Boston:
Houghton Mifflin; 1911:211.

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 R E F L E C T I O N S / D AV I D A . D AV I S , M . D .

R E F L E C T I O N S
...

Persuasive evidence suggests that the learning phase in

formal CME begins not with the course, but with the
identification of clinical needs or deficits.
D AVID A. D AVIS , M.D.

After completing his medical training at the University of Western

Ontario and the University of Toronto in 1969, Dr. David Davis en-
tered private family practice in Burlington, Ontario, and began a
lifelong interest in continuing medical education (CME), culminat-
ing in the development of a community hospital-based continuing
education program at Burlington’s Joseph Brant Hospital. In 1977,
he became Director of CME at the new Faculty of Health Sciences,
McMaster University in Hamilton.
Dr. Davis’s efforts at McMaster led to a number of academic
CME developments: the concept of a CME Society, the application of

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problem-based learning principles to CME, a comprehensive compe-

tency assessment program supported by the provincial licensing
body, a Ministry of Health-funded national audioconferencing net-
work, the use of innovative needs-assessment and evaluative tech-
niques, including standardized patients, a unique database of CME
research (Research and Development Resource Base in CME), and
the evolution of an evidence-based CME working group.
In 1986, Dr. Davis became the Chairman of Continuing Health
Sciences Education and Clinical Professor in the Department of
Family Medicine at McMaster University. Three years later, leaving
his Burlington practice, he joined the full-time staff of the Faculty of
Health Sciences of McMaster University and became a staff physi-
cian at the North Hamilton Community Health Center, an inner-city
primary-care teaching practice. He is now a Professor in the Depart-
ments of Health Policy, Management, and Evaluation and of Family
and Community Medicine at the University of Toronto.
Dr. Davis has published nearly 100 articles, monographs, and
chapters and coedited a textbook on CME, The Physician as
Learner.1 A speaker, workshop leader, and consultant on four conti-
nents, he has served as Chairman of the CME Committee of the On-
tario Council of the Faculties of Medicine, President of the
Standing Committee on CME for the Association of Canadian Med-
ical Colleges, President of the Alliance for CME, and President of
the Society of Medical College Directors of CME (now the Society
for Academic CME).

REFERENCE
1. Davis DA, Fox RD, eds. The Physician as Learner. Linking
Research to Practice. Chicago, IL: American Medical Asso-
ciation; 1994.

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 Lifelong Learning:
A Physician’s Perspective

David A. Davis, M.D.

Associate Dean, Continuing Education, Faculty of Medicine
University of Toronto
Toronto, Ontario, Canada

F ormal continuing medical education (CME) has traditionally

comprised planned educational activities, usually didactic, with
stated objectives and accreditation standards. In the current profes-
sional environment, its effectiveness is being increasingly examined.
First, the rising number of accredited activities1 presents an often be-
wildering choice for the practicing physician. Second, each course in-
volves costs, including registration fees and travel. Third, most short
courses produce little change in physician performance.2 Finally, per-
haps most surprisingly, because many physicians have difficulty de-
termining their own learning needs, they do not select programs of
greatest value to them. In the 1980s, Sibley and colleagues3 reported
that family physicians often chose course subjects in which they were
already competent, ignoring, or ranking lower, topics in which they
were less proficient. Similar findings have been obtained in other
specialties.

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P R E C O U R S E : T H E D E T E R M I N AT I O N O F L E A R N I N G N E E D S
Persuasive evidence suggests that the learning phase in formal CME
begins not with the course, but with identification of clinical needs or
deficits. What steps can the physician take to gain the most from cur-
rent educational opportunities? A recent review of 14 randomized
controlled trials of CME activities showed that in four of five trials in
which needs were assessed in advance, the change in physicians’
clinical competence was greater than when no formal preliminary
needs assessment was done.4 Physicians can, of course, do their own
needs assessment. Reading and attending courses help uncover
knowledge deficits, but better still is a log or list of clinical questions
arising in individual practice, with steps to address those questions.
The ultimate test of any physician’s performance lies in the patient
outcomes, useful measures of which are infection rates, length of hos-
pitalization, blood pressure, and laboratory tests.

EVIDENCE FROM RANDOMIZED CONTROLLED TRIALS

In our previously mentioned review of 14 randomized controlled trials
(RCTs) of formal CME,4 physicians’ performance did not change when
instruction was didactic and little time was available for questions or
interaction. Interactive conferences and workshops, on the other hand,
or a mix of didactic and interactive sessions (hands-on workshops,
skills-building sessions, role play, animal labs, case discussion confer-
ences) improved physician performance or healthcare outcomes more.5
In addition, one-day events were less likely to change performance than
those held on two or more occasions over time. We theorized that re-
peated exposure at intervals allows the learner to reflect on the new
knowledge, incorporate it into practice, and then return to the next
learning session to reinforce the new practice, acquiring and incorpo-
rating new skills in the process.4
We also concluded that group size was not important to outcomes,
perhaps because even with large audiences, small-group learning ac-
tivities are possible. Also helpful was sending reminders to regis-

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trants after the course. Three of four trials incorporating patient edu-
cational material, or physician reminders and protocols, improved
healthcare outcomes.4

SOFTER EVIDENCE OF THE EFFECTIVENESS OF COURSES

Educational theories and common sense have dictated a number of
other questions that enhance learning and provide a fairly reliable
checklist for choosing formal CME (Table 1).6 First, what are the
major themes or broader goals of the conference? Do these, and the
learning objective listed in precourse materials, match the physi-
cian’s specific needs identified by subjective or objective means? The
more precise the answer, the better. In general, attending a course
with a clear and articulated vision of what you wish to accomplish is
better than a vague set of objectives (“I want an update in cardiol-
ogy”). Second, there may be impediments to the credibility of a pro-
gram. It is wise to inquire about sponsorship, industry involvement,
and the specific use of critically appraised material or publications.

AFTER THE COURSE: MAKING THE CONNECTION

TO PRACTICE, CLOSING THE LOOP
Follow-up after the course is as important as the course itself. Study
of materials distributed during the course or provided later (exam-
ples of patient contracts,7 reminders, and flow charts) can encour-
age changes in practice. Anecdotal evidence suggests that many
attendees do refer to course handouts to refresh their memory. Post-
course reminders generated from the CME director, a Web site at
which registrants can find support materials, and updated mailed in-
formation are helpful in reinforcing lessons learned.
The astute CME participant will complete the cycle that began with
needs assessment. With sufficient attention to the knowledge deficits
and related data sources, it should be relatively simple to satisfy the
learning need. If subjective data were used for the needs assessment (re-
viewing a learning log, reflecting on practice patterns and outcomes),

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TABLE 1
Choosing a CME Course: Factors to Weigh

Evidence
Factor Related Questions Basea

Precourse Have I done a needs-assessment on my own A

activity practice?
Are there specific and well-described objectives? D
Do they match my own objectives and goals?
The planning committee: have physicians with D
similar backgrounds planned this course?
Format Does the format allow for interactivity? A
Is there sufficient time for questions and answers? B
For interaction with the faculty?
Are there learning resources provided (protocols, A
reminders, patient education materials)?
Credibility Is the major sponsor of the event a credible D
institution or group?
Is there a corporate or other sponsor? If so, are the D
fees reduced or social activities provided that might
produce bias?
In general, am I satisfied that sufficient safeguards D
are in place to prevent or identify bias?
Logistics Are the conference site, timing, and other D
considerations convenient?
Is the conference locale suitable for interaction D
and comfortable learning?
Postcourse Is there a Web site or other resource for ongoing D
activity materials and support after the course? If so, is it
acceptable and accessible for me?
aLevel A evidence: from reviews of publications, meta-analysis of randomized clinical trials
(RCTs); level B evidence: from one or more RCTs; level C evidence: from descriptive stud-
ies; level D evidence: common sense.

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simple postcourse reflection may be sufficient to close the loop: Did I

meet my objectives? What questions were left unanswered? If more ob-
jective data were used (practice-based Continuous Quality Improvement
[CQI] data sources), reviewing them within three to six months may de-
termine the effectiveness of the course.

A LT E R N AT I V E S T O T H E S H O R T C O U R S E
For almost two decades, directors of continuing medical education have
been wrestling with alternatives to formal courses. Distributed CME
consists of such print materials as practice guidelines generated by
specialty societies and others or audiotapes, videotapes, monographs,
and newsletters. If unsolicited and unlinked to needs, they generally
have little effect.2 Other alternatives are visiting speakers and aca-
demic detailers. Visiting lectureships usually have little impact, espe-
cially if the subject is unrelated to local needs. Evidence suggests,
however, that academic medical educators who focus on some aspect of
clinical practice, such as prescribing practices, are effective.8,9
Community-based interventions, generally sponsored by a disease-
related organization (diabetes, HIV–AIDS, smoking cessation), include
media, public and patient education, and sessions with local physician
leaders. Practice-based interventions are increasingly used by cost-
and quality-conscious organizations. These may include a combination
of lectures, reminder systems (print or electronic), audit and feedback,
and other methods borrowed from CQI publications.10 Finally, interven-
tions that target the patient directly, for example, patient reminders
about preventive practices (flu shots in the elderly or mammography)
and more comprehensive practices, including patient education, as in
diabetes, have optimized physicians’ clinical performance.

REFERENCES
1. Accreditation Council for Continuing Medical Education
(ACCME) homepage. Available at www.accme.org/sec_
acc_fl.html. Accessed 2001 May 14.

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2. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing

physician performance. A systematic review of the effect
of continuing medical education strategies. JAMA. 1995;
274:700–705.
3. Sibley JC, Sacket DL, Neufeld V, Gerrard B, Rudnick KV,
Fraser WA. Randomized trial of continuing medical educa-
tion. N Engl J Med. 1982;306:511–515.
4. Davis D, Thomson O’Brien MA, Freemantle N, Wolf EM,
Mazmanian P, Taylor-Vaisey A. Impact of formal continuing
medical education: do conferences, workshops, rounds, and
other traditional continuing education activities change
physician behavior or health care outcomes? JAMA.
1999;282:867–874.
5. Steinert Y, Snell L. Interactive learning: strategies for in-
creasing participation in large group presentations. Med
Teach. 1999;21:37–42.
6. Davis DA, Thomson MA. Continuing medical education as a
means of lifelong learning. In: Silagy C, Haines A, eds. Evi-
dence Based Practice in Primary Care. London: BMJ Pub-
lishing Group; 1998:129–143.
7. Wilson DM, Taylor DW, Gilbert JR, et al. A randomized trial
of a family physician intervention for smoking cessation.
JAMA. 1988;260:1570–1574.
8. Thomson O’Brien MA, Oxman AD, Davis DA, Haynes RB,
Freemantle N, Harvey EL. Educational outreach visits: ef-
fects on professional practice and health care outcomes.
Cochrane Database and Systematic Reviews (2):CD000409,
2000.
9. Soumerai SB. Principles and uses of academic detailing to
improve the management of psychiatric disorders. Int J Psy-
chiatry Med. 1998;28:81–96.
10. Laffel G, Berwick DM. Quality in health care. JAMA.
1992;268:407–409.

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 R E F L E C T I O N S / C AT H E R I N E D . D E A N G E L I S , M . D .

R E F L E C T I O N S
...

The medical profession has been forced to function in a

business mode when providing clinical services. It is
imperative that our educational mission not be compro-
mised by the for-profit concept.
C ATHERINE D. D E A NGELIS , M.D.

D r. Catherine DeAngelis received her M.D. degree from the Uni-

versity of Pittsburgh School of Medicine and her M.P.H. from the
Harvard Graduate School of Public Health (Health Services Ad-
ministration). As Editor-in-chief she oversees The Journal of the
American Medical Association (JAMA) as well as the Archives publi-
cations and the JAMA-related Web site content. Before this ap-
pointment, she was Vice Dean for Academic Affairs and Faculty at
Johns Hopkins University School of Medicine, where she is still
Professor of Pediatrics. From 1994 to 2000, she was Editor of the

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Archives of Pediatrics and Adolescent Medicine. She has been a

member of numerous other medical journal editorial boards.
Dr. DeAngelis has written or edited 10 books, including Pedi-
atric Primary Care1 and An Introduction to Clinical Research2, and
has published more than 150 original articles, chapters, editorials,
and abstracts. Several of her recent publications have focused on
conflicts of interest in medicine, women in medicine, and medical
education. A member of the National Academy of Science, Institute
of Medicine, she has also served as an officer in a number of na-
tional academic societies, including the past chairmanship of the
American Board of Pediatrics.

REFERENCES
1. DeAngelis CD Pediatric Primary Care, 3rd ed. Boston:
Little, Brown; 1984.
2. DeAngelis CD An Introduction to Clinical Research. New
York: Oxford Univ Pres; 1990.

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 Physician Education
and Conflict of Interest

Catherine D. DeAngelis, M.D.

Editor-in-Chief, Scientific Publications and Multimedia Publications
American Medical Association
Chicago, Illinois

T he programs sponsored by medical schools and medical societies

are often supported in part by unrestricted educational grants
from pharmaceutical and technology companies. One major concern
is the potential misuse of the CME venue to sell or promote a product
rather than to educate. Such financial support is acceptable so long as
the rules promulgated by the Accreditation Council for Continuing
Medical Education (ACCME) are followed, that is, disclosure of po-
tential conflicts of interest and assurance that the accredited activity
is unbiased and scientifically sound. The result: better continuing ed-
ucation of physicians and, ultimately, better patient care.
Editors of medical journals, which provide a great deal of CME
with or without CME credits, are aware that subscription income
alone cannot sustain their publications. The real income is generated
by advertisements, reprint sales, and some licensing fees. Pharma-
ceutical and technology firms purchase most advertisements, and

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some pay licensing fees. Again, the potential for conflict of interest
weighs in heavily. Editors, authors, and reviewers must disclose per-
sonal or financial interest in any pharmaceutical company that has a
role in a manuscript accepted for publication. Many studies, espe-
cially clinical trials, are funded, at least in part, by pharmaceutical
companies that seek testing of drugs and publication of results. This
is acceptable if journals rigidly adhere to appropriate rules regarding
conflict of interest and if the companies’ grants are unrestricted, so
that results may be published, whether favorable or unfavorable.
Drug and technology companies spend hundreds of millions of
dollars and play a vital role in developing new products and evalu-
ating their efficacy beyond the requirements of the Food and Drug
Administration’s rules and regulations. In 1999, the top five pharma-
ceutical firms spent more than $20 billion on research, while the Na-
tional Institutes of Health spent $18 billion. The firms have a right to
profit from their investments and to make clinicians aware of their
products, but strict ethical principles are mandatory.
The medical profession has been forced to function in a business
mode when providing clinical services, but it is imperative that our
educational mission not be compromised by the for-profit concept.
Profits from the provision of educational services should be rein-
vested in educational enterprises to ensure that physicians will re-
ceive the most effective, current, and unbiased information for
ministering to patients. To mask the promulgation of biased informa-
tion as education rather than as promotion is to endanger the health of
the public. We simply cannot allow this to happen.

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 9

Learning by Teaching

...
Men learn while they teach.
[H]omines, dum docent discunt.
S ENECA 1

T he word “doctor” is from the Latin docere, meaning to teach. The

title of “doctor” became associated with the medical profession
after the 15th century, probably because only the medical doctors, of
all the members of faculties, went out among the people. “Doctor,” by
common usage, thus became associated with medicine. Physicians
often find themselves teaching patients, colleagues, other associates,
and the general public. Academic physicians have primary responsi-
bilities for teaching, but all practicing physicians have such opportu-
nities. In our interviews, we have explored teaching as a method of
learning for the physician, have elicited ways of ensuring self-
education as a by-product of teaching, have reviewed the attributes of
master teachers, and have discovered how practicing physicians cre-
ate opportunities to teach clinical medicine.

BENEFITS OF TEACHING
“The safest thing for a patient,” Charles Mayo was quoted as saying,
“was to be in the hands of a man engaged in teaching medicine. In order
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to be a teacher of medicine the doctor must always be a student.”2 Leigh

Thompson identified three ways teaching helps him to learn: “First, it
stimulates me to search published material, learn new facts, and update
my knowledge. Second, it forces me to organize my knowledge for my
presentation. Third, it provides the opportunity for feedback from the
audience.” Stephen Greenberg added: “I regularly teach someone—a
student, resident, fellow, or colleague—about the latest information on a
given topic. Having to communicate this information requires continu-
ously updating my own databases on various topics.” Garret T. Lynch
agreed: “Academicians have the advantage of learning while teaching.
Questions from students compel teachers to expand their knowledge
base. Teachers also learn from students who, at the bedside or during
conferences, share information from their own extensive reading.”

Attributes of Effective Teachers

In the words of Ralph Feigin, “The common thread through all of aca-
demic life is teaching, and although academicians may develop indi-
vidual styles, anyone can learn to be an effective teacher if the desire to
impart knowledge is sincere and if sufficient time and effort are in-
vested. The motivating forces for clinical teaching are caring for and re-
specting trainees and being committed to their success. Caring for
trainees implies being a good listener and focusing adequate effort and
attention on them. An effective teacher cares about students as people
beyond their training. This does not necessarily imply acceptance of all
the trainees’ qualities, but the teacher should encourage positive be-
havior and point out how certain behavior can be improved. The ideal
teacher is enthusiastic, has a good sense of humor, sets standards that
motivate students to do their best, and has a broad knowledge base or-
ganized in a way that the trainee readily understands.
“Respecting the trainee requires willingness to communicate by ex-
planation as well as demonstration. Every effort should be made to an-
swer questions satisfactorily without making the trainee feel inferior for
having posed the question. Ensuring the success of the trainee requires

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the teacher to have a clear and explicit expectation that is communi-

cated to the trainee. Teaching is important to me because it stimulates
me to pursue new knowledge continually and to grow professionally. I
generally learn something from every new teaching experience.”
In addition to knowledge of one’s discipline, Joseph Van Der
Meulen listed the following attributes of outstanding teachers: “They
must be able to abstract the essentials from a subject and present
them in an organized and interesting way. They should be able to ac-
commodate their pacing to the complexity of the subject. They should
be receptive to constructive criticism, be adaptable to change, and re-
main current. They must be sensitive to the needs of the audience and
to its receptivity. Sensitivity is probably innate; I doubt that it can be
acquired, but the other attributes can be acquired by experience and
constructive feedback.”
“An outstanding clinical teacher,” said Clifton Cleaveland,
“shows a profound regard and empathy for each patient seen on
teaching rounds. A second attribute is a dedication to upgrading and
renewing one’s own fund of clinical information. A third is the ability
to stimulate open, frank, nonthreatening communication with house
staff and students.”
For William Waters, the compulsion to share new learning, in-
sights, and revelations is the competent teacher’s primary attribute.
“Other qualifications include verbalism, enthusiasm, intellectualism,
warm feelings for students, and—not by any means least—brains.
Most of these can be developed by example and experience.”
Edwin Overholt emphasized “intellectual honesty, high intelli-
gence, enthusiasm, attention to detail, and a joy in interacting with
one’s colleagues. A teacher must respect his colleagues. The help that
an outstanding teacher can give his colleagues and his house staff is
the ultimate reward. Teachers should encourage young physicians
with a potential for teaching to pursue such a career. Exposure to an
outstanding teacher is a great motivator.” The opportunity to give case
presentations and literature reviews, with constructive comments
from their teachers, is extremely valuable to house officers.

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A good teacher should possess enthusiasm, self-discipline, and

the ability to transmit ideas with clarity, humor, and intelligence. The
teacher must show respect and sympathy for students without pander-
ing to sloppiness of thought or performance.
Teachers must know the subject from all standpoints, according to
Leigh Thompson, including personal involvement in research and
practice. “They must present the right amount of information in the
right sequence with the right timing and the right graphics.”
One phenomenon that is clearly a handicap, according to Thomas
Burns, is a large information differential between teacher and audi-
ence. “We all know people with a great fund of knowledge who are
barely able to impart any of it to their peers, let alone to house staff or
medical students. On the other hand, information seems to flow read-
ily from house officers to medical students and from senior students to
their juniors. A common characteristic among great teachers in med-
icine is an ability to uncover the learning receptors of students so as
not to impede the flow of information down the gradient.”
Olga Jonasson noted a change in the role of medical teachers:
“They are encouraged not to teach, but to inspire students to seek out
information they want and need. The hope is that this pattern of self-
teaching will become a habit that will produce lifelong learning.”
“A common mistake made by those in medical education,” said
Thorpe Ray, “is assuming that events such as graduation from med-
ical school and completion of residency or fellowship mark the end of
something. In reality, they mark the beginning of a career of perpetual
study. The recent graduate should be prepared for his clinical train-
ing program, and the finishing resident should be prepared for his
lifelong study. By this time, the habit of critical reading should have
been established, as well as the self-evaluation and honest self-
criticism that are essential for continued intellectual growth and
maintenance of clinical skills. The source of useful knowledge and
information for the physician is often self-instruction. Teachers help
most by establishing sound reasoning and a disciplined approach to
clinical problems. A good teacher should clearly demonstrate an ap-

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proach that identifies the patient as an important and interesting per-

son. The best teachers demonstrate that medicine is fun and learning
is fun. They stimulate and attract students of medicine at all stages.
Sometimes the manner of doing or saying something determines
whether it will be remembered by students.”
“Not all teaching experiences are pleasant or funny,” according to
Linda Clever. “I remember two nameless professors. They ‘led’ by
bad example—and no one emulated them. The first asked the patient
in a rheumatology clinic if she ‘had any trouble with your tempero-
mandibular joint.’ Her puzzled look spoke volumes and reminded us
to use lay language. The other professor asked an endocrine patient at
grand rounds, ‘How long have you looked like a frog?’ Humiliation is
never humorous, nor does it put anyone at ease.”
John Askey recalled the words of a mentor at the University of
Pennsylvania, O. H. Perry Pepper, who advised him one day as they
rode to Pepper’s home for an afternoon of tennis, “John, always have
an ‘arbeit.’ ” Askey remembers Pepper as a great stimulator who con-
sidered the main qualities of an investigator to be “the simplicity to
wonder, the ability to question, the power to generalize, and the ca-
pacity to apply.” At 86, Askey said that the virus for keeping him in
contact with medicine continued.

Full-time Faculty
The teaching principles described by physicians in academia are
equally applicable to the practicing physician.
“To me, teaching is essential for learning,” said Saul Farber.
“Throughout my adult life I have learned mainly through teaching.
You learn a great deal from your students while trying to impart
knowledge to them. I never go into a teaching session without being
prepared. No matter how many times I present lobar pneumonia to
medical students, I always read something about that subject the
night before, and I never fail to learn something that I had not known
before or to gain a new insight that had not occurred to me before, as,

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for example, about pathophysiology. When I return from a teaching

session or rounds, I look up things that I think I should have known or
try to find the answer to a question that has arisen. Preparation before
and catch-up after the sessions have been very useful and extremely
enjoyable.”
The importance of preparation was impressed on Ralph Waller-
stein during his training under William Castle, whose work on intrin-
sic and extrinsic factors in pernicious anemia led to the fundamental
understanding of that disease. Late one night, Wallerstein noticed a
light in Castle’s office and, entering to say hello, found him busy
studying and writing a presentation on pernicious anemia to be given
to medical students. The fact that Castle, an international expert on
pernicious anemia, felt it necessary to prepare for a lecture to stu-
dents left a strong impression on Wallerstein.
As Lloyd Smith noted, “The subject matter of medicine is so vast
that no one can master more than a part of it. Moreover, what we learn
is eroded by new insights from basic and clinical research. One’s
most cherished aphorisms are continually being disproved by indis-
putable facts. Teaching requires a reappraisal of one’s beliefs, a ‘loos-
ening of certainties,’ as Will Durant said. You must defend your ideas
once more both to yourself and, more important, to those being taught.
Most of my teaching is done on ward rounds rather than as formal lec-
tures. Fortunately, young people are remarkably forgiving of one’s
knowledge lacunae and are willing to play to one’s strengths, if they
can be found. This assumes that the teacher has a genuine interest in
medicine (it cannot be feigned), is humble before the facts, and is a
reasonable and secure master of ceremonies who brings out the best
in all who participate in the complex sociology of ward rounds.
“When one is caught off base, which happens to all clinical teach-
ers, it is imperative (a) to admit it, (b) to praise those who are better
informed, and (c) to return the next day better prepared on the subject.
Even when the clinical teacher is not well informed about a specific
problem, he must remember that education is what is left when he has
forgotten the facts. His personal interaction with the patient or general

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approach to the problem may be of more permanent value to those

being taught than his instant recall of statistics and references.”
Physicians should never be reluctant to acknowledge their limita-
tions of knowledge, as one student learned from Julius Bauer. Ac-
cording to Samuel Rapaport, the student was presenting a case on
rounds. He was doing very well, even as the questions got harder and
harder. Finally, Bauer asked a question to which the student replied:
“I am sorry, Dr. Bauer; I knew the answer to that question but I have
forgotten it.” Bauer countered: “I am sorry too, for you were the only
person in the world who knew the answer to that question.”
“The best self-education for clinical teachers is to remain conver-
sant within a broad sweep of medical problems by being on the firing
line frequently,” said Lloyd Smith. “Preferably, they should teach in a
way that encourages questions and alternative approaches. Unless their
intellectual epiphyses have already closed, this approach will inevitably
lead to their growth as teachers, physicians, and human beings.”
“Multiple heads are far more important and productive than one
head,” in Saul Farber’s experience. “No matter how uninformed a
medical student or house officer is about a particular subject, his in-
sight and curiosity often disclose an aspect of the situation that the
teacher was unaware of.” Arthur Fox pointed to yet another advantage
of teaching: “Teaching demands knowledge of facts and communica-
tion skills. If one does not communicate ideas clearly, the loss of in-
terest or the confusion of students and house staff is quickly apparent.
If they are bright and aggressive, they will tell you when they do not
understand or when they disagree. I learn from the bright young peo-
ple who show me when I have not martialed my facts. Then I go back
and read further to prove points.”
The most important point, for William Waters, is never to give the
same lecture twice. “Throw away your notes and start from scratch:
reread, rethink, reorganize. The result is relearning, new learning,
better information, new insights, and, of course, a much more sponta-
neous, enthusiastic lecture, seminar, or rounds.” The technique that
works for Marvin Turck is to “think of the two particular points that

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are clinically most relevant after I have read something, listened to a

seminar, or interacted in a consultation. I then try to use those two
points in teaching.”
Ralph Haymond advised physicians “to associate with students
with inquisitive minds, for they will stimulate you to keep current,
even if only to avoid embarrassment. And if you never teach, you
can assemble all the information you would need for a lecture, as
a method of reviewing your own knowledge of a topic.” Robert
Manning’s words summarized the consensus: “The old rule that you
don’t know something until you can teach it has a lot of validity.”

Full-time Practitioners
For those near medical schools, a teaching appointment is invaluable
in keeping up with new knowledge. Serving on the voluntary clinical
faculty of a medical school may be an economic hardship, but it pre-
vents obsolescence. “After World War II,” related Rodney Rodgers,
“I returned to three years of residency in medicine at Philadelphia
General Hospital. I found myself shockingly ignorant, but was
obliged to teach interns and medical students. The training was
largely clinical and highly integrated with patient care. I spent all my
spare time answering specific questions that arose while teaching
house staff. It took six months of hard work before I caught up from
my two years away from education. I resolved then to practice in a
town with a medical school, to which I would volunteer my teaching
services so as never to allow myself to decay again.”
Physicians who practice at some distance from medical schools can
still teach in local hospitals, as Alan Gordon does by conducting mor-
bidity and mortality conferences. Although Richard Field has literally
had to go to great lengths to maintain his ties with medical schools, it
has allowed him to bring up-to-date general surgery to his community.
As an Associate Professor at Tulane University and at the University of
Mississippi School of Medicine, both of which are 100 miles away, he
attends grand rounds and teaches students one day a month.

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“The most important aspect of teaching,” according to Saul Far-

ber, “is the security of knowledge of the teacher. People in practice
can feel secure by preparing in advance, and they can become as out-
standing teachers as full-time academicians.”
“Questions from students often point to inadequacy in your own
knowledge,” noted Sidney Howard. “Then pride forces you to update
your information.”
“The practitioner, perhaps without giving himself full credit, does
a great deal of teaching and learning every day,” said James Wyngaar-
den. “The kind of learning that appeals to me is that in which the roles
of student and teacher are mixed, each learning from the other while
working toward a shared objective. This is the kind that takes place on
the wards with patients and in the laboratory with fellows. The mere
transfer of information is certainly necessary to establish a joint
knowledge base, but the kind of learning that is the most fun and the
kind of teaching that is the most fun involve participatory collabora-
tion.” Major Bradshaw would like to capture the knowledge, experi-
ence, and skills of physicians who have retired, some at an early age,
because of their disenchantment with managed care, but are unhappy
about abandoning a profession that they clearly enjoy and find fulfill-
ing. Bradshaw would like to find some mechanism to reimburse out-
standing retired physicians for malpractice insurance, licensure fees,
society membership dues, modest travel expenses, and the like. In re-
turn, the physicians would teach at a designated clinic or hospital for
one-half day five days a week six months each year. These Senior Clin-
ical Educators could teach, by word and example, the basics of profes-
sionalism, the importance of establishing rapport with the patient, and
the skills of history-taking and physical examinations.
For James Young, working on projects and writing manuscripts
are the best form of education. “I concentrate my continuing medical
education activities on writing a variety of manuscripts, books, and
book chapters and on creating other educational packages, such as
video conferences, education slide lecture sets, and cyber sessions.
My lectures, however, have been most valuable to me; while creating

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presentations that are educational and entertaining for others, I para-

doxically learn the most. If I enjoy my own lecture and learn some-
thing new from it, I consider it a successful venture and don’t give
undue attention to criticism received from the audience. Nor do I take
seriously compliments about presentations that I think miss the mark.
Although this kind of continuing medical education is often consid-
ered to be solely the realm of academicians, I consider myself first a
clinician. I believe that any clinician can pursue education in this
way, and some of the most thoughtful and intriguing presentations I
have heard have been by clinicians rather than academicians.”
Writing and Speaking Richard Field liked to prepare at least one
paper each year. “I usually invite a colleague to be a co-author. We try
to stimulate our thinking and share anything we consider useful by
publishing it. The writing is a wonderful learning experience, as is the
presentation of exhibits at state medical meetings and at the Ameri-
can College of Surgeons’ clinical congresses.” Meeting interesting
people and the pleasure of traveling are added benefits.
Teaching the Office Staff As James Wyngaarden noted, “The practi-
tioner must do a great deal of teaching when interacting with patients,
nurses, physical therapists, or other hospital staff. The physician
must not be unduly impressed by rank; the concept of rank is one of
the greatest deterrents to learning.”
Brian Goodell, who has participated in in-service training ses-
sions in community hospitals in his area, pointed to the reduction in
turnover rate and the improved communication such sessions pro-
vide. “We make sure that the nurses have access to nursing journals
in the library. I encourage them to give me articles from these publi-
cations because they are often very practical.”
One of the provisions of employment for nurses in Richard Parkin-
son’s office is participation in a continuing education program. “I de-
vote about one-half hour three days a week to continuing education.
The program, which consists of a review of basic science and clinical
medicine, forced me to review all the subject material. The first nurse

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who came to work for me was an LVN whom I assisted in obtaining her
RN license, and who, after further training, was able to pass the physi-
cian’s assistant examination with a high mark. Another medical assis-
tant who handled the business end of my practice was so fascinated by
that nurse’s progress that she entered the field of nursing. She is cur-
rently working on her nursing degree, and I try to keep ahead of her and
to discuss with her the clinical significance of our cases.”

*****

The very nature of medicine requires that physicians be teachers.

Teaching is an impetus for study; it requires the teacher to acquire,
review, and organize the knowledge to be taught. In good teaching,
teachers are also learners, and exchanges of ideas, challenges, and
feedback make learning a lively affair.
The distinguished teachers we interviewed all stressed the impor-
tance of preparation. None was willing to rely totally on memory. The
practicing physician who has the opportunity to teach will profit im-
measurably from the experience. Those without access to medical
school teaching services will benefit from participating in hospital
staff meetings and from teaching nurses and office staff. Informal dis-
cussions are also an excellent way to gain knowledge. Physicians who
devote time to teaching their patients will be amply rewarded by im-
proved cooperation.

REFERENCES
1. Sénèque. Lettres à Lucilius, Tome I, text established by
François Préchac and translated by Henri Noblot. Paris:
Société d’Édition “Les Belles Lettres,” 1945:21.
2. Mayo, CH. Quoted in: Proc Staff Meetings Mayo Clinic.
1927;2:233.

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Analysis of Practice

...
We physicians had need be a self-confronting and a
self-reproving race; for we must be ready, without fear
or favour, to call in question our own Experience and to
judge it justly; to confirm it, to repeal it, to reverse
it. . . .
P ETER M ERE L ATHAM 1

W e have long believed that the best needs-assessment for contin-

uing education for physicians derives from practice analysis.
Our lengthy interviews with practicing physicians have yielded
a number of effective methods used to study individual practices
and profit maximally from experience. Many used index cards and
ledgers to note patient problems seen, treatments prescribed, and
outcomes obtained; some recorded lessons learned from puzzling pa-
tients; and others studied their mistakes. All were dedicated physi-
cians who developed methods to advance their learning from their
clinical experience. The concepts they related continue to be valid
and important today, although the computer has now replaced pen
and paper for the recording and manipulation of data. Whether physi-
cians view data electronically tallied and presented on a computer
screen or manually recorded, sorted, and stacked on index cards, the

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information allows physicians to use their clinical experience to im-

prove patient care. In fact, physicians developing such analytic meth-
ods should probably lay out their approach with pen and paper before
selecting appropriate software.
It is the concept of practice analysis that we wish to encourage. We
have noted that managed-care organizations, which include many
practicing physicians today, produce data for billing and cost-
containment that can also be used for practice analysis. Physicians
should begin to look at those same data to identify knowledge deficits
and to plan their educational activities as a means of improving pa-
tient outcomes.
William Budd’s duties as a country doctor permitted him to make
observations and collect evidence that typhoid fever was a communi-
cable disease.2 William Pickles tried to stimulate other country doc-
tors to keep records of epidemic diseases: “We country practitioners
are in a position to supply facts from our observation of nature, and it
is, I feel most strongly, our plain duty to make use of this unique op-
portunity.”3 Sir James Mackenzie believed that research in the physi-
cian’s office was a necessity, for the general practitioner “has
opportunities which no other worker possesses—opportunities which
are necessary to the solution of problems essential to the advance of
medicine.”4
In 1879, following an undistinguished career as a medical stu-
dent, Mackenzie entered general practice in a small English town.
“About 1883 or 1884,” he wrote, “I resolved to begin a series of care-
ful observations entirely for my own improvement, never dreaming of
research, for I was under the prevalent belief that medical research
could only be undertaken in a laboratory or, at least, in an [sic] hospi-
tal with all the appurtenances. I merely sought to find out something
about the nature of my patients’ complaints . . . . I had thus placed
before me two definite objects, at which to aim: (1) understanding of
the mechanism of symptoms, and (2) understanding of their prognos-
tic significance. When . . . I look back upon my work, I can recognize
that it was this simple resolution and these definite aims which

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guided me to such success as I have achieved. . . .” Mackenzie’s de-

tailed records of patients with heart disease enabled him to become
one of the leading heart specialists of his time, and a pioneer in symp-
tomatology.
The study and analysis of practice give physicians a reliable per-
spective and a formal record of their own work, thus permitting them
to profit maximally from lessons learned. This, we think, is the most
rewarding kind of continuing education.
The practice of medicine can and should be a scholarly and in-
tellectual process. “The only way I have found to do that,” said War-
ren Williams, “is through the study of the practice itself. I tried to
develop my practice by emulating my medical school professors,
who seemed to know exactly what they were doing. When I first
started my practice, it seemed to be one sore throat after another,
getting people in and getting people out. It was not intellectually
stimulating until I started my practice study and analysis.” John Fry
found that simple, inexpensive methods of recording, reviewing,
and analyzing everyday work not only yield better services, but add
immeasurably to his enjoyment of medicine. Thus, practice analysis
not only delivers the most benefit to physicians from their experi-
ence, but also heightens their zest for their work through greater im-
mersion and more focused direction for future study. These
advantages increase the likelihood of improving patient services
and enriching professional life.
Physicians may organize their practice for study by:

• indexing patient charts by clinical problem, to permit a critique of

aggregate experience in specific conditions;
• keeping statistics on the problems seen, drugs prescribed, and
laboratory studies ordered;
• compiling and classifying salient clinical features observed in
specific problems, diseases, and procedures, and recording mis-
takes and lessons learned;

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• performing an audit of patient records;

• tracking, and reacting to, patient outcome;

All of these are facilitated by electronic technology.

I N D E X I N G PAT I E N T C H A R T S B Y P R O B L E M
John Fry kept a card index of all patients diagnosed with certain dis-
eases, which permitted him to calculate incidence/prevalence rates and
facilitated follow-up reviews on patients with particular diseases. He
also collected the following sets of data: (1) day sheets that recorded all
physician–patient contacts by patient’s name, age, sex, diagnostic group,
and referrals for studies or consultation, and (2) an age–sex register that
provided the current population at risk. His studies enabled him to re-
duce his volume of work per patient and therefore to treat more patients,
to lower his prescribing costs, and to minimize his referrals to consult-
ants. It took him a few seconds per consultation to record the data, and a
secretary entered the data weekly into a ledger. Fry’s analyses of these
data led him to be more conservative in the use of antibiotics,6 and his
studies of emotional disorders, acute back pain, hay fever, and hyper-
tension in his practice prompted changes in treatment of these patients.7
This recording system allowed him to set down his long-term experience
in following patients in family practice, and the disease index provided
information that led to his book Common Diseases.8
William Cooper has kept an index of all his patients categorized
by disease. “If I read an article that does not quite agree with my rec-
ollection of my clinical experience, I can use the index to review my
patients and compare my experience with the author’s view.”
Warren Williams once listed patients’ names on cards by diagno-
sis so he could pull specific conditions for study. Each 5-by-8-inch
file card was labeled with the name and code number of a disease, ac-
cording to the International Classification of Diseases, 9th Revision,
Clinical Modification (ICD 9CM). “Simply recording this information

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made me pay attention to details and ask certain questions that I had
never before considered, such as: What is a ‘problem’? What is wor-
thy of being indexed? It was an intellectual process that had not been
alive in me before.” He also found his cards useful in constructing a
practice profile. “Some years ago, I asked my receptionists to tabulate
patients by their particular clinical problems while I was away at a
cardiology meeting. On my return, I found a completed practice pro-
file on my desk. Aside from smoking and obesity, the most frequent
diagnosis was depression. I then searched for cardiology, and found it
to represent less than one percent of my patients. It dawned on me
that this was a beautiful tool to define the postgraduate education I re-
quired. I had not attended a single psychiatric meeting or read a psy-
chiatric journal, and yet depression was one of the most common
problems I encountered. I realized that if I wanted to do the most for
my patients, I had better enroll in some psychiatric programs. Until
then, I had been concentrating on subjects I liked, and now I had a
tool for a more practical approach.”
His original 5-by-8-inch cards have been replaced by more versa-
tile and powerful computer systems, but he continues to benefit from
maintaining his practice database. “I am now on the medical staff at
St. Joseph’s Community Health Center in Hillsboro, Wisconsin, a 10-
bed hospital with an attached 65-bed nursing home, where I am the
Medical Director. My office practice is about ten miles away in Elroy,
a slightly larger town of 1300. I have been using Excel™ for cross-
indexing during the past few years because it is fairly intuitive and
easy to use. I can enter information myself, but retrieving data from
Excel is laborious, at least at my level of expertise. Microsoft Ac-
cess™ is much more sophisticated and has wonderful retrieval possi-
bilities, but I have not had time to learn the fine points of
programming it. I have hired a programmer to set up a customized
version of Access, specifically to cross-index my patients, including
the usual demographic data, diagnoses, medications, referrals, and
procedures. I hope to be able to download into Access the data in the
various Excel files so that they will not be lost or need to be reentered.

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“I now cross-index not only the problem list or diagnoses, but also
medications, including short-term medications, such as antibiotics.
This addition has proved useful. The Food and Drug Administration
(FDA) has removed previously approved medications from the formu-
lary on several occasions, and I have been able to retrieve the names
of all my patients who were taking those drugs, either by my direction
or a consultant’s, and advise them to discontinue the medication.
“It has also been helpful for me to have the medication cross-
indexed because of the close relationship I have with Scott Larson, a
young academic-minded pharmacist at our hospital. We discuss and re-
view medications for the hospital and nursing home patients daily, and
I use that information and his expertise in my office practice. The Palm
Pilot™, with the drug information database ePocrates™ and the infec-
tious disease database qID, also from ePocrates, along with the index-
ing, keeps me out of trouble. I maintain a list of all my hospital and
nursing home patients on the Palm Pilot™, along with the clinical
problem list and medication list. The drug interaction program from
ePocrates is run monthly on each patient’s medication list. The cross-
index list of clinical problems continues to be helpful in the evaluation
of my practice profile and answers the important question: What am I
seeing, and where do I need to concentrate my continuing medical ed-
ucation to improve the quality of care for my patients?
“At the Swedish Hospital in Colorado, we would close the office
and call in a consultant for our own Grand Rounds once a month.
Using the diagnosis index, we assembled the records of patients with
a specific problem and went through them with the consultant. We
asked certain patients to be present for these sessions, and they
loved it. The whole staff participated, and as a result we changed our
ways of doing things, including more effective use of certain drugs
and better patient education. We always asked the consultant for a
composite, constructively critical written report on the Grand
Rounds. Since we closed the office for a half day and paid the con-
sultant, we lost income on that day, but this intellectual part of the
practice was both enjoyable and instructive. The information gained

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in our Grand Rounds was 100 percent applicable to our practice,

and the patients ultimately benefited.
“In my current practice, I plan to ask consultants at my primary
referral centers, the University of Wisconsin and the Mayo Clinic, to
participate in our Grand Rounds. I am getting to know a few of the
consultants, some of whom are energetic and willing to teach an old
dog new tricks. Physicians at both institutions have been helpful in
giving their time for telephone consultations.
“The most difficult issue for me, here in rural practice, is the loss
of immediate consultative help. A consultation at Swedish Hospital
simply required someone to come up one floor or down two to see a
patient, but here it means a helicopter ride or an hour-and-a-half am-
bulance ride. A consultation for an ambulatory patient requires a two-
and-a-half-hour drive by car to the Mayo Clinic or an hour-and-a-half
drive to Madison, and many of my patients are just not willing or able
to do this. So the telephone consultation, which is not only docu-
mented in the record but is also cross-indexed in the computer, has
been a boon. I am impressed with the willingness of the various dis-
tinguished physicians at these great institutions to help me on a mo-
ment’s notice and without compensation. This is a view of medicine
that the general public does not always see.”

K E E P I N G S TAT I S T I C S O N C L I N I C A L P R O B L E M S ,
M E D I C AT I O N S , A N D L A B O R AT O RY S T U D I E S

The Need
Through extensive work in identifying educational needs in physi-
cians’ offices, S. E. Sivertson and Thomas Meyer found that the aver-
age physician really did not know what his practice constituted. Said
Sivertson, “Early in our work, we asked some physicians to predict
their practice profile. They were unable to do it accurately. They were
so far off, in fact, that we could not use their predictions to help plan
their continuing education. The physician frequently told the consult-

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ant: ‘This is the first time I have understood my practice and how my
continuing education should be related to it.’ In addition, older physi-
cians would say, ‘My practice and I are growing old together. I need to
focus more on geriatrics.’ ”
In an experiment to see if feedback about ambulatory practice
would influence the behavior of an internal medicine house staff, Reid
and Lantz found that only 50 percent of resident physicians could cor-
rectly guess the relative frequency of types of patients they saw.9
Jeremiah Barondess kept a detailed record of patient visits in his
practice. “For three months I kept track of the reason for each pa-
tient’s visit along with the diagnosis. In nearly a thousand office visits
over three months there were only two instances of nephrologic dis-
ease and five of hematologic disease, whereas nearly 350 patients had
cardiovascular disease. There were relatively few gastrointestinal or
infectious problems of major consequence.” Every physician can
profit from this type of study.
Aggregate data that permit analysis of the problems seen, drugs pre-
scribed, and laboratory studies ordered facilitate the study of practice. If
physicians also know the costs they generate, the time they spend with
patients, and the reasons for their consultation requests and hospital ad-
missions, they can improve their practice management. Managed-care
organizations capture clinical data on individual practices when they
compile claims data. If these are distributed for education and not for
cost-saving alone, they will simplify data collection for physicians. “The
effect of managed care on a physician’s continuing education and life-
long learning,” said Garrett Lynch, “has been a two-edged sword, albeit
chiefly a negative one. The increased paperwork and telephone ap-
provals for testing can drastically cut into the time physicians have to
read, study, or attend conferences. The demands to see more and more
patients for briefer and briefer periods has curtailed the time available to
seek specific information during a patient encounter. One positive effect
of managed care, however, has been the creation and implementation of
patient guidelines, which permit physicians to keep abreast of current
diagnosis and therapeutics for a specific disease.”

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Recording the Data

Cumulative data permit a description of practice activities, identifica-
tion of patients with particular conditions for further study, descrip-
tion of patterns of laboratory test-ordering, and listing of medications
prescribed. From such cumulative data, you can analyze your prac-
tice and compare it to similar practices in published reports as well as
to local and national standards. You may find, perhaps with the help
of consultants, that you are diagnosing certain conditions more often,
or less often, than other physicians are. Such a finding would not nec-
essarily mean that you are at fault, but might signal a need to reeval-
uate the implicit or explicit diagnostic criteria being used. If you are
prescribing certain medications more, or less, than your peers are, it
may be wise to learn more about these drugs, their efficacy, side ef-
fects, and contraindications.
You must, of course, be careful not to overestimate the significance
of a small series of observations, which may help physicians focus on
their practice, but should not give a false sense of security when the in-
cidence of harmful effects may become apparent only in a large series.
The compilation of outcome figures, however, is still useful because it
allows physicians to compare their results with those of a larger series.

N O TAT I O N O F S A L I E N T C L I N I C A L P R O B L E M S
To facilitate learning from experience, some physicians keep notes on
patients with certain problems, recording unusual manifestations, the
value of certain laboratory studies, the effect of treatments, and les-
sons learned, so their cumulative experience can be coordinated and
reviewed. From an analysis of the patient data Paul Dudley White
recorded on 4-by-6-inch cards, he was able to determine the fre-
quency of rheumatic heart disease and hypertension, among other
conditions, and this information formed the basis of his first book.
(See Reflections by Willis Hurst, pp. 43–56.)
For many years, Norton Greenberger used cards to keep notes on
patients and to remind himself to read published reports about cer-

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tain interesting diagnoses. He now uses the computer to record pa-

tient data, including the patient’s name, hospital number, and major
diagnosis or problems. When he reads pertinent articles, he abstracts
them in a format that is suitable for slides and then downloads the
abstracted material onto a floppy disk can use on PowerPoint™
software.
Telfer Reynolds categorizes his cards by disease. “We have
thousands of cards in the file, divided into two sets: one comprising
the consultations made by residents on my service and the other the
cases I have seen personally. Any time a question arises about a
particular disease, we can pull out 40 or 50 cards and spend a half
hour sorting them. It is not real research—you would have to go to
the charts to get the full data—but they often answer a question
quickly on the basis of our past few years’ experience. If I were
starting today, I would use the computer to store more legible notes
on instructive cases.”
A valuable asset in clinical practice, in the opinion of Walter
Somerville, is a memory aid to assemble the physician’s personal expe-
rience in specific diseases or procedures. “The data cards originated by
Paul Wood (Figure 1) are designed to tabulate the main features of se-
lected conditions or procedures. A comparison of this information in
the aggregate with the reported experience of others leads to logical
decision-making. For example, salient features of each candidate of
percutaneous transluminal coronary angioplasty (PTCA) are annotated
by hand. Time-consuming minutiae are left to the detailed case record.
Within weeks, impressions emerge, eventually to be confirmed or dis-
carded. Keeping records like this helps the physician draw on his en-
tire experience rather than only the past few cases.”

Notes on Experience
Since her medical student days, Celia Oakley has kept notes on what
she learned during the day. “As a student, this was a considerable
amount, but I had the time and the inclination to review what I had

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written. Now I am busier, but I still jot down the things that I learn
each day.”
Bruce Zawacki noted in his diary any problem that arose in the
course of practice or during presentations, after which he looked up
material on the subject. Robert Smith records in a little book notes on
his surgical patients, especially any unusual aspects of the operation.
“I also record my contacts with the referring physicians, to make sure
that we keep a good exchange and that I dictate letters. I can get
about six months’ use out of one book. I carry the book with me every-
where except the shower. With the pressure of all the administrative
and patient-care duties I have, if I don’t make notes and outline each
day’s schedule the evening before, I am apt to forget something.
The diary has become my auxiliary brain. I really couldn’t function

FIGURE 1. Card originated by Paul Wood and used by Walter Somerville to tabulate clini-
cal data on patients having percutaneous transluminal coronary angioplasty. Clinical data
can be similarly tabulated for patients with clinical conditions of particular interest. AP,
angina pectoris; MI, myocardial infarction; EX Test, exercise test; L Main, left main coronary
artery; AD, left anterior descending coronary artery; CX, left circumflex coronary artery; RC,
right coronary artery.

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without it. For our Grand Rounds or our weekly vascular conferences
at Emory, it is also useful to look back through the book and quickly
select a half-dozen interesting and unusual cases.” Some physicians
prefer a PDA device over the notebook.

Learning from Mistakes

Osler advised physicians to record their mistakes: “Begin early to make
a threefold category—clear cases, doubtful cases, mistakes. And learn
to play the game fair, no self-deception, no shrinking from the truth;
mercy and consideration for the other man, but none for yourself, upon
whom you have to keep an incessant watch. . . . It is only by getting
your cases grouped in this way that you can make any real progress in
your post-collegiate education; only in this way can you gain wisdom
with experience. It is a common error to think that the more a doctor
sees the greater his experience and the more he knows.”10
Jane Somerville considers her study of mistakes to be the single
most useful exercise she has undertaken. In the current climate of
medical litigiousness, records of mistakes may be subpoenaed and
used punitively. As a result, most physicians are now reluctant to
record mistakes as such, just as, in the U.S. government, Presidents
and their staffs do not like to preserve notes for fear that they will be
subpoenaed.

TRACING AND REACTING TO OUTCOMES

Without a specific mechanism for follow-up, physicians are often un-
aware of the therapeutic results in their patients. In this sense, they
know less about their practice and their performance than a football
coach knows about the performance of players and their opponents.
“Without statistics, we would be unable to maintain a high level of
performance,” said Tom Landry, former head coach of the Dallas
Cowboys. “We use a quality control system to monitor our football

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team, that is, we set guidelines for our individual player’s perform-
ance as well as for our team performance. Our quality-control coach
accumulates all the data and alerts the staff when performance levels
are below guidelines. We are then able to make adjustments to pre-
vent possible losses in future games. Our most vivid results come
when we fall into a slump late in the season. We then concentrate on
weaknesses and apply proper adjustments. This usually corrects the
weaknesses and returns us to the winning path. Without statistics,
however, we would not be able to identify the problems.”
Coach Joseph Paterno of Pennsylvania State University also found
that recording and analyzing data are invaluable. “We do not practice
without a doctor on the field. He records in a diary everything that hap-
pens at each practice. We keep a record of the temperature, the type of
drills, the number of injuries, and so on. We can tell if more injuries
occur when we scrimmage two days in a row or when we have a one- or
two-day break between scrimmages. If we are having more sprained an-
kles than usual, we can review our records and compare the current
year with past seasons. Statistics help us keep our team healthy. I use
medical statistics to make determinations about equipment, style of
practice, type of drills, and when not to practice.
“We also use statistics on the performance of other teams to deter-
mine their tendencies and therefore our best strategy in certain field
positions and at certain downs. We are constantly reviewing our com-
puter kickout for a better evaluation of the other team.”
Medicine is admittedly more complicated than athletic enter-
prises, but the analogy illustrates the value of analyzing one’s perform-
ance. Once problems are identified, solutions can be sought. A study
of results requires a routine method of tracing patient outcomes.
E. A. Codman was a strong advocate of the “End Result System.”
“In brief,” he wrote in 1918, “it is this: That the Trustees of Hospitals
should see to it that an effort is made to follow up each patient [the
staff treats], long enough to determine whether the treatment given
has permanently relieved the condition or symptoms complained of.

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That they should give the members of the Staff credit for taking the
responsibility of successful treatment and promote them accordingly.
Likewise they should see that all cases in which the treatment is
found to have been unsuccessful or unsatisfactory are carefully ana-
lyzed, in order to fix the responsibility for failure on:

1. The physician or surgeon responsible for the treatment.

2. The organization carrying out the detail of the treatment.
3. The disease or condition of the patient.
4. The personal or social conditions preventing the cooperation
of the patient.

This will give a definite basis on which to make effort at improve-

ment. . . .
“The Idea is so simple as to seem childlike. . . . It is simply to fol-
low the natural series of questions which any one asks in an individ-
ual case:
What was the matter?
Did they find it out beforehand?
Did the patient get entirely well?
If not—why not?
Was it the fault of the surgeon, the disease, or the patient?
What can we do to prevent similar failures in the future?

“We believe that the general acceptance of a system of hospital

organization based on the truthful record of the answers to these ques-
tions means the beginning of True Clinical Science.”11
Some surgeons send questionnaires to their patients at intervals
of three, six, or 12 months to determine the success or limitations of
their procedures. Michael DeBakey writes to his patients or the refer-
ring physicians at regular intervals to inquire about their progress.

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From his analysis of results so obtained, he has been able not only to
monitor and report on his clinical experience continually, but to rec-
ognize certain patterns of disease that have led him to devise new sur-
gical treatments, such as excision of aneurysms, coronary artery
bypass, and others.
Bruce Zawacki maintained an alphabetized file of operative
notes, supplemented with review articles on new techniques. “Before
performing a procedure not done regularly, I use this file to review my
experience and the articles I have collected. I also often present a
particularly difficult preoperative case at a regular medical school
conference. At our monthly mortality and morbidity conference, in-
vited guests critique our approach, and we review any untoward
events. We identify problems, plan solutions, and assign certain
physicians to implement those solutions. Yearly, we have an outcome
review, in which our current mortality and morbidity data are com-
pared to those of all previous years for possible trends.”
Gustavo Kuster sends every surgical patient a follow-up letter or
questionnaire six months after the operation and every year there-
after. “I have about 20 different kinds of questionnaires, coded ac-
cording to the operative procedure. These questionnaires allow me to
be precise in answering questions about our operations and to im-
prove my patient care. Through the questionnaires, for example, I
found that in repair of hiatal hernia, it was postoperative bloating that
made the patients most unhappy. I reviewed this technique more
carefully, visited other medical institutions, and then modified my
techniques slightly by making the fundal plication extremely loose
around the esophagus. That practically eliminated the unpleasant
side effects of the procedure.”
We have given examples of recording elements of practice experi-
ence on index cards, as ledger book entries, and as tabulations on a
chart to crystallize the concepts. Current computer software simpli-
fies data entry and access, and new products are continually being in-
troduced. When searching for software, you should ensure that the
functions described in this section are available.

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E N L I S T I N G H E L P I N T H E A N A LY S I S O F P R A C T I C E
Nothing is so difficult to deal with as a man’s own Expe-
rience, how to value it according to its amount, what to
conclude from it, and how to use it and do good with it.
P ETER M ERE L ATHAM 12

Most people find it threatening to have their work reviewed. For profes-
sionals, the threat may be real, since society often judges their short-
comings harshly, resulting in regulatory, even punitive, solutions. A few
physicians may, indeed, require regulatory sanctions, and all can bene-
fit from reminders of their errors of omission and commission. Careful,
constructive analysis of events in practice can motivate physicians to
continue their education, whereas draconian penalties may drive some
underground. The data on their practices then become unreliable, and
the opportunity to profit from experience is lost. We distinguish clearly
between formal external quality-assurance mechanisms and the im-
provement in medical practice that ensues from a well-motivated physi-
cian’s voluntary analysis of personal practice.
One byproduct of managed care is the collection of information on
individual practice from claims data. Most managed-care organiza-
tions can supply physicians with information on the sex ratio and pre-
dominant age group of patients seen, the most prevalent ICD9
diagnoses made and procedures performed, and, in some cases, the
medications most frequently prescribed. Unfortunately, these statis-
tics are not always presented to the physician, but they do provide an
outstanding opportunity to study, and gain from, one’s clinical experi-
ence, especially when physicians discuss the statistics with peers.
The National Committee for Quality Assurance (NCQA), an inde-
pendent nonprofit organization, evaluates and reports on the quality
of managed-care organizations in the United States through the
Health Plan Employer Data and Information Set (HEDIS).13 HEDIS
collects information for the Health Care Financing Administration
(HCFA) and audits five domains to assess the quality of a health plan,
including effectiveness of care, as measured by such HEDIS stan-

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dards as breast-cancer screening, beta-blocker treatment after a heart

attack, and eye examinations for diabetes. Other markers assess ac-
cess/availability of care, health-plan stability, use of services, and in-
formation on the Board certification of participating physicians. The
study of practice has been enhanced by HEDIS.
John Walther practices in an HMO in Ohio, a professional corpo-
ration of some 50 physicians, which decided to have its medical
records scrutinized for compliance with various quality indicators of
HEDIS. As an incentive, the group agreed that 20 percent of their
salary would depend on compliance with the various quality indica-
tors and the other 80 percent on production (the number of patients
seen). Of the portion related to quality, 35 percent concerns accurate
and complete coding, defined by the 1999 HCFA Coding Guidelines,
and 20 percent concerns quality of outcomes. For simplification of
the audit, one disease is selected each month. For example, the Inter-
nal Medicine/Family Practice audit in January might be: “Is the pa-
tient with diabetes assessed yearly for microalbuminuria?” and in
February: “Is the patient with a diagnosis of congestive heart failure
prescribed an angiotensin converting enzyme (ACE) inhibitor?”
Another 15 percent of the quality evaluation is concerned with
preventive medicine, including the following items:

• mammograms every two years for women age 50–70 years,

• Pap smears every three years for women age 20–65 years,
• colorectal screening yearly after age 50 years,
• flu vaccine yearly after age 65 years,
• tetanus every 10 years after age 18 years.

Other quality criteria relate to proper recording: 10 percent for diag-

nosis sheets; 10 percent for medication sheets; 5 percent for vital
signs and for minutes patients waited to see physicians (threshold 30
minutes or less), and 5 percent for attendance at site quality meet-

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ings. The audit is conducted by a full-time registered nurse with a

rank just under the vice-presidency.
The system encourages Walther to check more carefully on the
patient’s diagnostic criteria and therapy. For example, if he is seeing
a patient with congestive heart failure, he will review the chart care-
fully to be sure that the patient is taking an ACE inhibitor, if indi-
cated. The most difficult aspect is the coding. In the beginning,
Walther resented the system, but now believes that he is practicing
better medicine because of it. This system provides an incentive for
the physician to avoid overlooking certain details of care. Other
groups may prefer computerized reminder systems.
Arnold Goldschlager described meetings that one Independent
Physicians Association (IPA) conducts monthly. The IPA medical di-
rector attends each meeting with an agenda; a practicing physician is
selected as leader. Physicians who miss a meeting are fined $190.
Meetings focus on a particular subject, such as common eye problems
that do not need a specialist referral, common skin conditions for which
liquid nitrogen is used to remove the lesion, and a review of patients
who visited an emergency room instead of making an office visit.
Physicians are given report cards that analyze cost data. Those
whose costs are more than the group’s average are not considered to
have cost-effective practices. Referrals are encouraged to those surgi-
cal consultants who generate the least costs. Physicians are taught
how to instruct patients on therapeutic exercises and thus avoid refer-
rals to physical therapy. These policies encourage or enforce cost-
saving measures, with less emphasis on the quality of care, although
the administrators would argue, sometimes correctly, that this ap-
proach can provide equal or superior service. In any case, data col-
lected on individual practices can be used to discuss real events in
practice at these meetings and can generate ever-improving patient
care with cost containment receiving just attention. We stress the dis-
cussion of practice data as a major educational tool.
The Norwegian Medical Association has developed a method
(SATS) using the PDSA (Plan–Do–Study–Act) cycle, which is appli-

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cable to both quality improvement and self-directed learning. Tor

Carlsen described the approach: “This method combines three ele-
ments: (1) defining quality indicators, (2) selecting computer software
that enables simple input and retrieval of data from the electronic pa-
tient record, and (3) organizing study groups to discuss practice data.
Four topics were chosen for testing the method (clinical use of the
laboratory, and diagnosis and management of sore throat, migraine,
and diabetes).
“The groups, whose members were general practitioners with 10 to
20 years of practice, started discussing the need for improvement in
their own practice, and agreed on quality goals (how often quality crite-
ria should be met). Next, clinical performance was recorded in the com-
puter system. Reports were presented to the group, differences were
analyzed, and needs for improvement were identified. The group mem-
bers provided ideas on how to effect change in practice. A second pe-
riod completed a cycle of six to 12 months.
“The first trial, carried out in 1995–1997, included about 200
family physicians in 30 peer groups. Nearly all participants showed
improvement, those with the lowest initial scores showing the most.
Participants reported that SATS provides an attractive learning envi-
ronment and expressed high motivation for peer group work. The fact
that actual observations of practice were the focus of discussion, not
subjective opinions, enhanced awareness of the need for change. The
confrontation with facts, although unpleasant for many, was a major
driving force.”
Some academic institutions are using the computer to analyze vari-
ous aspects of practice. Lawrence Cohn described a system in place at
Brigham and Women’s Hospital: “At our institution we have a highly
developed computer database system that can analyze all elements of
patient practice. In this cost-conscious era, I believe that this is instru-
mental in reducing not only cost but waste, improving practice tech-
niques, and discovering where problems exist in the institution or
individual practitioner. We are able to analyze our Intensive Care Unit
(ICU) experience in terms of laboratory studies, expensive and inex-

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pensive medications prescribed, procedures performed, length of stay,

operating times, blood use, and patient outcomes. We consider this to
be extremely important, and we should look upon it as an impetus to
improve practice techniques rather than as an onerous “big brother”
oversight of activities. In addition, we compare our own practice with
that of our sister hospitals in the same health system. These techniques
may improve the outcomes for the same disease or procedure in a hos-
pital that has less positive outcomes than others. A simple adjustment
and consultation with the other team may lead to a safer and more cost-
effective technique, with better patient outcomes.”
The American Board of Family Practice conducts an office record
review that may be part of the certification process. Information that
should be available in the office chart includes the patient profile,
possible risk factors, presence or absence of allergies and drug intol-
erance, past history, current immunization status, clearly stated pri-
mary and associated health problems, current medications, laboratory
results, conclusions, treatment, and patient education plan for each
problem. Four patient charts representing conditions frequently seen
in the family physician’s office are required. Physicians complete
data scan forms based on their review of patient charts. The Board
may require physicians to submit photocopies of portions of patient
charts from which the data scan forms are completed. An individual
computerized report containing tutorial statements about recommen-
dations for management and record-keeping for specific problem cat-
egories is generated and mailed to each candidate. The reports
identify any discrepancy between the records provided and the rec-
ommendations of the appropriate advisory committee.

*****
To profit most from experience, physicians must know what their
practice consists of and what results they obtain. The methods of
study outlined in this chapter are, unfortunately, used by relatively
few physicians. The potential dividends in improved patient care and
physician satisfaction, however, are great and well worth the invest-

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Evidence-based medicine has certainly added a new

dimension to empirical medical practice, but it should
complement, not replace, the conventional skills of the
practitioner.
I AN R. M ACKAY, M.D.
Professional Fellow
Biochemistry and Molecular Biology
Monash University
Clayton, Victoria, Australia

ment of time in practice analysis. To be most useful, the physician’s

experience should be compared with that of others reported in publi-
cations, at meetings, and in discussions with colleagues.
We suggest that physicians not now engaged in analysis of their
practices consider establishing a simple method of indexing patient
charts by problem or diagnosis and periodically reviewing the charts
with a respected colleague to discuss diagnostic approaches and ther-
apeutic plans for specific common conditions, such as hypertension.

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In addition, physicians can profit from keeping simple notations on

cards, like those designed by Paul Wood, on one or two conditions or
procedures that interest them. Once the concepts recorded on index
cards and ledger entries are clearly in mind, most physicians will do
better to seek computer software to record, analyze, and access their
practice data.
Data collected by HMOs and HEDIS can be useful in helping
physicians review their practices. For maximum and sustained edu-
cational value, the identification of educational needs from events in
practice should avoid intimidating programs that may lead to defen-
siveness and inhibit the physician’s willingness to participate in as-
sessment of performance. Preserving the buoyant spirit in physicians
is important, so that they will continually strive to offer their patients
better care. External sources must therefore be careful not to stifle
enthusiasm for practice.

REFERENCES
1. Latham PM. General remarks on the practice of medicine.
In: Martin R, ed. The Collected Works of Dr. P. M. Latham.
London: New Sydenham Society; 1878:466.
2. Budd W. Typhoid Fever. Its Nature, Mode of Spreading, and
Prevention. New York: George Grady; 1931. Reprint of 1874
original.
3. Pickles WN. Epidemiology in Country Practice. Baltimore:
Williams & Wilkins; 1939:9.
4. Mackenzie J. Principles of Diagnosis and Treatment in Heart
Affections. Joint Committee of Henry Frowde and Hodder
and Stoughton. London: Oxford Univ Press; 1916:1–2.
5. Wilson RM. The Beloved Physician: Sir James Mackenzie.
New York: Macmillan Co; 1926:51–52.
6. Fry J. Information for patient care in office-based practice.
Med Care. 1973;11(Suppl 2):35–40.

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7. Fry J. On the natural history of some common diseases.

J Fam Pract. 1975;2:327–331.
8. Fry J. Common Diseases: Their Nature, Incidence and Care.
Ridgewood, NJ: George A. Bogden & Son; 1983.
9. Reid RA, Lantz KH. Physician profiles in training the grad-
uate internist. J Med Educ. 1977;52:301–307.
10. Osler W. The student life. A farewell address to Cana-
dian and American medical students. Med News.
1905;87:629–630.
11. Codman EA. A Study in Hospital Efficiency: As Demon-
strated by the Case Report of the First Five Years of a Private
Hospital. Boston: Thomas Todd Co; 1918:8–9.
12. Latham PM. General remarks on the practice of medicine.
In: Martin R, ed. The Collected Works of Dr. P. M. Latham.
London: The New Sydenham Society; 1878:465.
13. Health Care Financing Administration. Medicare HEDIS®
3.0/1998 Data Audit Report. Available at: /http://www.hcfa.
gov/ quality/3i2htm. Accessed Sept 13, 2000.

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R E F L E C T I O N S
...
Dr. A. McGehee Harvey received his M.D. degree, as well as his
intern and residency training, at Johns Hopkins University School
of Medicine. He had served as President of the Association of
American Physicians, and was a Fellow of the American Academy
of Arts and Sciences, Royal College of Physicians, and Royal Soci-
ety of Medicine. The American College of Physicians honored him
with the Distinguished Teaching Award. He was also Editor of The
Principles and Practice of Medicine1. According to Dr. Sherman
Mellinkoff, Dr. Harvey, a respected scholar of medical history,
brought to differential diagnosis “a blend of sagacious empiricism
and the scientific method, a combination that reflects . . . his moti-
vation: an abiding devotion to the dispassionate exercise of logic
and reason.”

REFERENCE
1. Harvey AM. The Principles and Practice of Medicine. Nor-
walk, CT: Appleton & Lange; 1998.

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 Personal Responsibility
for Learning

A. McGehee Harvey, M.D. (1911 – 1998)

Former Distinguished Service Professor of Medicine
Johns Hopkins University School of Medicine
Baltimore, Maryland

T o be a good physician, you have to make medicine your number

one priority. You cannot enter medicine with the soul of a money-
changer. You must love it and must develop your own expertise
through creative scholarship. That ideal alone will make you an out-
standing physician. It is a matter of developing the habit of learning
so that it becomes second nature and not something you turn on and
off at certain times. If you can keep your curiosity about medicine
alive, it will sustain you when you are in the middle of a difficult
problem.

PERSONAL RESPONSIBILITY FOR LEARNING

Education must be pursued actively, not through the passive receipt
of information distilled by someone else. I require all students, during
their medical quarter, to choose a clinical problem that has no ready

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answer but for which an answer is possible by examination of patient

records or by review of the literature. At the end of the quarter, they
present the results of their studies to their classmates. This exercise
establishes education as primarily the student’s responsibility. You
can motivate students to make the most of their experience by adding
the experience of others, as recorded in publications or other medical
records. That principle was enunciated by William Henry Welch and
later became a precept of the Western Reserve experiment in the mid-
1950s.
When physicians go into practice, they become members of the
medical community. If each physician presented personal experi-
ences on a particular subject to colleagues at a local medical meeting,
all would have a continuing flow of useful information, which would
not only improve their patient care but would constantly emphasize
the importance of keeping abreast of new knowledge. Special courses
are important, but what you get out of them is governed largely by
your motivation and the time and effort you invest in them.
Making self-education a habit—a part of your routine activities—is
important. The foremost principle is that no one else is going to provide
your continuing education; you must do it yourself. One way to do this is
to select certain key journals for regular review. Another is discussions
with colleagues, whether at lunch or at other times. You can learn a great
deal from your own cases if you share your experiences with others.

PUZZLING CASES
We used to keep a puzzling-case book and a mistake book at our
weekly resident rounds. It was surprising how often another case
would later come along about which you could learn something by re-
ferring to the previous one. By presenting your mistakes to your col-
leagues for discussion, you can often find out why you made the
mistake, and you can avoid a repetition of it.
Medicine is an exercise in problem-solving, and the same basic
techniques used in the scientific laboratory to approach an unknown

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are applicable to clinical problem-solving. In differential diagnosis,

you have to gather information systematically from the moment the
patient enters the room. You can get ideas each step of the way, and
those, in turn, will create new questions to be answered.
Most important for students to understand is that they must re-
main curious, alert, and eager for new information. Learning to organ-
ize, assess, and transmit information clearly to consultants is a
distinct advantage. A teacher can provide motivation and an environ-
ment for learning, but it is still up to the student to be an active
learner.

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 11

Social, Ethical, and Economic

Problems in Medicine

...
The exceptional advances of modern medicine have re-
stored to productive life many patients with previously
fatal or disabling diseases, but these very successes
have raised a host of troubling ethical and economic
questions. Reconciling society’s increasing demands on
medicine with the realities of inflation, governmental
regulations, changing social values, and an aging popu-
lation poses knotty problems.
M ICHAEL E. D E B AKEY, M.D., AND
L OIS D E B AKEY, P H .D. 1

O P P O R T U N I T I E S F O R I N V O LV E M E N T

T he methods and approaches physicians use to learn from their

clinical experiences not only perfect their skills, but heighten
their personal satisfaction and passion for practice. Such activities
can no longer be limited to the study of clinical findings, diagnosis,
and therapy, for extraordinary medical innovations have raised a rash
of problems—economic, social, legal, moral, and ethical. Can we af-
ford the advances? How do we control the escalating costs? How do
we provide the new services for the economically deprived? How do
we reconcile society’s ever-increasing demands and expectations of
medicine with its increasing criticism of rising costs? What role

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should medical and professional judgment play in ethical quan-

daries? How do we define the difference between prolonging living
and prolonging dying? All segments of society have become inter-
ested in these questions and problems.
“These issues have raised physicians’ interest in the problems
and have stimulated the desire to learn,” said Philip Lee. “The
changing responsibilities have begun to affect physician attitudes. I
believe that the time has come to address these questions actively.
Physicians must learn what the problems are and seek objective in-
formation, not base their judgments on the often biased discussions
provided through give-away journals or special-interest journals.
Physicians must seek out other sources of information, review and
evaluate them, and then make their own decisions.”
“Medical ethics is fascinating and important,” in Albert Jonsen’s
view, “but the way it is now taught to physicians poses some prob-
lems. Because ethics is based on academic philosophy, it can be, and
often is, presented purely theoretically. Moreover, when the ethicist
has little clinical experience, his approach may be abstract and sim-
plistic. Competent teaching of medical ethics requires concreteness
and practicality. It should result in broadening of vision as well as
have clinical relevance.” Physicians can use some of the methods
discussed in this book to address economic, social, and ethical is-
sues. How can they proceed?

I N D I V I D U A L I N V O LV E M E N T
Bruce Zawacki explained how the clinician can stay abreast of ad-
vances in the field: “Today, ethical problems, experienced most
poignantly at the bedside, are found to have their root causes as often
in healthcare organizations (HCOs) and systems as in the ethical val-
ues and skills of a few professionals, such as physicians, nurses, and
the clergy. Moreover, administrators and other members of the health-
care team have greatly increased their social and economic power, as
well as their ability to be heard. What used to be called ‘medical

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ethics,’ therefore, is now more functionally labeled ‘healthcare ethics’

and requires use of ever-broadening resources.
“ ‘Doing ethics’ is in many ways like ‘doing surgery’ because it is
at least as much a skill to be practiced as a body of knowledge to be
learned. Ethicists are earnest, reflective, scholarly, and enthusiastic,
regularly engaging in face-to-face ethical discourse and in reflection
on how to improve. For physicians, this usually means joining the
best healthcare ethics committee (HEC) available. The major, often
funded, mission of HECs is self-education. In teaching ethics not
only to one another but also to their patients and their HCOs, the
physicians teach themselves. The National Reference Center for
Bioethics Literature and the Bioethicsline databases option on the
National Library of Medicine Internet Grateful Med Web site
(www.igm.nlm.nih.gov) are additional sources of assistance in such
learn-while-teaching efforts.
“Of the serials most widely and routinely read by physicians, The
New England Journal of Medicine, The Journal of the American Med-
ical Association, the Archives of Internal Medicine, and The New York
Times provide the most authoritative, readable, and consistently rele-
vant articles and editorials about healthcare ethics. Those wishing to
satisfy a special interest or develop a special facility in dealing with
ethical issues will find the Journal of Clinical Ethics, the Hastings
Center Report, the Healthcare Ethics Committee Forum, and the Cam-
bridge Quarterly of Healthcare Ethics to be most helpful. Finally, such
enthusiasts will find the Web site http://www.asbh.org/ to be helpful,
and at least biannual attendance at the American Society of Bioethics
and Humanities multidisciplinary convention to be not only challeng-
ing but also collegial and encouraging. And we all need that kind of
collaboration in our self-education.”
“Consult other physicians or professionals regarding particular
ethical problems you face in caring for individual patients,” advised
Philip Lee. “Some physicians in university medical centers may con-
sult chaplains, philosophers, or others with particular expertise in
ethics, for example, regarding a decision not to resuscitate a patient

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who has cardiac arrest. When should the decision not to resuscitate
be discussed with the patient? When should the family be involved?
In the case of a hospitalized patient, when should the nurses or other
members of the staff become involved? In short, the very process of
deciding who should be involved in the decision and what rights the
patient, family, hospital staff, and attending physician have will help
to educate the physician about the issue.”
Thomas Hunter pointed out the need for physicians to educate
other groups, both lay and law, to the realities of medicine and biologi-
cal science and for physicians to listen to the concerns of these groups.
“The trust in physicians and scientists has been badly eroded for many
reasons beyond our control, partly because of the general mistrust of
authority since the 1960s. But our resistance to participation by the
laity in policy decisions has also played a part. We need to recognize
that ultimately we are responsible to the public and that we must work
actively with them in formulating ethical and social policy.” Zawacki
suggested that the attending staff should be encouraged to include such
considerations in their daily bedside teaching.

ORGANIZED MEDICINE
Robert Glaser urged medical organizations and academicians to
sponsor seminars, symposia, and conferences on ethical, social, and
economic problems. “The professional media also have a role in pub-
lishing thoughtful, informative articles on these subjects.”
County and state medical societies offer the opportunity for grass-
roots participation on committees studying and formulating policies in
sociomedical and economic problems. Philip Lee thinks that physi-
cians often deal with the broader issues through professional organiza-
tions such as county and state medical associations, the American
Medical Association (AMA), and specialty societies. “These bodies
often conduct policy studies and communicate the information to
members for further consideration of the policy position with respect to
the impact on an individual physician’s practice. Mechanisms for rep-

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resenting the views of physicians, although imperfect, fit very well

with our pluralistic approach to public policy and the kind of influence
accorded special interests, including the medical profession.”
Most medical societies have capable staffs that research pertinent
issues and distribute bulletins and newsletters to their constituents.
The AMA, for example, publishes the American Medical News, and
the American College of Physicians publishes The Observer. These
publications help the busy physician who cannot spend time reading
all published material on these subjects.

*****
Advances in medical science and practice, while improving pa-
tient care, have also raised countless social, ethical, and economic
problems. Their significance demands that physicians devote some
time to studying the issues and contributing to their solutions. When
ethical problems arise in the care of individual patients, the physi-
cian should discuss the issues with colleagues, the clergy, the pa-
tient’s family, and, in certain circumstances, an ethicist. Formal
consultations may be in order. The leading medical journals now have
regular features that discuss the issues authoritatively, and the public
media also devote considerable space to these topics, so the physi-
cian can be aware of current thinking on important issues. Medical
societies are becoming increasingly involved; some have formulated
formal positions on specific issues, and most publish newsletters and
bulletins to keep members informed. Despite time limitations, physi-
cians must actively participate in the solution of social, ethical, and
economic problems in medicine if they are to remain effective advo-
cates for excellent patient care. In Saul Farber’s words: “We are part
of a great profession; we must work to preserve it.”

REFERENCE
1. DeBakey ME, DeBakey L. The ethics and economics of
high-technology medicine. Compr Ther. 1983;9:15–16.

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 REFLECTIONS / C. ROLLINS HANLON, M.D.

R E F L E C T I O N S
...
Dr. C. Rollins Hanlon received his M.D. degree from Johns Hop-
kins University and attained the rank of Associate Professor of
Surgery there after U.S. Navy service in World War II. Thereafter,
he was Chairman of the Department of Surgery at Saint Louis Uni-
versity for 19 years before his 17-year tenure as Director of the
American College of Surgeons. During 49 years of Fellowship in
the College, he also served as Governor, Regent, and now Executive
Consultant.
An extraordinarily literate physician, he holds honorary de-
grees from four universities, honorary membership in 10 national
medical specialty societies, and honorary fellowship in five
English-speaking Surgical Colleges. His honors include the De-
Bakey International Surgical Society Award and the Fleur-de-Lis
Award of Saint Louis University. He has served as President of six
national and international surgical societies, of the Council of Med-
ical Specialty Societies and, currently, of the Warren and Clara
Cole Foundation, which he established in 1987. Widely known as a
distinguished scholar and aficionado of belles-lettres, he has had a
long-standing and active teaching career in the liberal arts related
to medicine, and is Editor of the Ethics Section of the Journal of the
American College of Surgeons.

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 Early Influential Habits

C. Rollins Hanlon, M.D.

Executive Consultant and Former Director
American College of Surgeons
Chicago, Illinois

T he challenge to write about surgery as a lifelong, passionate en-

counter recalls a comment of William F. Buckley, Jr. in his book,
Nearer My God,1 that for him to write about his faith would put his
faith at a fearful disadvantage. In the same way, describing my fasci-
nation with continuing education in surgery as a pattern for possible
emulation risks being inadequate or self-serving.
But my own inspiration from the biographies and anecdotal recol-
lections of other surgeons emboldens me to set down certain experi-
ences and personal lessons that might be useful to some now early in
their careers. As a start, I stress the essentiality of the habit of read-
ing, not merely in all aspects of medicine and science, but in the hu-
manities—biography, history, and philosophy. These liberal arts
enhance and deepen the physician–patient relationship.
Many physicians have exemplified how a medical education, with
its unique window on the human condition, can lead to a distin-

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guished literary career. Somerset Maugham and Walker Percy come

readily to mind, as well as other classic authors such as Chekhov and
a host of present-day physicians who have published novels and
essay collections about the medical career and life in general.
Kathryn Montgomery Hunter, in Doctors’ Stories,2 has cogently
portrayed how physicians rearrange the patient’s narration into a
“doctor’s story” that describes a recognizable clinical entity. Such re-
formulations may, however, risk the loss of those idiosyncratic partic-
ulars that individualize each patient’s illness. Similarly, a physician’s
personal story is calculated to provide not an exact template for other
physicians’ careers, but rather some biographic snippets that may
stimulate emulation.
The revolution in electronic packaging and transmission of data has
led some to predict obsolescence of the book. I do not concur. Nor do I
believe that early mastery and continuing cultivation of reading skills
may be abandoned. It seems scarcely necessary to defend the book as a
simple, durable, easily portable instrument to put us personally into
happy communion with the sages, free of encumbering technology.
Moreover, an early mastery of reading the printed word can facilitate
comprehension of the electronic monitor display. And recent studies of
cerebral function challenge the classic dictum that we are born with all
the brain cells we will ever have; there is even a hint that such cellular
recruitment may occur not merely in infants but in those of us at the age
when Alzheimer’s disease threatens.
Every medical student faces the daunting body of anatomic, phys-
iologic, and other data to be absorbed in a limited time and kept at the
ready for application to the diagnosis and treatment of patients in the
consulting room or hospital bed. Praise of the book in no sense di-
minishes the marvel of ready electronic retrieval of the vast holdings
of the National Library of Medicine and Internet resources for reliable
guidance in medical dilemmas. This requires a mastery of computer
and reading skills to supplement, rather than replace, the basic diag-
nostic process by which facts are marshaled to support or reject a
clinical hypothesis.

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We must recognize, as well, the challenge of sophisticated pa-

tients who arrive in the office not with newspaper or magazine clip-
pings, but with downloaded pages of sometimes questionable data
that prompt them to ask searching questions. For today’s urgent need
to keep abreast, the Internet search engines make it easier for physi-
cian and patient, but both should view such information with a criti-
cal eye.
My Father never attended college, but as an inveterate reader he
accumulated a large number of wisely selected books, housed in
glass-fronted sectional bookcases lining three walls of the room we
called “the library.” When the family built a smaller house, my broth-
ers and I split up the literary holdings; my part included the incom-
parable 11th edition of the Encyclopaedia Britannica, still frequently
consulted. The parochial school nuns gave us heavy reading assign-
ments, and Baltimore’s Enoch Pratt Free Library was only a 30-
minute walk from home. On Saturday mornings, we would often pause
in a nearby park after our library visit to read one or more of the gen-
erous five-book allowance, so we could sign out others before finally
heading home with full cargo.
As one of the various educational “clubs” my father formed for us
at home, the poetry branch had us commit to memory extended works,
such as “Hiawatha” or “Gunga Din,” to be recited on demand for a
small reward. The Jesuit high school introduced me to extended Latin
and Greek studies, continued in college, along with membership in
the debating society and editorship of the school newspaper. The
painful obligation of two editorials for each weekly issue instilled an
early appreciation for deadlines.
In the laboratory of a distinguished Jesuit biologist, I had the good
fortune of completing a summer college research project on the be-
havior of paramecia. An equally fortunate association with a medical
school classmate, William P. Longmire, Jr., brought us together as
volunteers in pathology during the summer after our first year. W. G.
MacCallum and Arnold R. Rich taught us the rudiments of gross and
microscopic pathology, and multiple, carefully studied autopsies

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helped us correlate the clinical story and the final anatomic report. I
shared with Longmire the surgical internship and a subsequent re-
search fellowship to study surgical shock under the incomparably
meticulous Philip B. Price, whose 12 years as a missionary surgeon in
China included an investigation of de-germing the surgeon’s hands
that will never be matched for sheer tenacity.
Longmire’s distinguished career in launching the Department of
Surgery at the University of California at Los Angeles and his frater-
nal help in getting me a position with Alfred Blalock led to my own
Chairmanship of the Department of Surgery at Saint Louis University
School of Medicine. Much later, I worked with Longmire in various
capacities at the American College of Surgeons. This personal and
professional association over more than 65 years illustrates the bene-
fits of a collegial relationship that began early in medical school and
grew steadily more vital in ensuing decades.
An early interest in medical history began when the great Swiss
medical historian Henry Sigerist came to Johns Hopkins as Chairman
of the W. H. Welch Institute for the History of Medicine. Six first-year
medical students had the unparalleled opportunity to join Sigerist in
close colloquy every week. These remarkable seminars generated a
keen appreciation of historiography, without necessarily inculcating
the master’s socialist philosophy. Sixty years later, I was privileged to
oversee seminars at Northwestern University with bright freshman
and sophomore medical students, sharing an analysis of the complex
issues posed by today’s technical and sociologic issues in medicine.
A continued mentoring relationship with some of these students is an-
other treasured reward.
A long administrative experience with the American College of
Surgeons has provided a front seat at the unfolding drama of the Sur-
gical Education and Self-Assessment Program (SESAP). Started 29
years ago with the benefit of generous advice from the American Col-
lege of Physicians and their Medical Knowledge Self-Assessment
Program, SESAP has been a resounding success in stimulating myri-
ads of surgeons to keep abreast of advances in surgery by a process

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that stresses individually directed learning and comparison with the

performance of one’s peers.
In addition, the American College of Surgeons has sponsored ex-
tended seminars on “teaching surgeons to teach” and on the mastery
of new technical procedures by simulation and by hands-on instruc-
tion. The worldwide dissemination of skillfully designed and adminis-
tered courses in Advanced Trauma Life Support is a gratifying
demonstration of personal learning modes that have improved public
health internationally.
Medical ethics is an increasingly relevant aspect of modern
healthcare that is moving from its philosophical roots to a more prag-
matic, case-based focus necessitated by technical and economic de-
velopments. Surgical journals now publish special articles on ethics,
and a splendid book, Surgical Ethics,3 includes chapters written
jointly by clinicians and ethicists or philosophers. The growing stress
on patient autonomy and the bitter criticism of paternalism may have
gone too far. A more judicious approach would permit patients to par-
ticipate actively in decisions about their care, but would not discour-
age clinicians, with their special education and training, from
advising patients what is in their best interest. Taking time to know
the patient gives at least a secular humanistic approach to the com-
munication between physician and patient, and there is room beyond
that for a spiritual, or even overtly religious, dimension to this thera-
peutic relationship.

REFERENCES:
1. Buckley WF Jr. Nearer, My God: An Autobiography of Faith.
New York: Doubleday; 1997.
2. Hunter KM. Doctors’ Stories: The Narrative Structure of Med-
ical Knowledge. Princeton, NJ: Princeton Univ Press, 1991.
3. McCullough LB, Jones JW, Brody BA, eds. Surgical Ethics.
New York: Oxford Univ Press; 1998.

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The Physician–Patient Relationship,

Physical Examination, and
New Procedures
...
The relationship between doctor and patient partakes of
a peculiar intimacy. It presupposes on the part of the
physician not only knowledge of his fellow men but
sympathy. . . . This aspect of the practice of medicine
has been designated as the art: yet; I wonder whether it
should not, most properly, be called the essence.
WARFIELD T. L ONGCOPE 1

G ene Stollerman would like to see continuing medical education

emphasize clinical skills.2 He deplores the growing gap between
medical technology and clinical skills, in which advice based on the
interview and examination is replaced by that based on results of lab-
oratory studies and technical procedures. The development of clinical
skills, he points out, enables physicians to obtain a better under-
standing of the patient’s problems and gain confidence in their own
ability to determine what technologic tool is required to substantiate
the clinical findings and what consultations would be to the patient’s
advantage. Learning about new tests and procedures, unfortunately, is
much easier than discovering how better to examine a patient.
Richard Lewis emphasized the value of the clinical history: “The im-
portance of the clinical history cannot be overestimated. The physical

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examination cannot be done in a vacuum; the history is critical to

alert the examiner to possible abnormal physical findings. Subtle ab-
normalities are discovered only when specifically searched for as a
result of the history.”3

P H Y S I C I A N – PAT I E N T R E L AT I O N S H I P
Stuart Yudofsky recalled: “During a required rotation in psychiatry in
my third year of medical school, I came under the supervision of Hilde
Bruch, a psychoanalyst and international expert in understanding and
treating patients with anorexia nervosa. Her demanding and perspica-
cious tutelage4 introduced me to a whole new universe of understand-
ing and providing meaningful help to those who suffer from disorders
of mood, behavior, and thinking. She considered every patient, regard-
less of any primary psychiatric illness, as a whole person whose med-
ical complaints and dysfunctions must be understood through a matrix
of biological, psychological, social, and spiritual domains.”
Many patients feel intimidated by the very presence of a physi-
cian and are reluctant to ask questions or even discuss fully the na-
ture and extent of their complaints. They may hesitate to impose on
the physician’s time; they may be embarrassed to expose their inner
selves; or they may be fearful of the consequences of their illness.
Eliminating these patient inhibitions requires special skills in inter-
viewing and communication.

Physician–Patient Relationship as a Therapeutic Tool

The physician–patient relationship is, of course, a powerful thera-
peutic tool that the physician should learn to use skillfully. Richard
Reitemeier gave this example of its importance: “J. Arnold Bargen was
one of America’s pioneers in the study and management of inflamma-
tory bowel disease. When he began this interest in the mid-1930s, he
recognized the terrible plight of such patients and did all he could to
help them. Because of that interest, many patients were referred to his

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care. I suspect they were referred with some gratitude on the part of
their own physicians, since the management of the disease was a great
challenge and usually extremely frustrating. Bargen welcomed the op-
portunity to care for such patients, and, as one of his assistants in the
hospital in the early 1950s, I recall seeing a remarkable demonstration
of the effect of that kind of welcome on an ill person.
“A young woman with severe ulcerative colitis of several years’
duration was admitted to St. Mary’s Hospital several days before Bar-
gen was to begin his term as the consultant in charge of such cases.
She arrived emaciated, with a high fever, considerable abdominal
pain, and the usual raging diarrhea. We did all that we could to make
her comfortable, but her symptoms continued without change until
the morning Bargen met her. He walked across the room and stood at
the bedside of this patient, reaching out to grasp her right hand with
his and placing his left hand on her forearm. Looking her straight in
the eye, he said, ‘I am so glad you have come! We are going to make
you better!’ He then went on with the usual interrogation of her his-
tory and a physical examination. However, we all noted that the very
moment that he greeted her with that welcome assertion, she seemed
to relax. As the day wore on, I was gratified and intrigued to watch all
of her clinical signs improve. The fever abated, her diarrhea and ab-
dominal pain quieted down, and indeed she did get better. I have al-
ways thought that the magic of his greeting was transferred to that
woman through the warmth of his handshake and his evident honesty.
He really did care about her.”

Understanding the Patient’s Point of View

The patient’s perception of the hospital may be quite different from
the physician’s, as Francis Moore learned. “As a senior resident in a
Boston hospital in a largely Italian-speaking neighborhood, I encoun-
tered a woman admitted for headache. Because all the simple tests
were negative, she was scheduled for the more rigorous tests that we
had in those days, including an encephalogram and a ventriculogram.

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Things that seem trivial to the physician may have great

significance for the patient.
K UNIO O KUDA , M.D., P H .D.
Director, Department of Medicine
Chiba University
Chiba City, Japan

One morning, as I was coming around with my white-suited junior

resident troupe behind me, she said, ‘Doctor, you know, I think I am
just too sick to be in the hospital.’ There was no response from the
dumbfounded residents. She continued: ‘I would like to go home for a
few days until I feel a little better. Then I will be happy to come back
to the hospital for the tests. But right now, I am just not feeling well
enough.’ How many patients she unwittingly spoke for!”
“One incident served to teach me,” recalled Kunio Okuda of
Japan, “that things that seem trivial to the physician may have great
significance for the patient. As a young resident at the Chiba National
Hospital, I was in charge of a ward room with five middle-aged

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women with chronic diseases. I made it a rule to see them in the

morning, starting from the right side of the door. One day, for no rea-
son and without thinking, I started seeing them from the left. I later
learned from the nurses that the woman on the right whom I used to
see first and the one on the left whom I saw first that particular day
had a big fight in the afternoon. I realized that I had been concentrat-
ing on the patients’ diseases and had been negligent of their feelings
and personalities. I learned an important lesson.”
Most physicians are relatively content with their clinical skills,
not realizing that even basic skills need to be analyzed to avoid bad
habits and omissions. There is even need to improve continually one’s
ability to listen intently and actively to patients. A common mistake
made by medical students is to refer to the patient as “a poor histo-
rian.” “Walter Cherny has always been a stickler for precise lan-
guage,” said Arthur Christakos. “Whenever students or residents
make the mistake of referring to the patient as a historian, Walt is al-
ways quick to remind them that the one who records the history is the
historian, and most of the time, he agreed, the historian was poor.”
The physician–patient relationship, moreover, is constantly
changing in response to societal changes as patients become more
aware of medical matters. Currently, the trend is to make the patient
more of a partner in health decisions. To adapt to these changes, the
physician must be ever alert to the human side of medicine, and daily
learning must therefore include improvement in the physician–
patient relationship, as well as in clinical skills.
Rebecca Kirkland noted how the Internet is affecting the physi-
cian–patient relation: “When a patient calls or enters the office with
documents printed from the Web, what is the appropriate protocol? If
the article is correct, the physician can volunteer to interpret the infor-
mation; if it is not accurate, he can refer the patient to reliable Web
sites. The primary focus should always remain the patient, and winning
the confidence is worth the time expended.”
Charles Parker lamented the diminishing opportunities to gain the
personal satisfaction that the physician–patient relation brings: “In-

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deed, many traditional customs have succumbed to cost-effectiveness.

The pleasure, for instance, of follow-up visits or suture removal, which
permitted precious moments to chat with the well patient, have be-
come the domain of the nurse-practitioner or the physician-assistant.
The days when a physician had the discretion to take an extra 20 min-
utes to explore the family life or a school problem have vanished with
managed care. Now a curt, anonymous telephone voice reminds us
that only a 10-minute visit is allowed. As the physician arrives at the
clinic for his morning r0utine, he is greeted not by a pleasant smile
from the receptionist, but by an indifferent printer spitting out the
daily schedule: name, time, and chief complaint.
“It seems to me that the physician–patient relationship no longer
allows enjoying the fruits of your labors because someone else sees
the happy, healing patients. The passion is now dependent on the mo-
ment at hand and satisfaction from learning and understanding the
patient’s problem.”
Maurice Bernstein believes that most changes in the physician–
patient relation involve time, access to resources, and multiple health-
care personnel: “Time seems to be limited in the physician–patient re-
lationship in this era of managed care. I say ‘seems’ because I think it
doesn’t have to be in all cases. Time to allow the patient to talk is
something we try to teach first to our students. It also involves time for
the physician to listen. Students new to interviewing sometimes give
the patient only a few seconds between the initial open-ended question
and the student’s follow-up direct questioning. This behavior is not,
however, limited to new students but includes physicians in practice.
The solution is for the physician to learn how to use the time available
more efficiently, allow more time through novel scheduling tech-
niques, and simply take the time to help the patient and let the chips
fall where they may.
“Access to resources is clearly more difficult in managed care.
Although there are examples of the non-beneficial effect of resource
limitations, there are also examples of the wisdom of not doing a pro-
cedure. In practice, even if the patient is seemingly ‘informed,’ time

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limitations imposed on the physician cause inadequate discussion of

the benefits and burdens and may cause the patients to demand ap-
proaches that are unnecessary or, worse, harmful. Screening for ap-
proval by a utilization committee of physicians can be beneficial.
“Time limitations may also cause poor communication among
members of the healthcare team, leading to confusion about the med-
ical goals expressed to the patient or family by each team member.
One physician must remain the attending physician.
“The hospitalist, an old profession overseas, is new and developing
in the United States because of the need for more specialized hospital
care and the need, in this managed care age, to reduce the number of
hospital days to a minimum. The relationship between the patient and
the office-based physician can be disrupted, although my experience is
that many patients are satisfied with the hospitalist but are eager to re-
turn to their own primary care physician. The disruption often occurs
because of limitation of time, the inability of the office-based physician
to communicate the history to the hospitalist, and the inability of the
hospitalist to provide the primary care physician with timely feedback
about the patient’s hospital course. This is generally recognized as a
systemic problem with the hospitalist system and has yet to be solved.
“I look at the problem of time in medical practice as the major
factor to establish, but also to destroy, the physician–patient relation-
ship. I worry that those in managed care find that the ‘bottom line’ has
more to offer than time.”
“Has the passion been drained from medicine?” asked Robert
Moser. “I think not. But there has been seepage. Medicine will always
be conducted on a human-to-human basis, but the interposition of
technology has been a mixed blessing. ‘Laying on of hands,’ the para-
digm for personal communication, alas, has become a time-
consuming anachronism. In this wondrous era of molecular biology
and instantaneous transmission of electronic data, our capability to
help our patients has soared to unprecedented heights. Yet never has
our reputation, respect, and esteem been lower in the public mind.
Why this unseemly paradox? Simply put, they expect even more than

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we can deliver; they want the vaunted science of medicine to be

repackaged into thoughtful care. It is an impossible immediate trans-
mutation. It will take some pain and more time.”

Methods That Hone Clinical Skills

Seminars Michael Balint pioneered research seminars to study

the psychological implications in general medicine. His discussion
groups, first organized at the Tavistock Clinic in England, consisted
of eight to ten general practitioners and two psychiatrists. Balint
noted that, at first, the general practitioners tried hard to entice the
psychiatrists into a teacher–pupil relationship, but for many reasons
it was thought advisable to resist this. Instead, he strove for a free
give-and-take atmosphere, in which everyone could discuss clinical
problems and receive assistance based on the experience of the oth-
ers. The chief purpose was an examination of the ever-changing
physician–patient relationship. Physicians’ recent experiences with
patients, reported by the physician in charge, provided the material
for Balint’s discussion groups. The physicians reported freely on their
experiences, using clinical notes and including an account of their
emotional responses to patients.5
In addition to participating
File of Clinical Biographies and Writing
in seminars that focus on physician–patient conversations and inter-
actions, Gayle Stephens also maintains a file of “clinical biographies”
of patients in his practice—narrative descriptions of patients’ longi-
tudinal experiences with illness. He also teaches and writes about in-
terviewing and the physician–patient interaction.
Keeping Abreast of Changing Attitudes Physicians need ways of en-
suring that they are reacting constructively to the changing attitudes
of their patients toward medicine. Stephens recommends that physi-
cians develop a circle of friends who are not physicians and listen to
their stories about physicians and hospitals. Reading lay articles
about health in newspapers, magazines, and books and watching tele-
vision programs and advertisements about health and related issues

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can be helpful. Stephens advocates a nonjudgmental listening style so

that patients will be uninhibited in their conversations with physi-
cians. Never should a physician deride or humiliate a patient for
doing something unorthodox.
“Listening is the most important way to learn what the changing
attitudes are,” said Jonathan Rodnick. “I serve on the Board of Direc-
tors of a community-based health organization that has predominately
laymen on its Board, and listening to their views makes me aware of
the public’s attitudes. If I were unaware of my patients’ changing atti-
tudes, however, I would hope that they or my staff would construc-
tively point out my inappropriate assumptions and actions.”
John Geyman advocates self-study to improve knowledge about
patients’ attitudes. “Increase your knowledge of the community, the
occupational settings, and the home environments. If, for example,
you practice in a logging town, visit the local lumber mill and make
occasional home visits. Encourage your patients to take an active role
in the decision-making concerning their health care.”
Each physician
Videotaping or Audiotaping Physician–Patient Encounters
should have the benefit of being videotaped periodically, or at least
audiotaped, while interviewing a patient and having the tape re-
viewed later with an expert. Both profit from the exercise. The
human interaction that takes place in medicine is too important to
be neglected in lifelong learning. Some medical schools offer
courses in this subject, but hospitals and specialty societies could
do more in this regard.
I. R. McWhinney considers videotapes of the physician–patient
encounter to be one of the most powerful tools we have. “The ideal is
for a learner, whether student, resident, or practicing physician, to re-
view the tape with a colleague skilled in the art of interviewing.”
Self-observation For those physicians without access to videotap-
ing facilities, self-observation can be useful. Geyman periodically au-
dits himself during a patient encounter. “I remind myself of the need
for a relaxed, approachable manner; open-ended questions and active
listening; and avoidance of distractions. I try to learn something new

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about the patient as a person in each encounter, that is, beyond infor-
mation related to his medical problems. I also ask myself whether the
patient has had sufficient opportunity to participate in decisions
about further diagnostic steps, management, and follow-up. In addi-
tion to self-audit techniques, it is useful to observe the patient’s reac-
tions to me as a physician, as well as the reactions of residents and
students to me as a teacher.”
Teaching Observing and teaching medical students at the bedside
increases the physician’s understanding of the basic techniques of the
physician–patient relationship. As part of the family practice residency
program in which Rodnick participates, residents are observed and
videotaped while interacting with patients. Rodnick explained: “By ob-
serving young physicians with patients, analyzing their styles, and try-
ing to give constructive feedback, I subsequently analyze my own office
behavior. This self-analysis gives me ideas to improve communication
in my practice and helps me understand both verbal and nonverbal
physician–patient communication. The adage that the teacher learns as
much as the students is certainly apt in this situation.”

T H E P H Y S I C A L E X A M I N AT I O N
According to Richard Lewis, “[T]he physical examination provides
information that improves clinical decision-making and reduces costs
by eliminating redundant testing.”3
A master clinician can gain astonishing information from a physi-
cal examination. “I often think of the best teaching that I ever had in
medical school,” said Marvyn Elgart. “It was the introductory demon-
stration by David Barr, Professor of Medicine at Cornell University.
An eminent clinician, Barr told us that he was going to show us all the
things that we could learn from a patient without having the patient
disrobe. He then had a patient come into his office, stood up to greet
him, and then stopped and turned to us. For the next 40 minutes, as
he and the patient remained standing, he pointed out from an unend-

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ing fountain of knowledge all the things he had discerned about the
patient’s eyes, skin, touch, and gait, as well as all the disease possi-
bilities that had entered his mind during those few minutes. It was re-
markable. In novels, only Sherlock Holmes came close.”
Bill Bennett recalled the considerable influence of Howard P.
Lewis, father of Richard P. Lewis, and an outstanding physical diag-
nostician, on the medical career of every student he touched. “Twice
weekly at a two-hour conference with interns and residents, Lewis
would elicit a history and do a physical examination. He would con-
struct a differential diagnosis brilliantly and would predict findings
that would be verified at operation or on chest x-ray. One need only
recall the dullness over Kernig’s isthmus, signifying scarring from tu-
berculosis, or percussion of dullness over Traube’s space, signifying
enlarging of the spleen, to realize his lasting impact on a young in-
tern. It would be interesting to pit this consummate clinician’s physi-
cal diagnostic skills, painstakingly developed over a career, against
modern imaging devices. In cost-effectiveness, I suspect that Lewis
would win hands down. After retirement, he remained very active for
some time in the teaching of physical diagnosis to medical students
and house officers. It is clinicians like Lewis who signify excellence
in the art of medicine.”
Once physicians have completed formal training, they have few
opportunities to improve their techniques of physical examination.
Most formal courses do not address this problem. Many physicians slip
into faulty habits that could easily be corrected. Being observed by a
colleague while performing a physical examination helps the physi-
cian avoid careless and sloppy approaches to physical diagnosis.

Experts’ Need for Advice on Fundamentals

One might wonder if being videotaped during a patient interview and
being observed in performing a physical examination is not too basic
for experienced physicians. Everyone, however, can profit from expert
advice and exhortation. In athletics, coaches help team members per-

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form their best. In sports such as tennis, even the champions continue
to receive instruction from coaches. In 1964, Charles MacKinley and
Dennis Ralston were preparing for a Davis Cup match at the Los An-
geles Tennis Club with the help of Pancho Gonzalez. MacKinley,
Wimbledon winner the previous year, was considered the number one
tennis player of the day. Watching the great Pancho Gonzalez, one of
the masters of the game, give a lesson to two champions offered spec-
tators the promise of learning some of the fine points of the game. But
Gonzalez’s first remark to MacKinley during a rally was the basic
“Watch the ball,” followed a little later by the admonition, “You’re not
bending your knees!” So even champions need reminders about the
fundamentals.6
Louis Kettel received a valuable reminder from a patient. “I once
volunteered for an evaluation of my history, physical examination,
and diagnostic skills using the patient–instructor program put in
place for competency evaluation of our medical students and house
officers. This program uses patients with well-established illnesses
and physical findings and with considerable knowledge of their dis-
eases, along with a validated, structured, gradable analysis form. In
the process, I fully expected to find that I lacked some skills, since I
have been an administrator for a number of years. I was taken aback,
however, by the major critique. In analyzing my overall skills, the pa-
tient informed me that I had neglected throughout the examination to
recognize that he was, in fact, a human being and that on no occasion
had I called him by name. What a depersonalizing experience for the
patient! Were I to function in the role of Dean in the absence of so
simple a social grace, I would surely deem myself a failure. I assure
you I corrected that behavior.”
Peter Lee cited an example of the value of being observed: “To
prepare for his discussion of the physician–patient relationship with
medical students, Seymour Pollack, then a young psychiatry faculty
member, asked to accompany me on ward rounds. Having recently re-
turned to clinical medicine after several years of almost full-time ad-
ministration, and therefore needing some positive reinforcement, I

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agreed, assuming that he would compliment me on my sensitivity and

skill. On the designated morning, Pollack accompanied me, my resi-
dent, and two interns. We reviewed the problems of the patients, dis-
cussing the appropriate publications and recommending plans for
diagnosis or management. At the end of the rounds, Pollack and I
stepped into a conference room, and I asked him for his observations.
I vividly remember his first sentence: ‘Pete, I’m shocked.’ He then
described the several ways in which my behavior on rounds had not
only been rather oblivious to the feelings of patients but, in some
cases, actually offensive. In one instance, I had examined a woman in
a ward with four or five other patients without pulling the curtains
around her bed, and, in another, I made what I felt was an appropriate
witticism across the bed of a patient who had no way of knowing that
the joke was not about him. In still another case, directly across the
supine body of an anemic patient in whom the question of tapeworm
disease had arisen, a resident and I thoughtlessly discussed acquiring
tapeworms from working in unsanitary mines. The impact of Pollock’s
honest description of my behavior at the bedside of patients was pro-
found. Over the succeeding years, I have been followed by the ghost
of Seymour Pollock as I have made rounds. The sensitivity I gained
from having my ward rounds observed by a friendly critic forever
changed my way of making rounds and greatly improved my bedside
behavior.”

NEW PROCEDURES
Physicians have too few opportunities to learn procedures that were
developed or perfected after their formal training. A surgeon usually
“scrubs in” with a colleague trained in the procedure. A few specialty
societies offer programs for this purpose. Since 1977, for example, the
American Academy of Orthopaedic Surgeons has included laboratory
components in courses on surgical skills, with hands-on experience
(see p. 356). Programs include Rotary Instability of the Knee, In-

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Students and residents are becoming the high priests of

radiographic and laboratory triage. In the presence of
negative imaging and laboratory reports, they may ask:
“How could the patient be sick?” Technology has its
value, but also its limitations; it is more important to
cerebrate than to viscerate. Learning, thinking, and an-
alyzing must be a budgeted part of our daily lives if we
are to be true professionals.
C LAUDE H. O RGAN , J R ., M.D.
Professor of Surgery
Chairman, East-Bay Surgery Program
University of California, San Francisco

tramedullary Nailing, Shoulder Disorders with Arthroscopy, and

Arthroscopy of the Knee.

*****
In all professions, basic skills need to be refined. But, embarrass-
ment and pressures of practice prevent most physicians from actively

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seeking to hone their skills in interviewing or doing a physical exam-

ination. Few formal courses address these issues. Physicians can,
however, ask a skilled colleague to observe them during these activi-
ties and then solicit suggestions for improvement. Observing a video-
tape of oneself in action and noting the problems recorded can also be
instructive. New procedures may be difficult for the average physi-
cian to learn, but colleagues are usually willing to help, and medical
societies are becoming more active in providing such instruction.

REFERENCES
1. Longcope WT. Methods and medicine. Bull Johns Hopkins
Hosp. 1932;50:20.
2. Stollerman GH. Care of your clinical skills [editorial]. Clin
Exp. 1984;1:11–12.
3. Lewis RP. Cardiac examination pearls. Cardiol Rev.
1996;4:34–46.
4. Yudofsky SC. Tribute to Hilde Bruch, the teacher. JAMA.
1987;257:196.
5. Balint M. The Doctor, His Patient and the Illness, 2nd ed.
New York: Pitman; 1964.
6. Manning PR. Continuing education, physician competence,
physician performance. Fed Bull. 1978;65:227–235.

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 REFLECTIONS / STEVEN CLEMENSON, M.D.

R E F L E C T I O N S
...
Dr. Steven Clemenson is a “country doctor” in northern Minnesota
who received his M.D. degree from Saint Louis University School of
Medicine and his residency training in Internal Medicine at Hen-
nepin County Medical Center, Minneapolis, Minnesota. The frus-
tration of increasing paperwork, combined with the difficulties
inducing physicians to use guidelines in their daily practice, di-
rected him into the new discipline of Medical Informatics, defined
as “the intelligent use of computers to improve medical care.” After
spending time in academia in Boston, he is now helping direct re-
search to determine if Form-Based Clinical Guidelines within the
Electronic Medical Record can improve healthcare delivery. He is
also leading the implementation of the Electronic Medical Record
and Physician Order Entry at the MeritCare Health System.

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 Using E-mail to Enrich
the Physician–Patient Relationship

Steven G. Clemenson, M.D.

MeritCare Health System
Bemidji, Minnesota

W hen we embark on a career of medicine, we feel genuine excite-

ment at the prospect of helping our patients through health and
illness. Unfortunately, far too much of this idealism dissipates as we
progress through our training and professional lives. As we enter the
everyday world of practice, the realities of managed care, insurance has-
sles, regulators, and other burdensome paperwork conspire to distance
us from the wonderful, strength-giving physician–patient relationship.
When you practice in a small town, you converse with your patients
every day—at the store, on the street, and at the corner café. In these
interchanges, you learn much about your patients that is not disclosed
in the examination room, but is part of the joy of being “my doctor” for
your patients. As our world has become more urban, specialized, and
scientifically sophisticated, we have lost some of the respect, trust, and,
yes, love of our patients. How can we regain and nurture that special
bond between physician and patient?

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Can we use today’s technology to regain the warm feeling

that comes from a true connection with our patients? I think we can.
E-mail is a start—a way for physicians and patients to gather infor-
mation, ask and answer simple questions, and determine whether,
and how urgently, a face-to-face meeting is needed. Of course, our
staff and nurses will need to help assess and direct these communica-
tions, just as they have always done with telephone calls. The primary
principle is to remove the barriers that have formed between physi-
cians and patients. If we do not, others, not always qualified, will step
in and assume our role.
We can also use the power of the Internet, along with our medical
knowledge about a specific patient, to regain the role of trusted advisor
and source of reliable information for our patients. There are many
faceless commercial enterprises that are trying to claim this hallowed
ground. Some have merit, but many are contaminated by the conflict-
ing interests of profits, drug sales, insurance companies, and advertis-
ers. The question for them is: What is the higher goal—the health of
the patient or the health of the corporation and its advertisers?
To regain the privileged position of trusted advisor, physicians
must make pertinent and valid information on healthcare available to
patients and then be prepared to answer resulting questions. Such
availability may be unsettling because it can be abused, but no more
so than when the small-town physician is stopped on the street to an-
swer patients’ questions. The advantage of the electronic interchange
is that physicians can have accurate information before them when
they record the answer, whereas on the street they must rely on mem-
ory and horse sense.
We need to establish health-system-based Web portals where pa-
tients can review their medications and problems in understandable
terms and then can be referred to medically correct and reasonable ed-
ucational materials for those problems. The “Wild Wild Web” is an un-
regulated frontier where there is much that is good, but also much that
is biased, incomplete, dated, or unreliable. Telling the difference is not

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always easy for lay persons or even for physicians in subjects outside
their expertise. We need to ensure that only current, valid information
is supplied. Why? Because it is part of our medical duty to improve the
health and quality of life for the patients and the communities we serve.
And it can also help us recapture the joy and passion for helping pa-
tients, which is the core of a rewarding career in medicine.

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R E F L E C T I O N S
...

It is useful for physicians to have little groups that pro-

vide someone near at hand with whom to exchange
ideas and discuss patients or published articles.
S HERMAN M. M ELLINKOFF, M.D

The remarkable march toward excellence of the University of Cal-

ifornia at Los Angeles School (UCLA) of Medicine was in no small
measure due to Dr. Sherman Mellinkoff’s wise and persistent guid-
ance during his deanship, 1961–1986. His outstanding contribu-
tions in the fields of medical education and gastroenterology have
brought him recognition in the United States and in Europe. Among
his awards are an Honorary Doctor of Humane Letters, Bowman
Gray School of Medicine; the Ad Astra Award, University of
Louisville; Physician of the Year Award, University of California;
Abraham Flexner Award, Association of American Medical Col-

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leges; and Honorary Alumnus Award, UCLA. Dr. Mellinkoff has re-
ceived the J. E. Wallace Sterling Distinguished Alumnus Award,
Stanford University School of Medicine and the Distinguished
Medical Alumnus Award, Johns Hopkins University School of Med-
icine. He is a member of the Institute of Medicine, the American
Academy of Arts and Sciences, and the Johns Hopkins Society of
Scholars, and is a Fellow of the Royal College of Physicians and the
Imperial College School of Medicine in London. His numerous
publications in gastroenterology and medical education include
several books.

* * * * *
Sherman Mellinkoff is a clinical mentor who never
preached. I shall never forget ward rounds as an intern
while he was Chief Resident on the Osler Medical Ser-
vice at Johns Hopkins. Never hurried, Sherm had two
important priorities—the patients and the house staff.
When a patient question arose, he always examined the
patient himself and later shared new clinical insights
with us in his gentle, wise way. His manner was invari-
ably good-humored. We especially looked forward to his
evening visits, when he became not only an able con-
sultant but also a special friend who inspired us to prove
worthy of our patients’ trust. A caring physician, a wise
academic leader, and a trusted friend for many faculty,
students, and patients, he gave generously of himself to
his family, his profession, and his colleagues. By exam-
ple, he demonstrated the science and art of medicine as
well as the best of personal human qualities.
C AROL J OHNSON J OHNS , M.D.

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 Medicine: A Collegial Profession

Sherman M. Mellinkoff, M.D.

Emeritus Professor of Medicine and Former Dean
University of California, Los Angeles School of Medicine
Los Angeles, California

C ontinuing learning in medicine is an individual matter; the human

mind is so complex that there are many different ways to approach
this subject. Most important, I think, is to maintain curiosity about pa-
tients. To like patients and to be intrigued by their problems brings to
medical practice both an emotional and intellectual attraction.
Looking at each patient independently before seeking opinions
and comments from others fosters learning. Sometimes, medical stu-
dents believe that they are not going to succeed unless they read the
write-up in the chart and decide, on that basis, what they should
record or say to the attending physician. On the contrary, to make the
wrong guess independently and to find out why it is wrong through
reading and discussion represent a good path to continued learning
from experience.
This approach to patients was encouraged by George De Forest
Barnett, who taught physical diagnosis at Stanford around 1940. He

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was a great bedside teacher. Although he did not publish a lot, he

kept abreast of progress and was always an inspiration to his students.
Another Stanford teacher to whom I am indebted was Arthur Bloom-
field, a profound scholar who always began his discussion of a pa-
tient, after the diagnosis was firmly made, by reviewing trenchantly
the history of that disease. Understanding what was known about a
disease in the past and how the present state of our ignorance or en-
lightment was reached is helpful to continued learning.
A great teacher of mine who was a distinguished medical histo-
rian, as well as a master of differential diagnosis, was A. McGehee
Harvey of Johns Hopkins. He inspired one’s best effort to be rational
and thorough in every clinical problem and to understand its histori-
cal and physiological implications. Another great bedside teacher at
Hopkins was Philip Tumulty. I have never known anyone who more
completely won a patient’s confidence. Confidence is a tremendous
asset, not only in caring for the patient, but also in obtaining an accu-
rate history.
In gastroenterology for many years, I was lucky to be associated
with Morton Grossman, a veritable gold mine of information and a
sagacious interpreter of new developments. Mort started a program at
the University of California, Los Angeles that was immensely helpful
in continuing education. Major topics covered annually at the meet-
ings of the American Gastroenterological Association were discussed
at open-to-all gatherings, with most of the time spent on critical ques-
tions and answers.
Once when Mark Ravitch and I were seeing a patient with jaun-
dice, he told me a story about William Thayer’s collar button. Dean
Lewis, who was described as the poor man’s Halsted, had taken Hal-
sted’s place. Lewis was a good surgeon, but down-to-earth and not
particularly eloquent. Thayer, who had taken Osler’s place, was a
Boston Brahman, and there was an imperious relation between him
and Lewis. One Sunday, Thayer telephoned Lewis to say that he was
sending his laundress into Johns Hopkins Hospital for an appendec-
tomy and asked Lewis to attend to the matter. Lewis agreed to do so.

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Some time later, Thayer was in the amphitheater and, to his conster-
nation, he observed Lewis operating in the right upper abdominal
quadrant. He asked, “What are you doing?” Lewis replied: “Well, I
asked the patient what she was doing when her pains started. She said
‘I was putting a collar button on one of Dr. Thayer’s shirts.’” The point
is that when a pain is really sudden, as it often is with a gallstone get-
ting lodged somewhere, the patient remembers exactly what is going
on at that time. But if the pain sneaks up, as it does with appendicitis,
no such precise answer will be forthcoming.
A complementary point was often made by Phil Tumulty: “Don’t
be overly precise. There are times to ask specific questions (What
were you doing when the pain started?), but there are other times
when it is best simply to let the patient ramble, and although it may
appear that it is a waste of time, it sometimes yields information that
would not be elicited by direct questioning.”
Physicians’ biographies periodically re-ignite love of the art. The
series that Mac Harvey wrote about the great pioneers at Johns Hop-
kins1,2 stimulates the reader’s appetite for continued learning.
I read articles in connection with the patients I have seen or heard
about, and that makes what I read come to life for me. Similarly, when
I am puzzled (and that is often), I like to discuss individual patients,
articles I have read, or ideas with colleagues who are more familiar
with the subjects than I am. I test new ideas in the same way.
In consultations, it is best to rely on what Dryden called the
“plain style,” that is, clear, precise, trenchant English. But we cannot
all expect to be Drydens. It is sometimes more helpful, therefore, to
obtain the consultation report through conversation. One of the worst
wastes is, for example, to send a patient with lupus erythematosus to
the radiology department with the request merely for a chest x-ray or
an x-ray of some bone. The radiologist ought to know what the pa-
tient’s problem is and what question is being asked about the patient.
I have a file at home of landmark articles to which I often refer. I
review my reprint files periodically and am sometimes amused that an
article I once considered important may no longer seem so. At other

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times, I am refreshed and amazed at how classical a particular paper

has turned out to be. My file is extremely simple: I use a filing cabinet
and manila folders and classify the material primarily by topic, but I
file some articles by authors’ names because I will remember them
that way.
As biomedical discoveries multiply in the opening decade of the
21st century, information will be more readily accessible electroni-
cally. The worldwide library has been greatly expanded, and its re-
sources are more immediately accessed. For the answers to some
questions, this kind of electronic search is exceedingly helpful. Gen-
erally, however, questions do not come in a vacuum; they arise in a ra-
tional mind seeking explanations. For the clinician, most questions
begin with the patient’s story and appearance, which may lead to a
search for information and to interpretation of the findings by consul-
tation or informal discussion. We are still a collegial profession. We
all need help; no one knows everything. And this obligatory interde-
pendence helps preserve the passion for medicine and for continued
learning.

REFERENCES
1. Harvey AM. Science at the Bedside. Clinical Research in
American Medicine, 1905–1945. Baltimore: Johns Hopkins
Univ Press; 1981.
2. Harvey AM. Adventures in Medical Research. A Century of
Discovery at Johns Hopkins. Baltimore: Johns Hopkins Univ
Press; 1974.

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 13

“Medical Errors” and

Other Problems in Practice
Unrelated to Medical Knowledge
...
If anything can go wrong, it will.
M URPHY ’ S L AW 1

Murphy was an optimist.

O’T OOLE ’ S COMMENTARY ON M URPHY ’ S L AW 1

P hysicians who review their practice continually will serve their pa-
tients well, but good health care requires more than medical
knowledge. At every step, extrinsic phenomena, errors, and omissions
may adversely affect medical practice despite the physician’s superb
knowledge. “The best performance is built upon sound information,”
said George Miller, “but sound information is no assurance that it will
occur.” John Williamson found, for example, that highly informed
physicians often did not respond to an unmistakably abnormal labora-
tory report.2 About two-thirds of the abnormal results of three routine
screening tests (urinalysis, fasting blood glucose, and hemoglobin)
elicited no response from the physicians in his study, even after they at-
tended a specially designed continuing education workshop and re-
ceived reminders about the problem. The simple device of obscuring
the abnormal findings on the laboratory report with a piece of remov-
able fluorescent tape, however, significantly improved the response.

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Starfield and Scheff illustrated that many of the problems inter-

fering with patient care are unrelated to the physician’s knowledge.3
In only 14 of 53 children with low hemoglobin identified by a review
of medical records and home interviews was the abnormality recog-
nized, diagnosed, and treated, and the test subsequently repeated.
The reasons for the oversights in the remaining 39 children varied.
The low hemoglobin was unrecognized in 24 patients, was recognized
but undiagnosed in six, was diagnosed but untreated in one, and was
treated but not reexamined in four. Four patients were diagnosed cor-
rectly, but did not keep their subsequent appointments. Patient care
can thus go wrong at any stage.
Morehead and Donaldson, after studying the care of patients with
serious diseases in 40 neighborhood health centers, concluded that
major problems resulted from failure to follow up on abnormal laboratory
or roentgenographic reports, failure to implement the suggestions of con-
sultants and others, and poor patient compliance.4 In a study of emer-
gency room care in an inner-city hospital, Brook and Stevenson
reviewed the medical records of patients referred to the radiology de-
partment for upper gastrointestinal series, oral cholecystography, or
barium-enema study.5 Of 136 patients for whom adequate data were
available, 30 (22 percent) did not receive appointments for treatment
after completion of diagnostic procedures. Of the 106 patients who did
receive appointments, only 54 (51 percent) kept them. Furthermore,
only 37 (38 percent) of 98 patients interviewed who had had radiologic
examinations could recall being told the results. The authors concluded
that effective care had been provided to only one-fourth of the patients.
Gonnella and coauthors studied the detection of urinary tract in-
fections at a university outpatient clinic.6 An interview designed to
elicit historical information about symptoms and signs of urinary tract
infection was used on 133 patients, and urine samples were obtained
from all of them. Thereafter, all patients were seen in the medical
clinic by the regularly assigned student-attending team, which was
unaware of the preliminary study. Eighteen patients with significant
bacilluria (105 colonies/ml urine) were discovered by the preliminary

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history and screening, whereas only eight had correct diagnoses on

the regular clinic routine. Yet when the knowledge of staff members
was tested, their average score of 83 percent on the diagnosis and
treatment of this condition showed that the problem was not primarily
a lack of knowledge but failure to perform.
These and other studies show that medical practice is subject to
oversights, lack of follow-up, and poor communication between physi-
cian and patient. Such quality-degrading incidents occur in any com-
plex organized system, whether involving medical practice or a large
engineering project. According to Chris Kraft, former Director of the Na-
tional Aeronautic and Space Administration (NASA), a constant vigil is
maintained in the space program to prevent errors of omission, misinter-
pretation, and lack of inspection: “After our initial years of experience,
we recognized that redundancy checks were required to prevent termi-
nation of an otherwise perfect mission. Hundreds of examples of human
error can be cited, including the problems of the Space Shuttle.
“We used color coding on liquid gas transport lines to warn of
their contents and to ensure proper attachment. In the Space Shuttle,
we even used different threads at junctions to prevent technicians
from assembling the support equipment improperly. Unfortunately,
they misassembled them anyway, forcing the lines together and caus-
ing damage to the system.
“In many instances parts were omitted from an assembly, despite
required inspection points and a recording as each step was com-
pleted. When such an omission occurred in a pressure regulator of a
space suit, we had to cancel a planned event on a 1982 Space Shuttle
flight. We have had parts assembled backwards, an error that eventu-
ally caused a profuse leak in a system and required the complete re-
design of a hydraulic actuator at great cost because the space team
lost confidence in the equipment.” In September 1999, the $87 mil-
lion Mars Climate Orbiter (MCO) failed because navigators used
English units of pound-seconds instead of metric newton-seconds in
guiding the space-craft. For this error, Science designated the inci-
dent the “blunder of the year.”7

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After the tragedy of Apollo 1, in which astronauts Grissom, White,

and Chaffee died in a fire while in a space capsule, Gene Kranz, a flight
director in NASA’s Mission Control, said, “From this day forward,
Flight Control will be known by two words: ‘Tough and Competent.’
Tough means we are forever accountable for what we do or what we fail
to do. We will never again compromise our responsibilities. Every time
we walk into Mission Control we will know what we stand for.
“Competent means we will never take anything for granted. We
will never be found short in our knowledge and in our skills. Mission
control will be perfect.”8 The fate of the Columbia highlights the im-
portance of this pledge.These principles, and the dire consequences
of ignoring them, also apply to all healthcare professionals.
The Institute of Medicine highlighted medical mistakes in a re-
port entitled To Err is Human: Building a Safer Health System9; in one
study, medical errors were said to kill some 44,000 people in U.S.
hospitals, but in another study, the number was 98,000, an inordi-
nately broad range. Although McDonald and coauthors10 make com-
pelling arguments that the Institute of Medicine report exaggerated
the frequency of the problem, everyone wants to reduce medical er-
rors to a minimum, regardless of their source.
A powerful analogy to the diminished effectiveness in complex
organized systems, whether medical practice or space missions,
comes from the second law of thermodynamics: energy sponta-
neously becomes less concentrated, that is, more diffused, in closed
systems, and inanimate matter tends to become random rather than
remaining neatly ordered and organized. As Frank Lambert noted:
“Complex human activities are inherently subject to becoming
disorderly—just as orderly groups of molecules in a high energy sys-
tem are unstable.”
Aspects of patient care have a similar tendency to become less or-
derly and more random if left alone. Constant monitoring and con-
stant feedback are essential to maximal efficiency. Considering the
analogy to systems governed by chemical thermodynamics, we should
not be surprised by this tendency. Physicians act as critical catalysts
in superior medical care. The need for rigorous control is recognized
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by physicians who must continually check on themselves and others

to ensure proper handling of even routine matters. We cite the analo-
gies of the space program and the second law of thermodynamics to
emphasize that the tendency for a system to become more disorderly
is universal and constant. The physician must therefore be ever alert
not only to medical but to nonmedical problems in practice.

THE PHYSICIAN AS MANAGER

How can physicians intervene to correct the tendency for the system
to become disorderly and thus less efficient? Joseph Gonnella sees
the physician as a manager, constantly monitoring the patient’s care
to ensure that everything is proceeding as it should and attending to
each problem as it occurs. Almost all physicians interviewed ac-
knowledged that numerous difficulties arise in medical practice that
are unrelated to medical knowledge, and almost all made conscious
efforts to combat them.

H I S T O RY A N D P H Y S I C A L E X A M I N AT I O N
Most physicians guard against an incomplete review of systems dur-
ing the physical examination by following an outline, preprinted form,
or checklist, even though they may know it by memory. Others have a
nurse or secretary scrutinize the chart after the examination and re-
turn it to the physician, noting any omissions. Physicians who use
checklists may also write occasional notes on the progress sheet, such
as “Next time do pelvic examination.”
Warren Williams had his office staff go over his charts for impor-
tant oversights in the history-taking or physical examination. As an
experiment, he discontinued these procedural audits only to find that
in two to three months his workups again had some omissions. The
second law of thermodynamics is always operating.
Overbooking patients’ appointments increases the risk of rushed
examinations, omissions, and inadequate recordings. Similar prob-
lems ensue when the patient or physician is late for an appointment.
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L A B O R AT O RY D ATA

Laboratory Studies Unordered, Unperformed, or Unreported

Most physicians use a checklist of possible laboratory studies as a re-
minder of relevant examinations to order, but the temptation to over-
order from such a list must be resisted. Other physicians set aside charts
on difficult patients for review at the end of the day, call patients back for
further tests, or write notes on progress sheets to order certain tests. Still
others ask new patients to return to review their laboratory reports with
them, and at that time note any needed tests that were not done.
To discover any unperformed or unreported laboratory studies,
physicians can advise patients of the tests ordered and, at the next
visit, ask them what was actually done. Was blood drawn or a
roentgenogram taken? Having the office staff check tests ordered and
completed can also minimize laboratory omissions. Writing laboratory
orders in a specific place in the patient chart, such as the left margin,
facilitates checking. Some physicians review each day’s laboratory re-
ports and ask patients either to call or to schedule another visit to re-
ceive the reports.

Lost Laboratory or Radiology Reports

Since loose data are liable to become lost, all laboratory reports
should be filed in the patient’s chart promptly or kept in a special box
for the physician to review and initial before being filed. A master file
of all laboratory reports is useful in case of a misfiled or lost report.
Some laboratories and departments of radiology have a policy of send-
ing a second report on all significantly abnormal studies, or a staff
member will telephone the physician to ensure that a seriously abnor-
mal study has not been lost or remained unnoticed. A backup report
on “critical findings,” such as suspected cancer, can prevent medical
disasters. Ideally, all serious findings should be called in to the physi-
cian’s office as well as reported in writing.

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Failure to Note or Act on Abnormal Laboratory Results

A report that contains a single abnormal result seems most likely to be
overlooked. Various techniques can help physicians avoid oversights,
such as a red “Alert” stamp on all abnormal laboratory findings or
highlighting of abnormal studies and leaving the laboratory sheets on
the physician’s desk until he reports the results to the patient.
Many physicians require their initials on all laboratory data be-
fore the office assistant places reports in patients’ charts. Other
physicians look over the chart for recent laboratory and roentgeno-
graphic reports while they are seeing the patient on a revisit, to make
sure that abnormal studies are followed properly. Partners sometimes
review one another’s hospital charts before a patient’s discharge to en-
sure that all abnormal results have been noted.

Flow Sheets
The advantage of a flow sheet, which can be generated by a computer,
is that you can see the data at a glance. “When it occupies four or five
pages,” said Telfer Reynolds, “the benefit of the flow sheet is lost. A
flow sheet for a liver patient contains results of the major studies
needed to treat liver diseases, just as that for a fluid-and-electrolyte
patient has the fluid and electrolyte data. The flow sheet also has a
couple of columns for important clinical information. For a general
internal medicine patient, the flow sheet should be adaptable, with
blank spaces for physicians to write in whatever they want to follow.”

MEDICAL RECORDS

Incomplete or Illegible Records

Physicians avoid forgetting pertinent facts by making notes during
the patient visit, but illegibility can cause problems, particularly if
their writing deteriorates as they become busier, more rushed, or

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older. Many physicians dictate their records for later transcription.

Physicians generally agree that charting can be improved in most
practices. Discipline and determination may provide the only solu-
tion, although the monitoring of records, particularly in the hospital,
has lessened the deficiencies.

Consulting the Wrong Chart

Consulting the wrong chart does not happen often, but physicians
should check the patient’s name on the chart at each visit. A safe-
guard used in some offices is to have patients record their names,
dates of birth, and telephone numbers at each visit and then to match
that with the information in the chart. Writing the name of the patient
on every progress sheet is also helpful, and when more than one pa-
tient has the same name, the charts can be labeled in a way to alert
the physician, nurse, and file clerk.

Lost or Misfiled Records

Patient records are more likely to be lost or misplaced in group prac-
tice than in solo practice. Computerized appointment systems are
said to be an aid in this regard. In most clinics, charts are not sup-
posed to leave the building or to be out of file overnight. Outcards can
be inserted into the file to indicate where the record is at all times.
Misfiling is more likely to occur in hospital practice, but medical
record administrators can help immensely.

L A C K O F F O L L O W- U P O F PAT I E N T S
At the end of each day, Murray Salkin’s nurse gives him the charts of
patients who missed their appointments. He evaluates the records
and gets in touch with patients with serious problems. Cathleen Caton
uses an FTKA (failed to keep appointment) stamp to denote patients
who do not show up or who cancel appointments. Some physicians

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use a card file to ensure following up patients with certain diseases,

and others have a secretary keep a separate list of seriously ill pa-
tients and their diagnoses to minimize loss to follow-up. Still others
send cards to remind patients of a follow-up visit and, if the condition
is particularly serious, they may telephone or e-mail the patient. In
addition to contributing to poor care, lack of follow-up can cause an
inaccurate perception of results. (See Chapter 10 about sending
follow-up questionnaires or letters to patients.)

PAT I E N T N O N C O M P L I A N C E :
FA I L U R E T O F I L L A P R E S C R I P T I O N O R F O L L O W D I R E C T I O N S
Physicians should never assume that patients are following instruc-
tions. Instead, they should ask their patients on each visit how they
are tolerating their medications, if they have finished their supply,
and other questions to determine if treatment is being followed. See-
ing chronically ill patients every few weeks allows the physician to
note symptoms and tolerance to drugs, to adjust dosage, and to en-
courage compliance. A special form for medications can be kept in
the chart, to be updated at each visit when therapy is discussed with
the patient. William Hart has his patients list their medications and
dosage, to be reviewed on each visit. He reemphasizes the need for
medication, explains the reason for the schedule, and relates the pos-
sibilities of drug interactions and adverse effects.
A good physician–patient relationship facilitates compliance.
When Page McGirr finds that a patient is not complying with pre-
scribed treatment, he restates the medical need, warns of the conse-
quences of omission, and enlists the patient’s cooperation, avoiding
intimidation. Talking to other members of the family can also be
useful.
Noncompliance can be a serious problem in patients with chronic
diseases, such as diabetes, hypertension, and mental illness. As long
as patients are feeling well, they may not exercise the self-discipline
necessary for long-range health preservation. Follow-up visits may be

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needed to reinforce the importance of treatment and to provide

encouragement.
Misunderstanding instructions is a common cause of patient non-
compliance. Making the instructions simple, having patients repeat
them, and writing them out reduce such misunderstandings. Some
physicians keep a copy of written instructions as a reminder of what
was communicated, and others ask the patient to bring all medica-
tions to the office. Elderly patients, in particular, need additional at-
tention, written instructions, and more frequent office visits.

Inattention of the Patient

Patients, of course, need to give their full attention during confer-
ences with the physician. You may need to ask distracting children or
other relatives to remain in the waiting room when the patient is
called in to see you. On the other hand, enlisting the aid of a spouse
or relative can often help the patient understand. It is your responsi-
bility to individualize your explanations and instructions to the pa-
tient’s needs, to be extremely careful in delivering them, and to use
language the patient understands. Roger Stickney likens a good
physician to a good teacher who can hold the attention of a class.

Patient Denial
Patients who are frightened and distracted by anxiety often fail to rec-
ognize or accept a serious diagnosis. The patient may use a psycho-
logical defense to reject what he does not want to hear. The physician
may give a clear description of the patient’s problem and its possible
solutions or prognosis, only to find that the patient has not absorbed,
or has totally misconstrued, what was said. The physician may there-
fore have to rephrase the information and even schedule another ap-
pointment to ensure that instructions are being followed. Pressing for
complete patient understanding immediately is not always wise, since
denial can offer the patient psychological protection initially. Where

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education is essential to the patient’s well-being and longevity, how-

ever, a thoughtful, compassionate, articulate, and attentive physician
can usually deliver the proper message.

FA C T O R S L I M I T I N G P H Y S I C I A N E F F E C T I V E N E S S

Inattention of the Physician

Perhaps the most significant barrier in the physician–patient relation-
ship is failure to give full attention to the patient. It may be necessary to
reduce the patient load in order to provide adequate time for patients.
Patients are receiving the physician’s full attention, according to Steven
Hamman, when they are allowed to tell their full story while the physi-
cian actively listens before asking specific questions. The ability to lis-
ten and filter carefully is a great asset in medicine. Fred Turrill warned
that “Some physicians look at their patients and make a snap diagnosis
without giving the patient time to say everything he has to say. Listening
may teach you something new about a disease, and the patient will al-
ways feel better for having been heard out.” Paul Bohannan, communi-
cations specialist, recommends paying attention to what is being said
instead of planning your next statement while the patient is speaking.
Try to discipline yourself to give full attention to your patients, includ-
ing their “silent messages” and body language.
Sometimes the messages will not be so silent. “The late Conrad
Wesselhoeft of Harvard Medical School told a classic story,” said
Francis Moore, “and the moral was simply that the physician has to
think of a diagnosis before he can make one, and listening carefully to
the patient is often the most important part of the examination. He il-
lustrated the point with the account of a man who lived on an island in
Boston Harbor and was stricken with a disease which made it difficult
for him to open his mouth. The physician ministered to him, giving all
the pukes, purges, and perspiring agents fashionable at the time, and
confiding to the patient all the various diagnoses that came into his
mind, ranging from diphtheria to glandular fever, quinsy sore throat,

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and epileptic seizures. Finally the patient, dying and hardly able to
open his mouth, muttered, ‘Doctor, don’t you think I might have lock-
jaw?’ To which the physician replied, ‘Doggonnit, my good man, why
didn’t you think of that before?’ ”
Many of us are so busy asking the patient questions that the pa-
tient can never tell a complete story. Kenton King recalled that “The
resident staff at Washington University customarily saved the most
puzzling and perplexing case on the ward for presentation to the Chief
about once a month. Accordingly, Dr. Carl Moore was brought to the
bedside of an elderly lady with neurologic findings, as well as abnor-
malities in many other systems. About 20 house officers were gath-
ered around the bed. A young, eager, well-meaning resident
presented the case in a rather dull and rambling manner. When he
finished, everybody looked at Dr. Moore, who turned to the patient
and asked: ‘Ma’am, what do you think your diagnosis is?’ She replied,
‘Well, when I visited Dr. Wintrobe about 20 years ago in Salt Lake
City, he said that I had pernicious anemia before he started treat-
ment.’ Dr. Moore, realizing that it all fit together, said, ‘My dear lady,
why didn’t you tell these doctors?’ To which she replied, ‘I tried to,
but they told me to be quiet and answer their questions.’ ”
William Bardsley is convinced that interest in, and attention to,
patients are sharpened by the physician’s own good health, proper
diet, adequate exercise, and adequate sleep. Interest is also enhanced
by a certain amount of teaching and medical student discussions; oth-
erwise, constantly listening to patients’ complaints can become te-
dious and stressful. Occasionally, something about a patient may
arouse resistance in the physician. If the physician cannot resolve the
matter, the patient should be referred to a more compatible colleague.

Distractions Diverting Attention from the Patient

Telephone calls should not be allowed to interrupt the physician–
patient conference unless they are extremely important. Many physi-

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cians try to take calls between patient visits, whereas others leave an
opening in their morning and afternoon schedules to accommodate
calls. When the physician must interrupt a patient interview to take
an urgent call, it is best to leave the consultation room and to return
afterward, ready to be fully attentive to the patient. Similarly, patients
should be asked to turn off cell phones during office visits.
“I have come to realize that the level of expertise a physician
develops may be altered significantly by various factors, including
fatigue, poor equipment, frequent interruptions, and emotional dis-
turbances,” said Francis Buck. “I now try to examine my most diffi-
cult diagnostic problems in the morning hours when I am mentally
alert and most efficient.”

Rushing Through an Examination

Cotton Feray allows a certain number of appointments for acute prob-
lems, a certain number for physicals, and a certain number for follow-
up appointments. The receptionist asks patients what problems they
are having, and Feray provides her with a list of patients who need
longer appointments because of multiple problems. By allowing cer-
tain slots for physicals and other examinations, he never has to do a
complete physical and Pap smear in a 10-minute slot. He schedules
acute problems in the morning and all office surgery in the afternoon.
Some physicians schedule patients to arrive 15 minutes before
their appointments, but they, too, have an obligation to be prompt. If
you find yourself rushing through examinations, you need to plan your
schedule more efficiently. To accommodate unexpected events, some
physicians schedule “catch-up” periods.

Physician Denial of Significant Data

Occasionally, physicians may psychologically deny significant data or
fail to absorb what a patient is saying because they do not wish to ac-

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cept the evidence that the patient has a life-threatening or socially

unacceptable disorder. A long physician–patient relationship may in-
tensify the resistance. The physician must, however, recognize that
venereal disease, cancer, child abuse, AIDS, and other serious disor-
ders exist and, regardless of any personal discomfort, should look for
them during the evaluation.

Acting on Insufficient Data

Some believe that pressure to reduce the cost of patient care has en-
couraged physicians to act on insufficient data. It puzzles Roger
Stickney that some patients seem to prefer his treating them on in-
stinct rather than factual data. But there is no substitute for a thor-
ough physical examination and penetrating analysis of the medical
history and symptoms. To avoid acting on inadequate data, Page
McGirr asks two questions: (1) “Do I have enough data on this patient
to make everything clear to another physician should I become ill or
go on vacation?” and (2) “If the case ends in death or legal action, will
my data support my actions?”

COLLEAGUES

Strained Relationships Within the Health Team

Unfortunately, strained and even destructive relationships can develop
among physicians or other health professionals attending a patient, just
as they can between any two human beings. Resolving the problem at
the earliest possible moment serves the patient’s interest best. Avoid-
ance or delay usually worsen the situation. In Osler’s words, “[W]hen
any dispute or trouble does arise, go frankly, ere sunset, and talk the
matter over, in which way you may gain a brother and a friend.”11 The
willingness of the physician to listen carefully to all concerned is cru-
cial, and frequent team meetings can maintain rapport.

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Reporting of Errors and Omissions

“It is a major responsibility of physicians,” Richard Reitemeier be-
lieves, “to report to the proper authorities all significant errors of com-
mission and omission by the professional staff.” Because physicians do
not always do this, either for want of time or fear of criticism, simple,
remediable problems may accumulate and become chronic. Reitemeier
relates three incidents involving personal or institutional responsive-
ness in identifying and reporting problems. The first occurred when,
during the middle of a hot summer, reports of prothrombin time at a
hospital were unexpectedly high. Residents on the service had stopped
believing the reports or using those data. Neither the residents nor the
attending physicians supervising them, however, had investigated the
cause of the abnormal prothrombin values. “When I came on the serv-
ice,” said Reitemeier, “I verified that the prothrombins were clinically
inconsistent and then advised Walter Bowey, head of our coagulation
laboratory. Bowey sent a technician to draw blood from a patient whose
prothrombin time we knew should be normal. He gave part of the blood
to the laboratory at the hospital and took the rest to the laboratory at the
clinic, where a normal prothrombin value was reported. The sample
processed at the hospital, transported in the regular fashion to the labo-
ratory, was reported as abnormal.
“Upon investigation, it was discovered that the technicians as-
signed to draw blood from patients throughout the hospital often did
not return to the laboratory for two to three hours. During that time the
tubes with the blood samples were kept in racks on their carts, and
the prothrombin became degraded as a result of the summer heat.
Bowey simply provided each cart with a styrofoam container filled
with dry ice to hold the blood samples, and the problem was immedi-
ately corrected. In addition, the incident led to a review by the labo-
ratory of all studies affected by the ambient temperature.
“The next incident occurred when I saw a sturdy, tough Wyoming
rancher weeping at his bedside on the morning he was to have colon
surgery. He had had some 22 enemas in the preceding two and one-

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half days and told me that he was simply demoralized and could not
endure having another one. Several months earlier the gastrointesti-
nal surgeons had complained that the patients’ colons were not com-
pletely free of feces at operation. This spurred the nurses performing
routine preoperative preparations to subject patients to increasing
numbers of enemas. A lack of communication among nursing supervi-
sors resulted in an occasional comment about the inadequacy of the
preparation, which led, in turn, to an effort to cleanse the colons com-
pletely. Large amounts of total body sodium and potassium may have
been needlessly washed from these patients. A meeting with each
group involved led to the conclusion that each patient needed only a
few enemas for cleansing, and a much more humane and comfortable
procedure was put into effect.
“The third example occurred while I was Chairman of Medicine. I
kept hearing complaints that, although we might be able to put a man
on the moon, we could never successfully collect three-day stool sam-
ples from a patient. I asked the administrative assistant in the De-
partment of Medicine to solve the problem. He assigned two young
men with Master’s degrees in business administration to find out what
could be done. They discovered that no one felt personally responsi-
ble for the collection or handling of the samples. The administrative
assistant implemented a program that included methods to identify
the samples clearly and specify directions for transferring the mate-
rial to the responsible party. For the first time in the history of the in-
stitution, we had successful three-day collections of stools.”

Solutions
Clement McDonald, recognizing man’s limited ability to process in-
formation, designed a computer program with protocol-based re-
minders for physicians.12 Physicians received computer-generated
suggestions once a week for two months. As a result, they detected,
and responded effectively to, twice as many clinical events and data
as previously.

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Monthly meetings for clinic and hospital staffs to discuss problems

in practice due to systems difficulties and not lack of scientific knowl-
edge should allow physicians and other healthcare professionals to iden-
tify, confront, and solve many of the problems outlined in this section.

*****

The tendency for a complex system to go from a state of order to a

state of disorder is a serious and frustrating reality in medical practice.
A lost laboratory report can sometimes be more devastating to good pa-
tient care than a lack of medical knowledge. Computer reminder-and-
monitoring systems can help prevent omissions, oversights, and
inattention to abnormal findings and can thus lessen disorder in prac-
tice. Without such assistance, physicians must themselves constantly
monitor and manage the care given their patients.
As Peter Mere Latham wrote: “[I]n medicine . . . it requires as
much labour and time fairly to lay hold of an error, and uproot it, and
have done with it, as to learn and settle a truth, and abide by it.”13

REFERENCES
1. Block A. Murphy’s Law and Other Reasons Why Things Go
Wrong. Los Angeles: Price Stern Sloan; 1982: 11–12.
2. Williamson JW, Alexander M, Miller GE. Continuing educa-
tion and patient care research: physician response to
screening test results. JAMA. 1967; 201:938–942.
3. Starfield B, Scheff D. Effectiveness of pediatric care: the re-
lationship between processes and outcome. Pediatrics.
1972; 49:547–552.
4. Morehead MA, Donaldson R. Quality of clinical manage-
ment of disease in comprehensive neighborhood health cen-
ters. Med Care. 1974; 12:301–315.
5. Brook RH, Stevenson RL Jr. Effectiveness of patient care in
an emergency room. N Engl J Med. 1970; 283:904–907.

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6. Gonnella JS, Goran MJ, Williamson JW, Cotsonas NJ Jr.

Evaluation of patient care: an approach. JAMA. 1970;
214:2040–2043.
7. Blunder of the year: NASA tangles with the metric system.
Science. 1999; 286:2238.
8. Kranz G. Failure Is not an Option. Mission Control from
Mercury to Apollo 13 and Beyond. New York: Simon &
Schuster; 2000:204.
9. Kohn LT, Corrigan JM, Donaldson M, eds. To Err Is Human:
Building a Health System. Washington: Institute of Medi-
cine; 1999.
10. McDonald CJ, Weiner M, Hui SL. Deaths due to medical er-
rors are exaggerated in Institute of Medicine report. JAMA.
2000; 284:93–95.
11. Osler W. The master-word in medicine. Bull Johns Hopkins
Hosp. 1904;15:7.
12. McDonald CJ. Protocol-based computer reminders, the
quality of care and the non-perfectability of man. N Engl J
Med. 1976; 295:1351–1355.
13. Latham PM. General remarks on the practice of medicine.
In: Martin R, ed. The Collected Works of Dr. P. M. Latham.
London: New Sydenham Society; 1878:382.

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C O M M E N T A R Y
...
Dr. Don Harper Mills received his M.D. degree from the Univer-
sity of Cincinnati and his J.D. degree from the University of South-
ern California. During 40-plus years of experience evaluating
medical malpractice claims and sorting out practice problems that
precipitate these claims, he has published professionally in the
medicolegal field. He was the principal investigator for the Califor-
nia Medical Insurance Feasibility Study, a seminal project that laid
the groundwork for Harvard’s New York Study on medical adverse
effects. Dr. Mills was Co-director of the California Hospital Associ-
ation’s Event Notification System, a program calculated to capture
adverse events as they occur. At the Medical School, he partici-
pates in ethics rounds with upper class students. He is a Past Pres-
ident of the American College of Legal Medicine and of the
American Academy of Forensic Sciences.

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 The Physician’s Art
of Self-defense

Don Harper Mills, M.D., J.D.

Clinical Professor of Pathology
Clinical Professor of Psychiatry and Behavioral Science
Keck School of Medicine, University of Southern California
Los Angeles, California
Medical Director, Octagon Risk Services
Long Beach, California

D espite the flood of reform legislation 25 years ago, malpractice

issues remain unresolved. The primary focus has been on cost
control, which, in some states like California, has been remarkably
successful. Lawsuits are still being filed, however, and they are still
very personal. Even in nonmeritorious cases, the physician is unduly
stressed by the accusations and by the need for self-defense. This will
not change so long as we have the present (fault) system of liability.
The remaining remedy, therefore, is to become skilled in the art of
self-defense (AOSD). Don’t confuse this with defensive medicine,
which is considered to be an irrational response to liability threats; it
involves rational approaches, which I shall outline here.

Y O U R PAT I E N T ’ S K E E P E R
You may have read a lot about the physician–patient relationship, but
it may not have been emphasized that even when you treat another

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physician, your special knowledge, training, and experience give you

an advantage. You need to assume at all times that the patient knows
less than you do about his condition and about your plans to manage
it. Since there is no way you can fully inform the patient medically
and scientifically, it is important to take adequate time to talk with
your patients and let them react to your observations and recommen-
dations. You are in the driver’s seat. The advent of managed care
tends to cloud that concept, but only slightly. Notwithstanding the re-
straints of managed care, you still have the primary obligation to
serve your patients, including being your patient’s keeper, at least
medically and surgically. Don’t defer to a patient’s decision that con-
travenes your best judgment for the patient’s well-being. Be sure you
explain fully; then if the patient rejects your opinion, at least you have
gone the extra mile your responsibility requires. This is a major ele-
ment in AOSD.

D U T Y T O WA R N
Suppose you prescribe a sedative-acting antihistamine drug without
warning of the dangers, and the patient proceeds to drive a bus, falls
asleep at the wheel, and crashes into a pole, injuring the 15 passen-
gers. They sue the bus company and the driver, but, during discovery,
their lawyers learn that the driver had just started taking a certain an-
tihistamine drug without knowledge of its sedative effect. You will be
the newest defendant. You have an obligation to people whom you
have never seen but who may be adversely affected by your patient’s
falling asleep at the wheel. The only way to protect these people is to
warn the driver. You cannot prevent your patient from driving, but you
are obliged to give warnings. If that warning is violated and injuries
occur, you will not be a culpable defendant in any lawsuits.
A similar warning is required for patients who have newly diag-
nosed seizure disorders and for whom drug control has not yet been
firmly established. In most states you are required to report these pa-
tients to the drivers licensing bureau. That agency usually revokes or

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otherwise restricts the patient’s driving license until medical manage-

ment can ensure driving competence. During the interval between
your report and the agency’s response, the patient should be advised
of the danger of driving. If you have failed to warn the patient in that
interval, you may have the same liability exposure as in the antihista-
mine case. Again, you have no authority to force the patient not to
drive. All you can do is warn.
In either instance, your documentation of the warning is vital and
becomes an integral part of AOSD. Remember that juries view physi-
cians no better than patients, giving all people equal status in credi-
bility assessment. If you contend that you warned the patient about
the dangers of driving and the patient contends that you did not, the
jury may believe either you or the patient. But if you have docu-
mented the warning, your credibility rises substantially above the
50/50 level. Documentation is not part of defensive medicine, but is a
rational, vital element of AOSD.
Warning the patient of the danger of refusing your recommenda-
tion is also a rational requirement of your more informed position in
the physician–patient relationship. Although you may believe that the
new consent procedures (described later) allow the patient to accept
the medical and surgical consequences, they do not relieve you of en-
suring a full understanding of those consequences. Any patient who
refuses your medical recommendations should be given written in-
structions documenting the refusal, as well as advice concerning al-
ternative care. For instance, a diabetic patient with an infected foot
ulcer needs hospitalization for intensive wound care and intravenous
antibiotic coverage, but has refused for personal or financial reasons.
You cannot force the patient to be hospitalized, nor should you aban-
don him. Rather, you should warn him of the dangers of ignoring your
counsel and suggest alternative care, even though it may not be the
best. If the problem is financial, you can direct the patient to a gov-
ernment hospital for care. If that is refused, the patient may choose
the best outpatient care available, and you should outline it in your
instructions. Remember, however, that you are not bound to care for

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this patient under such restrictions; your legal obligation is to resolve

the problem or give the patient notice to seek care elsewhere. If he re-
mains under your care, documentation of the decision-making pro-
cess is mandatory, that is, you might have the patient sign a statement
for your office record outlining your recommendation, the refusal, and
the alternative remedies available. This does not constitute a consent
in the strictest sense, but it certainly establishes that the patient rec-
ognized the serious consequences that were discussed and accepted
responsibility for them. Those who practice AOSD well often use
their office and hospital charts as communicating devices. As dis-
cussed later, this applies to interphysician communications as well as
physician–patient communications.
The duty to warn extends to cautioning the patient to be alert to
possible adverse effects of treatment (drug reactions, postoperative
infections). If a drug you have prescribed can cause a significant rash
(as in Stevens–Johnson syndrome), the patient should be advised to
call you immediately should a rash appear. If he fails to report the
rash promptly and continues taking the drug, one can infer that you
failed to warn the patient. If you prescribe a drug that can produce
liver toxicity (like isoniazid), you should instruct the patient, verbally
and in writing, to watch for jaundice or other manifestations of he-
patic toxicity and to notify you immediately, noting these instructions
in your office record. You must assume that patients will not remem-
ber oral instructions once they leave your office and that if you fail to
give written instructions or to document them in your records, the pa-
tients will say that you did not give oral instructions. Juries of non-
physicians tend to believe that physicians are obligated to look out for
their patients, and AOSD demands that you know that. Of course, if
your patient does notify you as instructed, you must react with the
best medical advice; failing to discontinue the drug is indefensible.
The duty to warn also applies to instructions for follow-up care. If
a return visit is required, you must advise the patient of the date be-
fore he leaves the office or clinic. If the patient fails to appear at the
appointed hour and the condition is relatively minor, it may be disre-

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garded. If, on the other hand, the follow-up is essential and the
patient fails to appear, your office staff must color-code or otherwise
tag the chart for immediate follow-up by telephone, facsimile, postal
mail, or e-mail. You might consider setting aside charts of difficult
patients for review at the end of the day. Occasionally, you might want
to call a patient that evening to check on the patient’s progress, or you
might write a follow-up letter. Such actions are becoming more diffi-
cult in the controlled atmosphere of managed care, but they remain
positive elements in AOSD. The bottom line of this discussion is that
a patient’s noncompliance may not free you from a lawsuit.

C O N S E N T F O R T R E AT M E N T
The movement toward autonomy and the patient’s right to choose does
not contravene the principle that your more informed position in the
physician–patient relationship creates special obligations. Your duty
to decide what is best for your patient includes the duty to describe
what is wrong, what should be done, what benefits may ensue, and
what adverse effects may occur. Once you have made your recom-
mendations, the patient must have enough information to say “no” or
to choose some reasonable alternative. If the answer is “no” and your
recommendation is important, AOSD requires trying to convince the
patient to change his mind. The autonomy movement does not extin-
guish your duty to try to convince patients to do what you think is best
for them.
Lawsuits arising from postoperative or medicinal complications
may allege lack of informed consent or negligence in the performance
of the procedure or the prescribing of the drug. If the patient’s attorney
fails to prove that your negligence caused the adverse outcome, a sec-
ond arrow in the bow is to try to prove you failed to communicate with
the patient—that there was no informed consent. The consent problem,
therefore, is not a medical practice problem. In most states, the patient
does not need to have an expert physician show that you were negligent
for failing to disclose the necessary information to permit a valid con-

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sent. All that is necessary is to show the court that the missing informa-
tion was material to the decision to accept your recommendation. If, for
example, you recommend a subtotal gastric resection for benign gastric
disease, you must disclose the risk of injuring the spleen during the
procedure. If you recommend a thyroidectomy, you must disclose the
risk of injury to the recurrent laryngeal nerve and the parathyroid
glands. If you fail to make these disclosures, the patient may later con-
tend in court that he would not have consented to the procedure had he
known the truth about the consequences. You still have the opportunity
to show the jury that what you intended to do was vitally necessary for
the patient’s well-being—that a reasonable patient would have con-
sented to the procedure even had you made the proper disclosures
about the adverse consequences. If the case is medically clean (no neg-
ligence in the decision to perform the procedure or in the way it was
done), the decision is usually for the defense, even if the jury believes
complete disclosure was not made for a valid consent.
Such a favorable decision does not obtain with misdisclosures. If
you underplay the risks of the procedure by saying, “It’s simple” or “It’s
no more dangerous than crossing the street,” you may be held responsi-
ble for the adverse outcome because a jury will be told that your mini-
mizing the risks influenced the patient’s decision to proceed and be
subjected to the real risks. Misdisclosures almost always result in a ver-
dict for the prosecution. The AOSD requires you to understand the dif-
ference between nondisclosure and misdisclosure. Defense against
nondisclosure still requires showing that your management was other-
wise above reproach. If the medical aspects of the case are not clean,
you will not win the consent issue, even though it is only a nondisclo-
sure problem.

JUDGMENT DECISIONS
Most malpractice lawsuits that turn sour for the defense are the result
of the physician’s poor judgment, not technical malperformance. The
first critical focus in the lawsuit deals with the decision to perform the

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procedure or to prescribe the drug. “Were there adequate medical or

surgical indications?” is a medical, not a legal, question. By acting
without adequate indication, you expose the patient to the unneces-
sary risk of an adverse outcome or drug reaction. You cannot justify
this exposure by telling the patient that such an outcome may happen,
that is, consent is no defense for an unnecessary procedure. A patient
who comes in with pharyngitis, asks you for penicillin, and receives it
may have a viable lawsuit if he suffers a significant adverse reaction
to that drug. There may be reasons for overusing oral antibiotics, in-
cluding diagnostic uncertainty and even the perceived threat of litiga-
tion, but the latter factor is irrational at best. The patient with
streptococcal pharyngitis who is given penicillin may have the same
adverse outcome, but at least the issue of the need for the drug has
been settled by the medical facts.
The second judgment issue focuses on contraindications: Should
the patient not be given the drug at this time? Should the operation not
be performed today or on this patient? Even for streptococcal pharyngi-
tis, penicillin should not be prescribed for a patient who is allergic to it.
Such a case leads into the issue of asking about drug sensitivity and
documenting the answers. How are charts flagged in your office? Is
someone assigned to monitor the sensitivity history once you have pre-
scribed a particular drug? These are critical elements in AOSD.
If you injudiciously tamper with your records, be sure to notify
your attorney at the outset. With critical retrospection, it may be pos-
sible to explain away your alterations. But if not, at least you will not
compound your problem in deposition or on the witness stand by
claiming that the records are real and proper. Remember that there
are expert document examiners in every major community who de-
cide the authenticity of record entries. Don’t try to fool them; the more
you try, the worse it looks.
Is this something you can do, or should you call in a consultant?
You decide daily whether you are competent to do what you intend to
do. Assuming you are trained to do well what you intend to do, do you
do it often enough to maintain your judgment and dexterity? The past

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decade has seen a growing list of procedures that require specific vol-
umes to avoid increased risks of adverse outcomes. A recent study
analyzed repair of abdominal aortic aneurysms performed between
1990 and 1995. The mortality rate was 2.5 percent at hospitals where
more than 100 operations were performed, but 4.2 percent at hospi-
tals with fewer aneurysm operations. Surgeons doing 10 or more pro-
cedures had a mortality rate for aneurysmal repair of 2.8 percent to
3.8 percent, but those doing only 2 to 9 procedures had a rate of 4.9
percent.1 You need to know what procedures are volume-sensitive
and when volume-sensitivity also applies to the hospital. Addition-
ally, surgical research has created a new field of minimally invasive
procedures. If these were not part of your original training, you need
to establish adequate credentials to perform them. “See one, do one”
is not the best approach.
Even “performance” problems involve judgment. When do you
convert a laparoscopic-assisted gallbladder operation to an open one?
What measures do you take to prevent injuring a ureter or the bladder
during a pelvic operation? What measures do you take to ensure the in-
tegrity of the ureter or the bladder before closing the incision? Lawsuits
arising from such injuries during operation are lost more often because
of delayed diagnosis and repair than because of the operative injury.
Disclosing the risk of ureteral injury to the patient for consent purposes
does not absolve you of liability. Nothing is further from the truth. You
still have the responsibility of deciding that the procedure was neces-
sary, that you were competent to perform it, that you took precautions to
prevent the injury, and that you did what was needed to discover that
the injury occurred and to ameliorate the outcome, if possible. Recog-
nition of these additional issues is a critical part of AOSD.
You are allowed to be wrong about a patient’s diagnosis, but only
if the missed diagnosis or nondiagnosis is reasonable and founded
on adequate data (historical information, physical examination, and
special diagnostic procedures indicated). Failure to consider the
white blood and differential counts in deciding between appendici-
tis and viral enteritis has resulted in liability when the diagnosis

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was wrong. Similar outcomes have occurred in cases regarding

meningitis and pneumonia. Lawyers like these cases because, in
retrospect, the jury will realize that you made a mistake in the diag-
nosis (you diagnosed viral encephalitis and so failed to prescribe
antibiotics for an actual bacterial meningitis), and the burden shifts
to you to justify having been wrong. The AOSD requires you to con-
sider the adequacy of the data in each instance. Some people con-
sider this defensive medicine at its worst, requiring excessive tests
and procedures. That is a misconception. You should know what the
data require for most of the diseases you treat. You need not go be-
yond those data; indeed, if you do, you may be exposing yourself to
liability for unnecessary procedures. The AOSD requires that you
know the difference between doing all that is necessary and not
doing what is unnecessary.

C O M P L I C AT I N G C O N S U LTAT I O N S
You and your consultant must know who is going to do what. If he
makes recommendations but does not write orders, you are required
to follow up. If you expected him to write the orders, but failed to no-
tice that he did not, the patient will suffer, and so will your defense.
Such a physician–physician communication breakdown is a totally
indefensible, but remarkably common, problem. Many hospitals have
established guidelines to cover consultant responsibility, and you
need to learn precisely what the hospital protocol requires. Don’t
leave to chance your commitment to the patient.
Curbstone consultations are another matter. Be careful about rely-
ing on the off-the-cuff opinions of colleagues who have not had the
opportunity to evaluate your patient’s complete data, and avoid put-
ting those consultants’ names in the patient’s chart without consent. If
a colleague asks your advice in the dressing room, you may certainly
offer generalized statements, but be sure to state you need to see the
patient before speaking with certainty. That will either lead to a for-
mal consultation or terminate the discussion.

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Sending specimens out for laboratory analysis and having imag-

ing studies performed are consultations of a sort. You need to ensure
that abnormal results are noticed. This requires a system to get these
results before your eyes, to prompt you to call a patient back or to ad-
vise the patient on the next visit. I regularly see instances in which
abnormal data enter charts (office or hospital) without the attending
physician’s awareness. The patient suffers in such a system break-
down. Finally, I strongly urge the creation of flow sheets, by hand or
computer, to provide sequential laboratory or x-ray data at a glance.
Trends are much more readily recognized in this way.

GUIDELINES
Today, there are guidelines and guidelines. You need to differentiate
the good from the bad for the conditions you usually treat. Most will
not be introduced into direct evidence against you, but will be
brought in by opposing experts who will claim you did not follow stan-
dard procedure in arriving at a diagnosis or treating a particular con-
dition. On cross-examination, that expert will buttress his contention
about the standard of practice by citing certain guidelines. This en-
ters the guidelines into evidence through the back door. It is your re-
sponsibility to be as informed as possible about guidelines applicable
to your practice. Review them and decide whether your practice will
abide by them; if not, formulate a statement rationalizing your differ-
ences and put them in a special file. Then, if you are accused of vio-
lating the standard, you will be able to show that you thought about it
at the time this patient was being treated and decided on alternative
treatment for the reasons stated in your rationalization.
This brings us to a discussion of the drug package insert, pre-
pared by the manufacturer and published in the Physician’s Desk
Reference. For drugs you administer, you should be fully aware of
the contents of the package insert, since in most states the insert ap-
plicable to your patent’s drug can be introduced into evidence
against you. The contents do not establish the standard of practice

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regarding a particular drug, but may be considered by a jury in

deciding what the standard of practice is. If you deviate from rec-
ommended usage, you need to document the reasons (as with guide-
lines). Clearly, AOSD requires you to be prepared with the type of
medical documentation you may need if a patient should suffer ad-
verse outcomes.
You have the right, medically and legally, to use a drug “off label,”
but, again, you need to know that your usage is “off label,” and you
must be able to support the “off label” use with appropriate citations.
Like the rationalizations discussed previously, these citations need not
be in the patient’s chart, but may be kept in a separate file.

MANAGING ADVERSE OUTCOMES

How you handle poor results often determines whether you will face a
lawsuit and how it will be resolved. If you clam up, requiring the patient
to go to a lawyer to find out what really happened, you can expect the
worst. You have been told over the years not to confess, because your
statements to the patient or to the family can be used against you in a
subsequent lawsuit, but you can talk to a patient and explain what hap-
pened without becoming confessional. Indeed, many cases are resolved
in subsequent mediation, without the full litigation process, merely by a
discussion of what happened. Even that procedure, however, is enough
to cause you considerable stress. The AOSD requires you to communi-
cate adequately with the patient about what happened, and even why it
happened, if necessary. And it may reduce your stress to say occasion-
ally that you are sorry. You do not need to tinge your remarks with guilt
by saying “It’s my fault” or “I shouldn’t have done that.”
The AOSD may require you to reevaluate your status with patients
now and then. While making money is a business, treating patients is
not. Your advantageous position vis-à-vis patients obligates you to pro-
tect and guide them through the highly technical and judgmental as-
pects of modern healthcare. My discussion of these issues may have
seemed provocative at times, but with good cause.

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SYSTEM AND PERSONAL ERRORS

Patients are sometimes injured in hospitals, not by physicians, but by
system management problems. Delays by hospital personnel in fol-
lowing orders or in getting patients to the operating room can have
devastating adverse outcomes. You need to be alert that such short-
comings might affect one of your own patients. Your only recourse
may be to report the problem to the department head or chief of staff.
Failure to do so may lead to your own liability if your patient is mis-
handled. Sometimes AOSD requires you to rattle someone else’s cage.

REFERENCE
1. Dardik A, Lin JW, Eng M, Gordon TA, Williams GM, Perler
BA. Results of elective abdominal aortic aneurysm repair in
the 1990s: a population based analysis of 2335 cases. J Vasc
Surg. 1999;30:985–995.

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Organized Medicine and

Lifelong Learning

...
The AAMC believes that specialty societies and spe-
cialty boards are best able to assist physicians in their
efforts to maintain their clinical competence.
J ORDAN J. C OHEN , M.D. 1

P hysicians in the United States have unprecedented educational

resources from county, state, and national medical organiza-
tions, and particularly specialty societies. County societies sponsor
computer bulletin boards, chat rooms, legislative updates, and, often,
short reviews of important medical studies. State associations provide
in-depth information on current state and national medical legislation
and ethics, and may offer help and advice to impaired physicians and
those with other such problems. Dennis Wentz addressed the issue of
organized medicine: “Despite diminishing membership, city, county,
and state medical societies still serve a valuable purpose. Unlike the
major specialty societies, which convene a single annual meeting,
city and county medical societies meet at least monthly and promote
collegiality to all members. In an address to the Canadian Medical
Association, Osler highlighted these assets: ‘By no means the small-
est advantage of our meetings is the promotion of harmony and good
fellowship. Medical men, particularly in smaller places, live too much

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apart and do not see enough of each other. In large cities we rub each
other’s angles down and carom off each other without feeling the
shock very much, but it is an unfortunate circumstance that in many
towns the friction, being on a small surface, hurts; and mutual misun-
derstandings arise to the destruction of all harmony. As a result of this
may come a professional isolation with a corroding influence of a most
disastrous nature, converting, in a few years, a genial, good fellow into
a bitter old Timon, railing against the practice of medicine and his
colleagues in particular.’ ”2
The American Medical Association (AMA) has taken the lead in
establishing quality standards for continuing medical education
(CME). In 1955, the AMA began evaluating institutions offering
“postgraduate medical education,” as it was then known, and the
major postgraduate/CME activities that met the standards were listed
in The Journal of the American Medical Association (JAMA). Now, a
major change is underway, with CME encompassing lifetime learning
for all physicians in a rapidly changing environment. In September
1999, the AMA’s Division of CME became the Division of Continuing
Physician Professional Development, a change that may dismiss the
notion that continuing medical education is limited to lecture courses
and conferences. Physician development comprises many concepts
beyond teaching and learning, including emphasis on professional-
ism, patient outcomes, population-based medicine, office manage-
ment, and physician leadership.
The National Medical Association (NMA) began in 1895 as a
major provider of continuing medical education for African-
American physicians. Its culture-sensitive educational activities at
annual scientific assemblies and at regional, state, and local society
meetings stress diseases common to African-Americans. The an-
nual assembly includes 25 specialty programs with a nationally
renowned faculty from such institutions as Howard University,
Meharry College, and Morehouse College. William Matory, Director
of Continuing Medical Education for NMA, believes that “The cul-

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tural atmosphere provides African-American classmates, friends,

and former teachers with opportunities for leadership in a particu-
larly salutary environment.”

N AT I O N A L M E D I C A L O R G A N I Z AT I O N S
Most specialty societies were founded to foster quality medical care
by setting standards and providing education. The American Col-
lege of Physicians (ACP), for example, was founded in 1915 to
uphold the highest standards in medical education, practice,
and research for internal medicine. The American Academy of
Orthopaedic Surgeons (AAOS) formally endorsed a lifelong commit-
ment to continuing education as essential for its fellows, issuing an
“Advisory Statement” in 1991 (updated in 1996) on the “Commit-
ment to Excellence: Maintaining Skills and Knowledge Through
Lifelong Learning.” The American Academy of Family Physicians
(AAFP), founded in 1947 to promote and maintain higher standards
for family physicians providing continuing comprehensive health-
care, was the first to set standards for, and to require, CME for its
membership. Its three-pronged approach includes producing a vari-
ety of CME formats designed to meet members’ needs and prefer-
ences, maintaining detailed records of individual members’ CME
activities, and, in 1948, establishing its own system of identifying
and accrediting programs relevant to family physicians. This system
will soon incorporate evidence-based medicine into CME accredita-
tion for family physicians.
Medical societies have fulfilled their pledge to support their
members by providing more quality educational products and oppor-
tunities. Changes are evolving so rapidly that the educational prod-
ucts described here may be improved and retitled within a few
months or years, but the principles and commitment to lifelong learn-
ing will remain. Physicians should take advantage of the extraordi-
nary opportunities now available.

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All specialty societies have annual sessions featuring a wide

variety of learning formats, including lectures, panel discussions, de-
bates, scientific and technical exhibits, poster exhibits, and multime-
dia education (videotapes and computer instructional programs).
Meet-the-professor sessions permit fairly close contact with experts.
Often available are hands-on training in computer skills and practice
sessions on clinical skills, such as physical examinations, skin biop-
sies, arthrocentesis, and the opportunity to “work up” a live standard-
ized patient. All annual sessions provide extensive commercial
exhibits of state-of-the-art diagnosis, therapy, and practice manage-
ment for many conditions. The American College of Cardiology’s An-
nual Session includes “Spotlight Sessions,” with intensive instruction
in such subjects as echocardiography, interventional cardiology, and
clinical cardiology, and ends with a wrap-up discussion of “Meeting
Highlights.” Annual meetings of many specialty societies include
late-breaking reports of clinical trials.
Since the wide variety of offerings at the annual session can be
overwhelming to new attendees, they should select in advance which
sessions to attend and make an hour-by-hour schedule to prevent
wasting significant time wandering around a large convention center.
The Web sites of many specialty societies now allow scanning and cre-
ating a personalized meeting schedule. Reading the abstracts, usually
provided in advance, and framing specific questions to ask are helpful.
If your questions are not answered during the formal presentation,
there is usually time to question the speaker during a designated pe-
riod or directly after the session. For maximum profit, take notes and
review them at the end of the day to ensure legibility and comprehen-
sion. Discussing content with a colleague at the meeting or after re-
turning home will further solidify the newly acquired information.
From 1991 to 1999, The American College of Physicians oper-
ated a “College within the College,” which used small groups to en-
hance learning. Eight to 10 physicians would meet each morning of
the annual meeting and determine which sessions each member
would attend. At lunch and in the early evening, members of each

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group would discuss the presentations they attended, giving each the
advantage of multiple sessions. Moreover, the collegiality thus estab-
lished converted a large, sometimes impersonal, meeting to a friendly
and enjoyable activity. Physicians can, of course, form their own in-
formal groups to share information and interact with colleagues.
Specialty societies have expanded their educational activities be-
yond their flagship annual session. In addition to regional meetings or-
ganized jointly by the society staff and local physicians, most societies
publish a peer-reviewed journal. Many offer audiotapes (pioneered by
Audio-Digest) and videotapes, as well as self-assessment programs of
study material and test questions in print or on compact disks (CD-
ROMs). The American Academy of Orthopaedic Surgeons offers a
dozen self-assessment programs—one in general orthopedics and sev-
eral in specialized topics, such as the shoulder and sports medicine.
The American College of Physicians–American Society of Internal
Medicine (ACP–ASIM) has supplemented its printed Medical Knowl-
edge Self-Assessment Program (MKSAP) with an Audio Companion
featuring a general internist discussing highlights of the program with a
leading subspecialist. Self-assessment programs, which provide an op-
portunity to keep abreast and to review basic principles, provide excel-
lent preparation for recertification board examinations.
Many societies provide interactive programs on CD-ROMs: the
physician is presented a case study and allowed to answer questions
by selecting diagnostic and therapeutic choices. Also available are
audiovisual libraries containing slides, audiotapes, and videotapes.
The American Academy of Ophthalmology (AAO) produces Focal
Points, a subscription print series of practical applications of re-
search, and Ophthalmology Monographs, a text series on clinical
skills in specialized topics. The AAO also cooperates with other spe-
cialty societies to produce teaching materials for medical students
and practicing primary-care physicians. The American College of
Obstetrics and Gynecology offers numerous educational opportunities
to enhance the development of healthcare professionals in all aspects
of women’s healthcare.

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Some societies have learning centers at their headquarters. The

Heart House of the American College of Cardiology in Bethesda,
Maryland, has exceptional audiovisual capabilities, as well as spe-
cially designed chairs with built-in response systems that allow
physicians to answer multiple-choice questions. The AAOS conducts
surgical skills programs at its headquarters, where physicians can
practice techniques using cadaver specimens or bone models with the
hand tools and power tools provided. The Orthopaedic Learning Cen-
ter was jointly developed and funded by the AAOS and the
Arthroscopy Association of North America, which coordinate sched-
uling their respective courses, primarily on weekends. The AAOS is
beginning virtual-reality demonstrations and investigating the devel-
opment of a knee arthroscopy simulation that would provide experi-
ence indistinguishable from the actual procedure.
Medical societies are embracing the Internet to disseminate infor-
mation to physicians as well as the general public. Numerous formats
are offered, including case presentations with discussion as well as di-
dactic lectures, often from the annual meeting. Frequently, societies
offer monographs, short quizzes, and online CME. The AAOS offers
various images: plain radiographs, CTs, MRIs, and arthrograms. The
Academy of Family Physicians emphasizes the “Case of the Month.”
The American Academy of Pediatrics (AAP) Web site presents spe-
cialty news, guideline endorsements, treatment recommendations, and
AAP policy statements on many diagnostic, therapeutic, and societal
issues related to pediatric care. The American Academy of Ophthal-
mology’s Web site features an Online Education Center that offers
short courses, self-assessment cases, selected annual meeting lec-
tures, and reviews of recent research in major ophthalmology topics.
The American College of Physicians–American Society of Internal
Medicine offers Clinical Problem Solving Cases for CME credit, An-
nals of Internal Medicine online (http://www.annals.org), and a Web
site for patients (http://www.doctorsforadults.com). It is a safe bet that
societies will continue to expand online educational opportunities.

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The American College of Cardiology is exploring methods to as-

sist individual physicians in self-directed, practice-oriented educa-
tion, including the development or adoption of tools to help define
and address educational needs. Databases are being developed to
help physicians pose specific clinical questions at the point of care
and retrieve brief answers from practice guidelines and other sources.
Other information, such as case studies, self-assessment questions,
journal articles, and slides from lecture presentations, will also be
available. The goal is to provide brief answers to immediate questions
as well as in-depth study materials that the physician may review at
another time.
These are just a few examples of effective educational products
and aids available from medical societies. The programs are directed
by practicing and academic physicians with the help of the societies’
experienced, full-time staff members. In recent years, societies have
become more involved in political and ethical issues affecting their
specialty, but the dedication to aiding physicians in lifelong learning
is intensifying, not waning. Future directions posited by the Ameri-
can Board of Medical Specialties and the consequent planning activ-
ities of several member boards indicate that recertification will
emphasize the lifelong learning of individual physicians.

REFERENCE
1. Cohen JJ. Association of American Medical Colleges Memo-
randum #00-32, issued 2000 Jul 31.
2. Osler W. The growth of a profession. Presidential address,
Canadian Medical Association, Chatham, Ontario, 1885
Sep 2. Can Med & Surg J. 1885;14:129–155.

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 REFLECTIONS / DENNIS K. WENTZ, M.D.

R E F L E C T I O N S
...

The first benefit of medical society membership is to

provide collegial camaraderie, to get us connected with
peers and associates outside our usual sphere of inter-
action.
D ENNIS K. W ENTZ , M.D.

D r. Dennis Wentz has had a lifelong interest in the values and stan-
dards of medicine. Stimulated by his professors at the University of
Chicago, he trained in internal medicine and gastroenterology but
moved from clinical and academic pursuits to a career in medical
management. He strongly believes that physicians must hold senior
administrative positions in academic medical institutions and that
they must be educated to fill such roles. After further studies in
health systems management, Dr. Wentz became the medical director
of two university hospitals and a senior administrator in another aca-

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demic center. In 1988, he accepted an invitation from the American

Medical Association (AMA) to lead its program on Continuing Med-
ical Education (CME), later renamed Continuing Physician Profes-
sional Development (CPPD). Using the mechanism of the AMA
Physician’s Recognition Award, the AMA has broadened the concept
of CME to recognize individual learning by physicians in the larger
context of continuing professional development.
In January 2002, Dr. Wentz received the Distinguished Service
Award in CME from the Alliance for Continuing Medical Education
in recognition of his lifelong service to the field of CME as a CME
professional, a national policy maker, and a proponent of collabora-
tive CME efforts, which have now been extended internationally.
More recently, Dr. Wentz has spearheaded a national effort to create
awareness among physicians and industry representatives of the
ethical guidelines developed by the profession to address the issues
of gift-giving by industry to physicians.

380
 Medical Organizations
and Professionalism

Dennis K. Wentz, M.D.

Director, Division of Continuing Physician Professional Development
American Medical Association
Chicago, Illinois

关N兴o physician has a right to consider himself as be-

longing to himself; but all ought to regard themselves as
belonging to the profession, inasmuch as each is part of
the profession; and care for the part naturally looks to
care for the whole.
W ILLIAM O SLER 1

A s a medical student, and even as a house officer, I rarely consid-

eered belonging to organized
v medicine. None
e of my professorsr
mentioned it. But I was dutiful and perhaps a bit excited when
Theodore E. Woodward, Professor of Medicine and my mentor at the
University of Maryland, encouraged me to accompany him to a meet-
ing of the Baltimore City Medical Society. At that time, the meetings
consisted of a scientific program followed by a reception, responsibil-
ity for the scientific program alternating between the University of
Maryland and Johns Hopkins medical schools. Because the meetings
were at the headquarters of the Medical and Chirurgical Faculty of
Maryland, I saw for the first time the extensive and historically im-
portant library of the Faculty and the frequency with which members
used it. The portraits of famous Maryland physicians hanging in the
hallways were both fascinating and humbling. But it was my initial
exposure to the practicing physicians, as well as the tough questions
and high quality of the scientific discourse, that impressed me most.
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Thus, when I joined the faculty at the University of Maryland, it

wasn’t difficult to decide to join the medical societies, even though
the dues seemed high to a young assistant professor. Although my ob-
jectives may have been unclear, my membership proved salutary. Par-
ticularly at the monthly meetings, I benefited from getting to know my
colleagues and learning what all the real issues were, not just those in
academia. Although the scientific programs were good, I inevitably
learned more in the hallways than in the sessions. Society activities
brought new knowledge about the practice of medicine: I came to un-
derstand, and even influence, our organization’s policies. Osler was
correct when he said: “No class of men need friction so much as
physicians; no class gets less. . . . [T]he medical society is the best
corrective, and a man misses a good part of his education who does
not get knocked about a bit by his colleagues in discussions and
criticisms.”1
The first benefit of medical society membership is to provide col-
legial camaraderie, to get us connected with peers and associates out-
side our usual sphere of interaction. Whether in a general medical
society, where we can learn from all the medical specialties, or in our
own specialty societies, the sharing of information, ideas, problems,
and opportunities is a significant part of continuing education.
The second benefit of a medical society membership is to keep us
aware of new developments and new information at the cutting edge of
medicine. Without a constant dose of such information, no one can
deliver the quality of healthcare required by colleagues and patients.
To those who discount continuing education’s impact, ask yourself:
Are you practicing the medicine taught in formal education and train-
ing five years ago? Has any clinician failed to make significant
changes in daily practice as a result of new knowledge and skills?
A third benefit of our medical societies is a commitment to pro-
fessionalism, including the promotion of standards of education and
quality assurance to society at large. In this regard, acknowledgment
is due the prestigious journals sponsored by medical societies. Physi-
cians, on average, report reading five to seven hours a week, much of

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it in medical journals, a key source of continuing education. Increas-

ingly, societies are turning to the Internet to disseminate information.
In print or online, these publications inform physicians of new med-
ical developments.
Another important contribution of the medical societies can be
best identified as advocacy. In the radically changing environment of
medicine over the past 20 years, societies have interceded on behalf
of practicing physicians locally and nationally.
Medical societies provide instruction in leadership, negotiation,
and management skills. The American Medical Association (AMA)
critically reviews the scientific aspects of medicine, and, through its
Institute of Medical Ethics, has sponsored major educational pro-
grams in end-of-life care. The AMA Council on Ethical and Judicial
Affairs determines the code of ethics for the profession.
The aggregate output of our medical societies on behalf of all of us
who practice medicine is considerable. The rest of the world looks to
this country for the ideal in educational and practice standards.

REFERENCE
1. Osler W. The functions of a state faculty. In Bryan CS. Osler.
Inspiration from a Great Physician. New York: Oxford Univ
Press; 1997:50.

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 15

Women Physicians

...
Man may work from sun to sun,
But woman’s work is never done.
A NONYMOUS

T I M E P R E S S U R E S F R O M M U LT I P L E R O L E S

T he Association of American Medical Colleges reported that in

1977–1978 women graduates of U.S. medical schools repre-
sented 21.4 percent of the class; by 1999–2000, that figure had risen
to 42.5 percent. If this upward trend continues, women will constitute
the majority of the medical profession within the next few decades.
Unless the roles of men and women change dramatically, women
physicians will continue to have more difficulty than men in finding
time for continuing education. Because women often have multiple
roles as physician, wife, mother, and homemaker, they must set prior-
ities, especially in assigning time for education, sometimes at the ex-
pense of recreational activities. Fortunately, a balancing trend is
occurring in the United States, with men taking a more active role in
household duties and child-rearing. And more working couples with
children are relying on outside help from relatives or nannies.

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The techniques and resources to facilitate lifelong learning in

medicine are the same for men and women. In this chapter, women
physicians describe how they manage their multiple duties.
Jacqueline Miller believed that early in her career she faced a
larger problem than women have today, since mores have changed
somewhat. But when she questioned younger associates and friends
who work in other occupations, she concluded that women with
homes and families generally have more responsibilities than their
husbands. “Even when the husbands help,” she explained, “the daily
responsibilities for the home and the family continue to rest largely
with the wives. A woman physician’s attention is divided between
practice and home, whereas a man’s primary concern is his practice
and only secondarily duties in the home. This situation may lead
women to feel conflicted, and the stress becomes more acute when
they have children who are having problems.”
Time is the major problem women physicians face, according to
Marjorie Price Wilson. “They do more than full-time housewives in
the same socioeconomic circles. When they enter medicine, women
often do not abandon any of the traditional roles of mother and house-
hold manager. As I look back on my life, I realize that although my
husband shared the time with the children, I actually spent more time
than he did with them while never compromising my professional du-
ties. His life would have been the same if I had been a full-time
housewife. I maintained a fairly traditional lifestyle at home; even
with a great deal of good help, I still managed the ‘helpers’ and the
household. Most women who assume multiple roles, regardless of
their profession, perform them all with great intensity. Some profes-
sional men, on the other hand, may feel a greater intensity about their
profession than their family responsibilities.”
Laurel Weibel traces the difference between men and women
physicians in this regard to the fact that few women can go home from
their medical offices and relax—read journals, listen to the radio, or
watch television. “There are always meals to prepare, children to
counsel, and after-dinner chores to do. Even when there is an evening

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meeting to attend, the family must first be fed. And in the morning,
babies have to be bathed and fed, or lunches have to be made.”
This “time-vise” has troubled Eileen Duggan. “Being locked into
a schedule makes me feel as if I am compressing my professional and
private spheres too much. Medicine can be extremely seductive, es-
pecially to someone who likes to think of herself as indispensable.
Because of the wear-and-tear on my physical and mental health, I
have had to set priorities in my work. Mornings with my children are
special times, and so I do not attend early rounds, even though my as-
sociate does. I make my commitments at work very specific and man-
ageable. I also schedule three to five meetings each year for
education. Most are two- or three-day meetings and are inspiring and
invigorating. Getting away for a fresh perspective is necessary, I be-
lieve. Women physicians should not begrudge paying part of their
earnings to another person to do housework. My friends who insist on
doing their own housework seem dissatisfied with themselves unless
it is done perfectly.”
Women physicians are vulnerable to interruptions by husbands,
children, and household responsibilities, and this vulnerability makes
it difficult to establish a “do not disturb” period. Whereas men physi-
cians face interruptions from medical emergencies, women face inter-
ruptions from multiple sources.
There is still great reliance on women for housecleaning, cooking,
laundering, and shopping, observed Lailee Bakhtiar. “Few husbands
want their day interrupted by household chores. A live-in housekeeper
can help with some of these tasks, but this is only a partial solution.
Housekeepers quit, children get sick, and the final responsibility for
organizing usually falls on the wife. Organization, strength, and a
spouse willing to share duties can all help.”
Karin Jamison also sees multiple roles as a major problem. “Add
to the list any personal interest the woman has outside of medicine
and her family, and the demands on her time and energy pose a real
conflict. Only the housekeeper role can be delegated, not that of the
‘homemaker.’ A responsible male physician will also have conflicts if

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he takes his roles as father, husband, son, sibling, friend, and neigh-
bor seriously, but the role of physician is superimposed on the roles of
husband and father, since a traditional aspect of both the latter has
been to be a good provider. So he does not experience the same ‘short-
age’ of time or the same degree of inner conflict. For a woman physi-
cian, fatigue is a constant companion.”
Motherhood complicates the matter. Lailee Bakhtiar sees flexibility
and physical well-being as two desirable qualities of a woman physi-
cian. “A pregnant woman can work until delivery, and her husband can
be supportive, loving, and helpful, but the man married to a woman
physician pays a toll as her professional life and the size of their family
grow. The difficulty in striking a balance probably accounts for the high
divorce rate among women physicians. An extended family, with a solid
bond among parents and in-laws, can help with problems arising from
the mother’s absence when she is at meetings or work.”
During pregnancy, Linda Shortliffe had some physical incapacita-
tion, but it did not affect her daytime work. “I worked up to the time
of the delivery and was not bothered much by pregnancy, but I was
not as efficient in reading and writing in the evenings. I took four
weeks off after delivery and found it difficult to return to work after
that. Being physically present in the hospital during the day was not a
problem, but the chronic fatigue from rising every two to three hours
for nursing was. It was difficult to find opportunities to freeze breast
milk during the first several months after I returned to work. During
that time, many routine home chores, such as laundry, cooking, gro-
cery shopping, and housecleaning, were taking valuable time from
our baby. As a result, we employed a live-in ‘nanny’ and delegated
some of the household chores to her so that we could have more time
with our child and still fulfill our professional responsibilities.”

Interruption of Practice by Childbirth and Child-rearing

For six years, while Karin Jamison’s children were in high school, she
closed her private practice and worked only two days a week at an Air

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Force Base outpatient clinic. “Because I was free of the heavy re-
sponsibility of a solo family practice, I was able to attend many med-
ical meetings. The patient contact at the Air Force Base helped me
maintain my clinical skills, although I had no acutely ill patients to
care for at that time. When I returned to private practice, I wanted to
do emergency medicine and so took some intensive courses in that
field. I also studied a great deal on subjects for which I knew I would
have responsibilities.”
When Jacqueline Miller had a child just a few weeks after she
completed her residency, she stayed away from work for a year. “I en-
joyed my child and did not keep up with medicine, so I found it very
difficult when I went back. I don’t think I did any of it quite right. I
would now recommend that a woman do everything possible to main-
tain her intellectual activities and her contact with medicine. You can
get out of touch in a year. One thing that helped me catch up was that
I had not yet taken my clinical pathology boards. I settled down and
prepared myself for them, spending the better part of a year in inten-
sive study. I did my studying after the baby went to bed. During that
time I had household help and considered it a wise investment.”
Kit Chambers sums up her successful career as an anesthesiologist:
“I did not marry until seven years after graduation from medical school;
I was out of residency and getting ready to take anesthesia boards. Hav-
ing a husband in academic medicine prompted me to enter private prac-
tice because academic salaries were less than adequate at that time. I
had expected my working hours to be more flexible than they were, but
my work in the group practice was a joy. Several coworkers were of my
age and had similar training. The San Fernando Valley population was
increasing by 1,000 a day, so the demand for medical services was high.
We worked long hours at 10 hospitals, and attended University of South-
ern California or University of California at Los Angeles weekly Grand
Rounds. The group was well-organized, and everyone except the older
physicians was Board-certified.
“Before our first child was born, I hired a nanny who stayed with
us for three years. A wonderful lady became our substitute grand-

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An understanding husband is of inestimable help to the

woman physician.
Dame Sheila Sherlock, M.D. (1918–2002)
Former Emeritus Professor.
The Royal Free Hospital, London, England

mother, filling in for the nannies when necessary. Our last nanny left
us when both children were teenagers, and I stopped working so I
could assume the childcare and carpooling. I have never regretted the
time that I was a stay-at-home mother.
“When the children were away at college, I returned to work in
the County Health Services. It was not easy. Anesthesia had contin-
ued to change rapidly, with an amazing array of new agents, tech-
niques, and equipment. I was fortunate to have several mentors who
helped me.
“I cannot think of another profession that gives such a sense of
service to humanity and continuous personal satisfaction for doing
your best in your daily work. The patients reward you with gratitude

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and trust. Pediatric patients are a bonus. It also helps to have good
health and boundless energy. Support from your husband is essential,
and I was fortunate to have that. We took the children on vacations to
medical meetings, which they described as magical times. Neither
child considered having two working parents a problem, but were
pleased to have another adult available for care and counseling.”
Because Barbara Buchanan’s third child had a congenital anom-
aly requiring surgery and a prolonged recovery period, she took off six
months from medicine. “I never thought it was difficult to ‘keep up’
during the months I took off, or to ‘catch-up’ once I started practicing
again. If anything, I had more time to read journals and books during
that time.”
Some women physicians do not take time off for childbirth. Susan
Tully went back to work within a couple of weeks after her children
were born. “I paid people to care for the children and was never out
any longer than my scheduled vacation.”

ENLISTING SUPPORT
“The first thing a young woman physician with a family needs to ac-
knowledge,” in Jacqueline Miller’s view, “is that she cannot do every-
thing herself and do it as well as she would like. Physicians in
general, and women physicians in particular, are perfectionists, and it
is difficult to acknowledge that you are not going to be superb in all
your efforts; there is simply not enough time. You must accept your
need for help. My own solution has been to recognize that I will not
have as much spendable income as I might expect because I must
employ help. Economizing on household and babysitting help is a
mistake. The woman physician may also want to spend a few more
hours a week at the office or hospital than a man, since she can do
some of her studying there. I can get a lot done from 5:00 to 6:00 p.m.,
or from 5:30 to 7:00 p.m., whereas when I go home, I get little or no
work done. Sharing the responsibilities at home with others as much
as possible is very helpful.”

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Success in juggling multiple roles depends on the ability to dele-

gate, according to Joan Hodgman: “Some things require the woman’s
full attention, whereas some can be performed by others. I firmly be-
lieve in child labor at home, so my daughters always had household
chores. More important, however, most household tasks can be per-
formed by employees. I was fortunate in having a graduate of the Uni-
versity of California at Berkeley as a housekeeper for 21 years. As the
children grew, she drove them to after-school lessons and other activ-
ities. Admittedly, I was fortunate, but I paid her twice as much as my
colleagues paid their helpers, and she was worth pearls and rubies.
My husband complained about her salary until one Saturday when I
left him home with our year-old daughter. After six hours of trying to
paint some furniture while caring for one small child, he never com-
plained again. Good household help meant that I could go to the hos-
pital reassured that all was well at home.”
Of paramount importance to Alice Bessman, when one’s children
are young, is strong family support (grandparents) or reliable full-time
help—someone to be home during the illnesses of children, at the
end of the school day, and for errands. “After my training, I did not
work full-time until the youngest child was in junior high school.
Until then, I worked half-time or less.”
Career women need to have realistic expectations for the home,
according to Bernice Brown. “To me, being a career woman means
settling for standards at home that are not the highest but are accept-
able. I try not to look in corners or under beds.” Genevieve Burk
agreed: “To attempt to satisfy one’s mother-in-law regarding house-
hold duties is folly. Mine once expressed dismay that I did not save
my grease to make soap! Set priorities and stick to them.”
Gail Clark identified three major parts of her solution: “(1) a true
partnership with your husband at home concerning all duties (house
and children), (2) working in an academic setting where lectures and
day-to-day conversations with interns, residents, and colleagues keep
you in touch with prevailing ideas in your specialty, and (3) setting
your priorities and realizing that you cannot be an A-1 wife, mother,

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and physician everyday, but that your best should be satisfactory for
you, your family, and your patients’ well-being. You are not an island,
and there is backup all around you if you will accept it.”
“Those who combine marriage and medicine have a very difficult
time meeting the needs of both,” said Ruth Bain. “Some do it, but it
isn’t easy. It requires an understanding husband who is willing to
share what is usually seen as women’s duties.” Dame Sheila Sherlock
agreed: “An understanding husband is of inestimable help to the
woman physician.”
Joan Hodgman concurs, “It is often said that behind every suc-
cessful man is a helpful woman. Conversely, behind every successful
married career woman is a confident husband who takes pride in her
success and helps with the housework.”
For Maureen Sims, “Choosing a housekeeper is very important
and deserves top priority. I would advise my colleagues to interview
several candidates and be prepared to pay top dollar for the type of
services they expect. Above all, you must be able to communicate ef-
fectively with the housekeeper. Many unpleasant situations with long-
term ramifications can develop if inappropriate choices are made,
especially in the early developmental phases of child-rearing. In such
cases, if difficulties cannot be resolved, it may be necessary to dis-
miss the housekeeper and start over. If your own employer is not un-
derstanding, it can lead to frustration. Fortunately, my boss and my
colleagues had been in similar situations and understood.

C O L L E G I A L R E L AT I O N S H I P S
“I enjoy the exchange of ideas and discussion of interesting cases with
colleagues in the surgery lounge,” said Laurel Weibel, “and have never
felt excluded because of my sex. I am frequently assigned to commit-
tees to investigate female problem-physicians because ‘You’re not so
prone to be vindictive or biased’ or ‘You can be the devil’s advocate.’ ”
Jacqueline Miller has obtained support from belonging to a colle-
gial group. “If you are in a group, you never feel alone, and you learn

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Trying to do my best forces me to be curious, to reeval-

uate constantly, and to learn.
L INDA D. S HORTLIFFE , M.D.
Professor and Chairman, Department of Urology
Stanford School of Medicine, Stanford, California

how to have a productive relationship with your peers. I have practiced

with only an occasional woman physician, so I have had little experi-
ence with the ‘old girl’ network. I have not felt any direct prejudice from
men, although on occasion I have observed some reservations about
women in medicine. If you sit back and relax, however, it goes away.”
Linda Shortliffe, practicing in the male-dominated specialty of
urology, has not had any specific collegial difficulties. “My best profes-
sional relationships have been with residents with whom I have worked.
Probably the most important professional advantage has resulted from
interactions with a male faculty mentor, who, fortunately, appears to
have overcome the traditional ideas about women in surgery.”

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In Ruth Bain’s experience, you become a full participating mem-

ber of the ‘old boy’ network by doing your best at every committee or
other assignment. “Some young women seem convinced that they will
not be accepted or allowed to participate in organized medicine; that
simply is not true. We tend to find what we look for; in expecting
problems, many young women create them.”
“Although career, marriage, and children impose great stresses on
a woman’s time and energy,” Joan Hodgman strongly recommends join-
ing, and being active in, medical organizations. “As my family duties
declined, I was able to assume more responsible roles in medical
organizations. This has proved most rewarding, not only educationally,
but also in allowing me some influence on the profession I love and in
expanding my circle of colleagues in the community, state, and nation.”

THE SINGLE WOMAN–PHYSICIAN

Kit Chambers observed that “Single women can devote more time to
their work and have more leisure time to develop hobbies.” Marjorie
Price Wilson agrees: “The single physician can plan more effectively.
When you have a family, you must set priorities; that is the dilemma.
On the other hand, the single woman may miss the joys of having
children and a family.” Although unmarried men and women should
be able to organize their continuing education more efficiently, moti-
vation is a highly individual matter, and they may not always do so.

S AT I S FA C T I O N F R O M M U LT I P L E R O L E S
The time demands described by the women physicians interviewed
lead to the question: “Is it worth it?” The following represent typical
responses from our interviewees.
“Looking back over 50 years of my medical career,” Joan Hodg-
man reminisced, “I have found it extremely rewarding. My friends ask
why I am still working, and I can honestly answer that I am working
for fun. Earlier in my career, the care of individual infants was my

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focus. At this stage, I am conducting research about pathophysiology

and treatment of groups of infant patients. I also enjoy working with
students and young physicians-in-training. Some of their enthusiasm
rubs off. One of the unsung benefits of a medical career is the oppor-
tunity to continue working in a stimulating environment after the ear-
lier demands of marriage and family have been met.”
“Professional activities such as clinical teaching and participa-
tion in professional organizations expose you to new experiences,
people, ideas, and aspects of life outside medicine,” said Bernice
Brown. “If you believe that we have only one ‘go-round’ in life, it
makes sense to pack in as much as possible and make it as mean-
ingful as possible in the time we have. Being a professional woman
leads to a hectic, busy, often overextended life, and a woman physi-
cian must strive to save moments for herself so she does not become
a machine. A medical career is fulfilling and stimulating, but being
a homemaker and having children are also fulfilling, although when
the children grow up and lead their own lives, it creates a void for
the woman who has dedicated herself solely to her children. A pro-
fession, on the other hand, can provide a feeling of self-worth, of
making a contribution to society, and of keeping the brain cells
working.
“A real source of pleasure in being a physician, wife, and mother
is that your children and husband are proud of your accomplishments
and let you know it now and then, in sometimes amusing or offhand
ways. They do not treat you like a ‘has been’ or someone not to be
reckoned with, as many children seem to treat parents. Once, after I
repaired a deep laceration on my 13-year-old daughter’s ankle in a
backwoods place where we were vacationing but where there were not
good medical facilities, she turned to me and said, ‘Say Mom, you’re
not a half-bad doc.’ ”
The human element is the most rewarding factor in the medical
career of Kit Chambers. “I enjoy helping and caring for people. Al-
laying their anxiety is a large part of my contact with patients, as well
as explaining what they can expect from me.”

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For Beverly Gregorius, the practice of medicine is the best thing

that ever happened to her—with the exception of marrying her hus-
band and having her daughter. “One cannot have a better mood-
elevator, energizer, or ego-builder than seeing patients. They are
always glad to see me and are fond of me as their physician. I can’t
imagine anything more interesting, exciting, and fulfilling than the
practice of medicine.”
When Karin Jamison’s four children were grown and almost out of
college, she was practicing from 24 to 48 hours a week in an emer-
gency room. “This was far and away the happiest time in my profes-
sional life because the sometimes agonizing conflict between the
legitimate demands of my family and my medical career was over.
The benefit of the busy life women physicians lead is that they can re-
alize their intellectual, physical, emotional, and creative potential in
a way few others are privileged to do. I would here acknowledge that
our dear husbands play a vital part in facilitating this. And, if one has
an intrinsic interest in medicine and people, all the effort is richly
rewarded.”
Linda Shortliffe has enjoyed several benefits from the lifelong as-
sociations made through her medical career: “It is gratifying to attend
meetings and recognize old friends and acquaintances with whom I
can discuss research ideas or academic problems. In addition, there
is a fulfilling relationship with residents and young people. Perhaps
the most important satisfaction is a constant association with new
ideas, and later seeing those ideas turned into action. It is exciting to
see hypotheses become research protocols for experimental studies
and later have them accepted as facts or routine treatments. Partici-
pating in the evolution of ideas is most gratifying.”
Shortliffe reports a number of changes in her life since the publi-
cation of the first edition of this book. In 1995, she assumed the
chairmanship of the Department of Urology at Stanford and was di-
vorced in 1997. She believes that all events influence her thinking
and her approach to learning: “Over the past few years, I decided that
my impetus for learning is not that I work in medicine, but rather a

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simple desire to perform to the best of my ability, unlimited by ‘good

enough’ as a goal. Trying to do my best forces me to be curious, to
reevaluate constantly, and to learn. I have been told that ‘nothing is
ever good enough for you,’ and that may be correct. Just because I
have found ‘an answer’ does not mean that I will stop looking for, or
learning about, other or better answers. I believe that people and con-
ditions can always improve, usually through new information. From
this perspective, I am optimistic about, not dissatisfied with, condi-
tions and people. My original goals have always been limited by
childhood ideas. As I have changed, readjusted my goals and plans,
and taken some risks to accomplish my responsibilities, I have con-
stantly required new information. Watching my residents, faculty, and
others, I have learned that inflexibility is probably the greatest im-
pediment to continued learning. The most dogmatic are the least
likely to continue to learn or contribute to learning. The correct an-
swer at one time may later be wrong.”
As Jacqueline Miller looked back over the past several decades,
which included years of postgraduate training and practice, she found
that she had been extremely happy in her choice of medicine as a pro-
fession. “Each day has been stimulating and interesting, full of intel-
lectual challenges and interesting cases. My professional associates
and companions have been intelligent, motivated by concern for their
fellow man, and compulsive in their desire to excel. This kind of as-
sociation is well worth the sacrifices. The most difficult problem is
the inability to do as much as you would like for and with your family,
which leads to a pervasive sense of guilt. The variety of experiences
from combining a marriage and family with a career is nonetheless a
satisfying life.”
In Alice Bessman’s view, academic advancement should not be
the physician’s only goal. “An oft-heard dissatisfaction is that women
do not advance as rapidly as their male colleagues. In many cases,
however, outside distractions may limit productivity. The contribu-
tions to the social structure in general and to the family in particular

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should more than outweigh this lack of academic advancement. My

satisfaction from having contributed to increased medical knowledge
and to the replenishment of the younger generation of physicians is
satisfaction enough.”

*****

Since many women physicians have more diverse responsibilities

than men physicians, they may feel time pressures more acutely. Or-
ganization of time and development of efficient study methods are
therefore even more critical for women in medicine. All the women
physicians we interviewed agreed that it is mandatory to rely heavily
on outside or extended family help for household tasks and child
care. A woman physician who marries would do well to discuss with
her prospective husband the time difficulties that are certain to occur
so as to come to a mutual agreement in advance. If the woman physi-
cian plans carefully, sets realistic goals for each of her roles, and ac-
cepts competent household help to permit the best use of her time, a
medical career can offer her great opportunities for service and ful-
fillment. This rich professional life can go hand-in-hand with an
equally rewarding personal life, one enhancing the other.

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 REFLECTIONS / NORA GOLDSCHLAGER, M.D.

R E F L E C T I O N S
...

I always wanted to pull my own weight, never to receive

concessions because I am a woman.
N ORA G OLDSCHLAGER , M.D.

Dr. Nora Goldschlager, Associate Chief, Division of Cardiology and

Director of the Coronary Care Unit, ECG Laboratory and Pacemaker
Clinic at San Francisco General Hospital, received her M.D. degree
from New York University School of Medicine, her residency training
in internal medicine at Montefiere Hospital Medical Center and
Henry Ford Hospital, Detroit, Michigan, and her cardiology training
from Wayne State University in Detroit and the Presbyterian Hospi-
tal/Pacific Medical Center in San Francisco. She has received honors
as a gifted teacher and cardiovascular specialist.
Dr. Goldschlager has served on the editorial board of the Amer-
ican Journal of Cardiology, American Journal of Geriatric Cardiol-

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ogy, and the Journal of Interventional Cardiac Electrophysiology. A

Fellow of the American College of Cardiology and American Col-
lege of Physicians and a member of the Council on Clinical Cardi-
ology of the American Heart Association, she is the author or
coauthor of more than 147 peer-reviewed publications, 15 book re-
views, and 10 books.

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 Triple Careers:
Physician, Wife, Mother

Nora Goldschlager, M.D.

Professor of Clinical Medicine
University of California at San Francisco
San Francisco, California

S ince the age of seven, I have wanted to be a cardiologist, and my

ambition never wavered except for two weeks in college when I
thought perhaps I would get a Ph.D. in philosophy and then teach. I
married a medical student who liked independent women, and we post-
poned having children until my fellowship was almost completed, since
I did not want to go out on night call when I had babies at home. I was
pregnant during my second (and, in those years, last) year of fellowship
and was not received favorably by the other fellows who would have to
take up the slack when I delivered. The women were ruder than the
men regarding my absence. I took three weeks off to have my first baby
and was grateful to get back to work; a nurse for the baby and then a
live-in housekeeper helped considerably. I took only two weeks off to
have my second baby, again grateful to get back to work.
In the early 1970s, long maternity leave was not an issue; most of
us did not take it, or, if we did, we were prepared to leave medicine for

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a prolonged period. I always believed that the more time off new
mothers took, the more justified would be the questions about the pro-
priety of our role in medicine. In that sense, things are now much im-
proved, reentry into medicine being common and not especially
penalized. The ability to leave the field for a period seemed specialty-
dependent in part; if, for example, your specialty was critical care, it
was more difficult to leave. I always wanted to pull my own weight,
never to receive concessions because I am a woman. And I never
wanted to deal with the resentment resulting from a prolonged ab-
sence to have and rear children.
Having reliable housekeepers was mandatory for continuing to
work. In my case, it helped my two daughters become independent
much earlier than their peers. My unrealistic fears of fire, trauma, and
dog bites were actually guilt for leaving my children at home. When I
asked them, at ages 12 and 14, if they regretted my absence when
they came home from school, they replied: “No! If you hadn’t gone to
work, we would all have needed therapy!” I was grateful that they
bore me no malice. Interestingly, some nonworking mothers, whom I
would have relied on for carpooling when I was working, were so re-
sentful that they did not want to participate in carpooling, even
though I made myself available for entire weekends.
My career in academic cardiology has been extremely rewarding.
While many in practice are retiring early or taking immense pressure
from managed care, I continue to love what I do (clinical cardiology,
with 60 percent education of house staff and physicians). Unlike
many of my colleagues, I do not envision retiring until I have to.
I have not encountered the glass ceiling and have been promoted
on schedule at all levels of academic rank. Not once have I experi-
enced unfair treatment or discrimination. Maybe I did not recognize it
when it existed, but why search for it? Making issues of slights—real
or imagined—is unproductive and distracts from important activities.
I have always advised the house staff, “Do what you love and be good
at it, and you will be rewarded.”

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 REFLECTIONS / NORA GOLDSCHLAGER, M.D.

How do I keep up? I prepare talks and keep them current, and
that means reading medical publications. Can I keep up in all fields?
Definitely not. But so long as you have consultants and a friendly,
nonthreatening atmosphere in which to ask questions, you can keep
reasonably abreast. Having an area or two of expertise, by the way,
will lead to being sought out for your opinion.
When you begin your career, you have to do everything, check
everything, micromanage a great deal, and be frazzled if you take
pride in your performance. But if you enjoy your work, it will still be
worthwhile. Somewhere in your late thirties, you begin to have a bet-
ter perspective, and your life settles down. But nobody ever promised
you a rose garden when you went into medicine.

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 REFLECTIONS / E. CONNIE MARIANO, M.D.

R E F L E C T I O N S
...

Dr. Mariano was in the Medical Unit 关of the White

House兴, and I had the highest regard for her. She was a
tireless worker, always available, and often gave me the
best of counsel.
P RESIDENT G EORGE H ERBERT WALKER B USH

Dr. Connie Mariano was born in Sangley Point, Philippines, to a

Navy steward and his dentist wife. She received a B.A. cum laude
in biology from Revelle College at the University of California at
San Diego in 1977 and an M.D. degree from the Uniformed Ser-
vices University School of Medicine in Bethesda, Maryland, in
1981. After an internship in internal medicine at San Diego Naval
Hospital in 1982, she was assigned as the General Medical Officer
onboard the USS Prairie, a destroyer tender, where she served as
the sole physician for a ship’s company of 750 men and women. She

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developed a mass casualty training program that earned her ship

the title of “Benchmark Ship in Mass Casualty Control” for two con-
secutive years during her tour. After completing her internal medi-
cine residency in 1986 at the Naval Hospital in San Diego, Dr.
Mariano was assigned to the Naval Medical Clinic in Port Huen-
eme, California, where she was the only internist serving a commu-
nity of more than 75,000 healthcare beneficiaries.
In 1991, Dr. Mariano became Division Head of General Inter-
nal Medicine and Director of the Internal Medical Clinic at the
Naval Hospital in San Diego. In June 1992, she became the first
military woman to be named White House Physician when she was
selected as the Navy White House Physician under President
George H. W. Bush. In February 1994, under President Clinton,
she was promoted to Director of the White House Medical Unit and
Senior White House Physician, commanding a 21-member tri-ser-
vice healthcare team responsible for worldwide comprehensive
medical care to the President, Vice President, and their families.
She has served three sitting American presidents.
In February 2000, President Clinton awarded Dr. Mariano the
presidential appointment of Physician to the President. She was
promoted to Rear Admiral (lower half) on July 1, 2000, the first
Filipino-American to become Admiral in the United States Navy.
She is currently the highest ranking Asian-American woman in the
armed forces of the United States and is also the first graduate of
Uniformed Services University School of Medicine to achieve flag
rank. Admiral Mariano’s decorations include the Defense Distin-
guished Service Medal and the Joint Service Commendation Medal,
among others.

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 Journey to the White House:
A Passion for Medicine and People

E. Connie Mariano, M.D.

Rear Admiral, Medical Corps, United States Navy (Retired)
Former Physician to the President and
Commander, White House Medical Unit

I have been blessed throughout my life with numerous opportunities

to learn. Education has always been the cornerstone of my survival
and achievement. I was born in the Philippines to a Navy steward and
his wife, a dentist. When I was two years old, my family moved to
Pearl Harbor, Hawaii, where I learned to speak English and quickly
acquired the lifelong practice of adapting to a new environment. For
our family, home was wherever the Navy sent us; we moved every two
or three years throughout the United States and overseas to Taiwan.
My father finally retired in San Diego, California, where I completed
high school and college. Instead of the traditional medical school, my
Navy upbringing led me naturally to select the Uniformed Services
University School of Medicine. In 1977, I was one of 15 women in a
class of 65 students, the second class to enroll in the nation’s military
medical school. On the first day of medical school, we underwent bat-
tlefield training. Instead of short white coats and small black medical

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bags, we donned camouflage fatigues with Army boots and wielded

M-16s. The first week of medical school looked more like a scene
from the sitcom “MASH” than from “Marcus Welby, M.D.”
Medical school provided me with superb clinical training and the
unique perspective to become a career Navy medical officer. In 1982,
after an internship in internal medicine, I was assigned as the general
medical officer aboard the Navy destroyer tender, USS Prairie. For
the first time in Navy history, women were being assigned to ships.
When I reported aboard Prairie, only a handful of women officers
were assigned to a ship’s company of 650 men. A few months later,
the first enlisted women crew members came aboard.
As a woman officer and the only physician on the ship during this
historic time, I learned many lessons about leadership, military organ-
izational structure, and acute-care medicine. The crew came to “sick
bay” for medical care and sometimes just to “check out the new doc.”
Making it possible to do my job well was the shipboard medical de-
partment, consisting of 15 hospital corpsmen led by a seasoned senior
chief who served as my division officer and mentor. My first few
months on the ship taught me that before the crew would accept me, I
would have to prove first and foremost that I was a good physician.
There is nothing like an extended sea cruise to test your clinical
skills. There is a period during a seven-month Western Pacific de-
ployment when the nearest medical facility is seven days sailing time
away. During such a voyage, the ship’s physician maintains a close
eye on the crew, prays frequently, and relies solely on the skills of
good history-taking and physical diagnosis.The Prairie’s Captain
once assured me that he would turn the ship around and return to port
if I needed to get a sick sailor ashore. Reversing the ship’s course,
however, would not be a trivial matter, but a major undertaking. As
ship’s doctor, not only was I responsible for the lives of all crew mem-
bers onboard, but if a patient were too ill for treatment in my sick bay,
I was responsible for advising the Captain to evacuate the patient to
another facility. This responsibility bore directly on the ship’s course
and the overall mission.

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 REFLECTIONS / E. CONNIE MARIANO, M.D.

Fortunately, I enjoyed many quiet nights at sea. I relished the mo-

ments when I would sit in my small stateroom, reading medical jour-
nals and chapters from the Scientific American Medicine series that I
brought with me on the cruise. I would use the evenings to prepare
lectures for my corpsmen. Whenever the corpsmen would evaluate a
patient in sick bay, we would quickly look up the disease in the Merck
Manual or in my Harrison’s Internal Medicine. Our shipboard lecture
series focused on the patients we saw every day.
After my two-year tour as ship’s doctor, I returned to the Naval
Hospital in San Diego to complete my residency in internal medicine.
Compared to my tiny sick bay, the large teaching hospital seemed lux-
uriously appointed with technology and expertise available to treat
patients. The rigorous training consisted of countless hours at the
bedside and in the library. Learning was obtained directly from pa-
tients, grand rounds, morning report, journal club, bibliographic
searches, and required reading material for subspecialty rotations.
Following residency, I was assigned to the medical clinic that
supported the Navy’s Construction Battalion (“Seabee”) Center. Dur-
ing my four-year tour there, I provided outpatient and emergency
medical care to a large, diverse community. I enjoyed a busy internal
medicine practice and continued to teach corpsmen. My own educa-
tion continued as I attended grand rounds at the local hospital, par-
ticipated in annual review courses in internal medicine, and
maintained my journal reading.
After completing my tour at the medical clinic in 1990, the Navy
assigned me to be the division head for internal medicine at the
teaching hospital in San Diego where I had earlier trained. I returned
to attend on the wards and to continue teaching residents, interns,
and medical students.
My career path was to veer dramatically in 1991, when, as one of
six Navy candidates, I was nominated for the position of White House
Physician. Following an interview at the White House, I was selected
for this honor. I reported to the White House in June 1992, and served
in the White House Medical Unit during the last seven months of the

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Bush administration. When President Clinton was inaugurated in

1993, he did not bring a personal physician with him to the White
House. In 1994, he named me as his personal physician and pro-
moted me to Director of the White House Medical Unit.
My original assignment to the White House was to be two years.
President Clinton extended my tour to four years to allow me to serve
throughout his first term of office. With his reelection, I was asked to re-
main until the end of his second term. An original two-year stint ended
in January, 2001, with an eight-and-one-half year incredible, historic
journey for me.
I could not have planned or predicted this career path. I have
been blessed with amazing opportunities. Recalling that I came to
this country speaking no English, I am living testimony to the fact
that education leads to opportunity. As I reflect upon my career, every
step that allowed my education to expand both professionally and per-
sonally has moved me closer to the position I held at the White
House.
When I was aboard ship, I was asked to be a member of a panel of
officers who would select the Sailor of the Quarter. As the only woman
among the panelists, I endured my male officer colleagues asking all
the male enlisted candidates, “What do you think about women on
board ships?” When the one and only female candidate came before
the panel, I asked her, “What do you think about men on board
ships?” The candidate laughed, gave an excellent answer, and was
selected Sailor of the Quarter.
How has being a woman affected my career? One might further
ask: How has being a Filipino woman affected my career? Throughout
my professional life, I have always “stood out.” In medical school, I
was the only Asian-American woman in my class. In internship, I was
one of two Asian-American women. In my internal medicine resi-
dency group, I was the only woman. Onboard ship, I was the only
physician. As one of two women physicians at the Navy’s Construc-
tion Battalion Center, I was conspicuous in maternity clothes during
my two pregnancies.

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 REFLECTIONS / E. CONNIE MARIANO, M.D.

Being a woman at this time in American history has allowed me to

stand out in positive and beneficial ways. I believe that if you are going
to be “standing out,” you might as well be “outstanding.” Often people
will notice upon meeting me that I am not the typical American physi-
cian. But when the dialogue begins, I believe people do not think of
me in stereotypical terms. Instead, through communication and famil-
iarization, the people I meet will know me for the person I am.
In June 1992, President George Bush was told that the new White
House Physician selected by the Navy was a Commander, a specialist
in internal medicine, and a woman. I was that Navy Commander who
would be the first military woman White House Physician. The only
other woman physician who had served in the White House was Dr.
Janet Travell, a rehabilitation medicine specialist who was President
Kennedy’s personal civilian physician.
When President Bush learned that a woman physician was to join
his all-male team of physicians, he wanted to know only two things
about her: (1) Was she athletic? and (2) Did she have a sense of
humor? As it turned out, President Bush’s inquiries showed consider-
able wisdom.
First, White House Physicians have to be in good physical condi-
tion to follow the President of the United States all over the country
and all over the world. The presidency demands superhuman levels of
energy of its occupants. White House physicians must be able to walk
briskly as they “shadow” the President, be ready to jump on and off
moving vehicles, climb onto helicopters, scramble up stairs to a wait-
ing airplane, and do all this while lugging around a 40-pound medical
bag.
And what about a sense of humor? As a White House Physician, if
you do not learn to laugh, you may want to cry. A sense of humor—the
ability to laugh at yourself and with (not at) others—is vital to that job.
As Physician to the President, I was responsible for the medical
care of the leader of the free world. With this responsibility came the
obligation to seek the “world’s best” care for my patients. This meant
that medicine was never practiced in a vacuum. Whenever I or my

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patients had a question beyond my immediate knowledge or specialty,

I actively sought second opinions for guidance.
The Internet and information explosion have helped patients
gather medical knowledge independently. As a result, I have often
seen patients in clinic who showed me the latest information from the
Internet or a newspaper article. It is vital for me to know what infor-
mation my patients are getting from cyberspace and newsprint. In my
position at the White House, not only did I maintain my journal read-
ing, but I also read at least three different newspapers a day.
I was fortunate to have a panel of excellent consultants for current
information and advice. The medicine I practiced had to be consis-
tent with the medicine practiced by my colleagues at respected med-
ical institutions. White House medicine must be state-of-the-art
medicine. Many of my consultants were the world’s experts in their
respective fields, and I frequently received the benefit of one-on-one
training from them. Continuing medical education (CME) is vital to
the practice of state-of-the art medicine. All members of the White
House Medical Unit must participate in CME courses every year. I at-
tended or participated in at least three conferences a year. In addition
to receiving continuing medical education, White House Physicians
also teach. My teaching responsibilities included proctoring medical
students at the Uniformed Services University School of Medicine, as
well as serving as instructor for courses in advanced cardiac life sup-
port and advanced trauma life support.
The White House Medical Unit consistently draws data from infor-
mation technology resources. Its mission involves a large amount of
travel, with heavy reliance upon current health advisories and informa-
tion on medical facilities. For overseas travel, the Unit uses computer-
based information systems, such as Travax, as well as the network of
contacts with state departments and the Centers for Disease Control.
My passion for the profession of medicine has always been fueled
by my love of people. Practicing medicine at the White House gave
me a unique opportunity to serve my country. My feelings about my

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 REFLECTIONS / E. CONNIE MARIANO, M.D.

White House responsibilities are captured in the following poignant

letter written in 1961 by Admiral Joel Boone, physician to President
Hoover, to Dr. Janet Travell, physician to President Kennedy: “I hope,
Doctor, you will enjoy thoroughly your new life of vital service to our
country in a position of transcendent responsibility only second in
importance to the Presidency because you will be the one to keep him
fit and physically and mentally well so that he can carry on his in-
comparable tasks in this volatile world. . . . You will be faced with se-
rious demanding obligations; however, you will be a most privileged
person in your profession. I found the White House to be a house of
joy, sorrow, and tragedy. It always has been such.”

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 16

Professionalism

...
Medical professionalism is more than first-rate knowl-
edge, proficiency, and dedication. It requires compas-
sion, integrity, and the highest ethical standards, free of
the shackles of profit as a priority.
P HIL R. M ANNING , M.D., AND L OIS D E B AKEY, P H .D.

T he lexical definition of professional is: having or showing great

skill; expert; following a profession, especially a learned pro-
fession; conforming to the standards of professional behavior; an
occupation, such as law, medicine, engineering, that requires consid-
erable training and specialized study. In medicine, professionalism
connotes not only knowledge and skills, but character as well, specif-
ically compassion and ethics.
Of late, those within and without medicine seem to believe, cor-
rectly or not, that physicians evince less professionalism than previ-
ously. To Robert Moser, “Professionalism is first cousin to
humanitarianism and ethical behavior. It is what we used to call
‘character’ (before that fine word was appropriated by actors and
comics). It applies to all professions: jurisprudence, medicine, legis-
lation, engineering.”1

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A number of factors have influenced contemporary medical profes-

sionalism. Words, for example, have a potent, if sometimes intangible,
effect on attitudes, behavior, and actions. Michael and Lois DeBakey
have addressed this insidious issue: “Today patients are called ‘con-
sumers,’ physicians are ‘providers,’ and health care is a ‘product’—all
terms of commerce, not of a profession, and certainly not of a humani-
tarian profession. The new vocabulary, and its obvious intentions, are
grossly inappropriate. Physicians do not provide inanimate commodi-
ties, as salespeople and service people do; they treat human beings.
They deal with our most precious possession—our health and well-
being—and to apply rules of commerce to such activities is unsound,
indeed disastrous.”2 The onerous restrictions and regulations imposed
by managed care, they point out, have wreaked havoc on the quality of
healthcare.3,4 “Instead of being allowed to focus primarily on the pa-
tient’s health problems,” they lament, “physicians must now expend
much of their time complying with unreasonable paperwork, avoiding
specious litigation, and awaiting a decision regarding treatment from a
faceless nonphysician ‘authority’ at a remote point who has never seen
the patient, but consults a computer for the ‘guidelines.’ . . . 关M兴any
HMOs have gag rules prohibiting a physician from telling patients
when the HMO rejects a procedure he deems necessary.”2
“When a physician cannot be honest with a patient,” they con-
tend, “the relationship is compromised, and the patient is victimized.
Many HMOs reward physicians with a bonus on the basis of how
much care they deny patients and punish them if they exceed a cer-
tain cost for health care. Thus, the overriding dictum is to save money
for corporate officers, not to provide quality health care to patients.”2
This, the DeBakeys assert, is the goal of business, and should never
be that of the medical profession. Finally, they plead “for a single
code for all politicians, bureaucrats, managed-care executives,
health-care professionals, and others, who themselves may one day
be patients: Primum non nocere. First do no harm.”2
Although concerned about the current status of medical profes-
sionalism, Robert Moser envisions a brighter future: “The hard fact is

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that over the years most of us did become complacent. Many lost
some sensitivity. (How often have you heard ‘quality of life’ discussed
on teaching rounds?) We also suffered a lapse of intellectual disci-
pline. In our naive zeal to ‘leave no stone unturned’ on behalf of our
patients, we neglected the realities of fiscal responsibility. In our be-
nignly paternalistic fashion, we did things our way for a long time.
And that is how the unwelcome nose of the managed care camel suc-
ceeded in creeping under our tent. Undoubtedly, managed care has
imposed a renewed sense of fiscal discipline on medicine. But as it
exists, it has excessive warts. Major modifications are already evi-
dent; we will retain the good ones, but we are obliged to abandon
those that have caused grief.” In an editorial in the Southern Medical
Journal, Moser wrote: “关W兴e must fight for our individual patients
testing the limits of whatever constraining envelopes that bind us. I
do not advocate dishonesty, but I do believe in taking action when the
constraints imposed seem unfair or unreasonable. If we are driven by
the ‘system’ to provide less than optimal care, we must seek other op-
tions, external to the system, as we protest most vigorously for change.
To do less is truly to ‘capitulate.’ ”1
Thomas Lincoln reminds us that “Healthcare is not first and
foremost a consumer industry, as viewed from the physician’s or pa-
tient’s perspective. Although the financial costs are often supported
by insurance, all serious medical care is a personal patient invest-
ment in time, sometimes with pain and anxiety, and commonly with
discipline, the physician serving as an active participant and advi-
sor. One does not ‘consume’ an artificial hip or a cardiac vessel
bypass.”
Moser hopes that “Ultimately, a system will evolve that will elim-
inate the unsavory profit motive, and those infamous mantras ‘obliga-
tion to shareholder’ and ‘incentive and disincentive’ will be purged
from the medical lexicon. Once this is accomplished, the intangibles
of compassion, caring, and patient advocacy—elements intrinsic to
our self-fulfillment—will re-emerge. These virtues must, of course,
always be coupled with the best possible medical science. We will

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survive this dark night of the soul of medicine to enjoy a truly en-
lightened partnership with those for whom we care.”
Professionalism not only serves our patients best, but also pre-
serves our passion for medicine. The invited thoughts on this subject
from Jordan Cohen and Kenneth Shine follow this chapter in their
“Reflections.”

REFERENCES
1. Moser RH. A few thoughts about professionalism 关editorial兴.
South Med J. 2000;93:1132–1133.
2. DeBakey ME, DeBakey L. Should physicians unionize? The
Wall Street Journal. 1999 Jul 7;CIV(4):A22.
3. DeBakey ME. Winds of change in medicine. South Med J.
1993;86:1316–1317.
4. DeBakey ME. A surgical perspective. Ann Surg. 1991;
213:525–526.

420
 REFLECTIONS / JORDAN J. COHEN, M.D.

R E F L E C T I O N S
...

Professionalism, the commitment to subordinate our

self-interest to the interest of our patients, is the foun-
dation of trust upon which our social contract rests.
J ORDAN J. C OHEN , M.D.

Dr. Jordan Cohen, who leads the Association of American Medical

College’s support and service to the nation’s medical schools and
teaching hospitals, received his M.D. degree from Harvard Medical
School. During an almost 40-year career in academic medicine, he
has held faculty positions at Harvard Medical School, Brown Uni-
versity, Tufts University School of Medicine, the University of
Chicago Pritzker School of Medicine, and the State University of
New York at Stony Brook. He has served as Chairman of the Amer-
ican Board of Internal Medicine and the Accreditation Council for

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Graduate Medical Education, and has been a Regent and Vice

Chairman of the Board of Regents of the American College of
Physicians. He is the author of more than 100 publications and is
an Editor of Nephrology Forum.

422
 Requisites for Physicians:
Competence, Service, Trust

Jordan J. Cohen, M.D.

President, Association of American Medical Colleges
Washington, D.C.

W hat, precisely, defines a profession? That not only medical stu-

dents, but practicing physicians as well, are uncertain of the
meaning of professionalism in medicine1 is troubling, particularly
when turbulent market forces threaten to distract us frequently, if not
permanently, from our mission. How can we safeguard the values of
our calling if we are not entirely sure what they are?
A profession is defined by its specialized body of knowledge, its or-
ganized activities for continuous advancement, its responsibility to reg-
ulate itself, its pledge to public service above personal gain, and its
implied contract with society. In medicine, the pledge to societal good
is particularly sacred because our mission affects life itself. We hold the
lives of others in our hands; they trust us with their health, and the mo-
ment we take the Hippocratic Oath, we vow to prove forevermore wor-
thy of that trust. No small commitment, and one that I fear is in danger
of being lost in the financial dissonance pervading today’s healthcare

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system. The concept of professionalism, powerful though it may be, is

not so deeply rooted in American medical history as to be immune from
contemporary forces. Far from it. In Social Transformation of American
Medicine,2 Princeton economist Paul Starr recounted what a fledgling
concept this is. Professionalism, hinging as it does on an exceedingly
lofty principle, is thus altogether too fragile for us to take for granted.
Too often of late, people in need of healthcare are called “health-
care consumers” rather than “patients.” Admittedly, “patient” im-
plies illness, and some people who seek wellness care and other
services from medical professionals are not ill. Moreover, for some,
the word “patient” evokes the notion of “patiently” waiting for a
physician to get around, finally, to seeing him for all of five minutes.
But “healthcare consumers”? If the people we treat are consumers,
what does that make physicians? Salespeople? Retailers? Is the care,
the guidance, the expertise we provide just another commodity to be
traded? Unfortunately, in today’s market-driven economy, with rising
costs squeezing the entire healthcare system, the answer may be
“yes.” And we physicians may well have contributed to the commer-
cialization of medicine by allowing the erosion of the core values of
professionalism, which elevate medicine from a nine-to-five job to a
calling in the service of healing.
Inculcating professional attitudes and values in medical students
and residents through curricula and practical experience is at the
heart of the Association of American Medical Colleges’ Medical
School Objectives Project (MSOP),3 which identifies four major at-
tributes of a good physician:

• altruistic, compassionate, and truthful;

• well informed in the scientific basis of medicine and the normal
and abnormal functioning of the body;
• skillful in communicating with and caring for patients;
• dutiful in working with others to promote the health of individual
patients and the broader community.

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 REFLECTIONS / JORDAN J. COHEN, M.D.

MSOP also identifies objectives for medical school education, objec-

tives designed to instill and reinforce traits that can be honed both to
withstand the rigors of a professional life and to compel adherence to
the norms of professionalism. Among these traits are old-fashioned
words like honesty, integrity, altruism, compassion, and respect.
I am encouraged that more and more medical schools around the
country are adding specific topics to their curricula that focus on
teaching and measuring professionalism, no longer assuming that
medical students will absorb professional values by osmosis. But it
will profit us little to bathe aspiring physicians in the precepts of pro-
fessionalism if, when they receive the coveted M.D. and complete
their residencies, we turn them out into a healthcare system that has
become cavalier in its commitment to professionalism. That is the
point where the community of practicing physicians must retake the
reins. In order to value our profession, we must not only profess but
also practice its values. And how do we do that?
Many factors that have contributed to a decline in medical profes-
sionalism can serve as an impetus to reinvigorate professional values.
The current backlash against managed care provides an opportunity
for physicians to reassert their traditional role as advocates for pa-
tients and as servants of society. An alignment of interests among pa-
tients and physicians can be a powerful motivator for rectitude, rather
than for expediency or profit. In a number of communities, thoughtful
people with concerns about how their healthcare is delivered have be-
come involved with their local hospitals, clinics, and medical schools
to promote nonhierarchic patient- and family-centered care, with pa-
tients and family as partners rather than passive recipients of a physi-
cian’s wisdom. Such a partnership can reinvigorate professionalism
by constantly reminding physicians about the needs, the lives, and
the priorities of the people they serve.
I urge practicing physicians to reexamine constantly their com-
mitment to public and community service, a fundamental ethic of pro-
fessionalism. How much time do you devote to uncompensated care?
Countless opportunities exist for physicians to reconnect with the

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central values of their profession by volunteering at shelters for the

homeless and for battered women, treatment programs for addicts,
and walk-in clinics for adolescents and pregnant women, among
many others.
In addition, physicians should pursue continuing medical educa-
tion that examines and refines their commitment to professionalism.
Courses in medical ethics and other aspects of professionalism can be
just as vital to your lifelong learning as the study of the latest devel-
opments in gene-mapping, oncology, or psychopharmacology.
I wholeheartedly agree with the recommendation of Richard and
Sylvia Cruess that physicians assume responsibility for their local
and national associations. In “Renewing Professionalism: An Oppor-
tunity for Medicine,” they state that if physicians and medical schools
and organizations fulfill the obligations implicit in their contracts
with society, the morality inherent in medical professionalism will
predominate, and optimal healthcare will result.4
Professionalism, the commitment to subordinate our self-interest to
the interest of our patients, is the foundation of trust upon which our so-
cial contract rests. And maintaining mutual trust in the physician–
patient relationship is, to my mind, the only way to assure the public
that medicine is fulfilling its sacred obligation. No laws, no regulations,
no patients’ bill of rights, no fine print in the insurance policy, no watch-
dog federal agency can substitute for trustworthy physicians who care.
Fending off the powerful forces of commercialism and placing our
confidence in the tenets of professionalism will require considerable
courage. Taking a strong stand may be risky, but the larger risk is to
lose sight of what we are defending. We are not fighting to protect the
medical profession because it is “our turf” or because we want to pre-
serve our autonomy or, even worse, protect our incomes. The issue for
us, as physicians who care, is the welfare of patients. In this age of
Health Maintenance Organizations (HMOs), Preferred Provider Orga-
nizations (PPOs), Physician/Hospital Organizatins (PHOs), gatekeep-
ers, and utilization reviews, we must be the ones our patients can
trust.

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 REFLECTIONS / JORDAN J. COHEN, M.D.

REFERENCES
1. Shaw G. A calling, not a nine-to-five job: teaching tomor-
row’s physicians what it means to be a professional. AAMC
Reporter. 1998;7:10–11.
2. Starr P. Social Transformation of American Medicine. New
York: Basic Books, 1982.
3. Anderson MB, Cohen JJ, Hallock JE, Kassebaum DG, Turn-
bull J, Whitcomb M. Learning objectives for medical stu-
dent education—guidelines for medical schools: Report I of
the Medical Schools Objectives Project. Acad Med. 1999;
74:13–18.
4. Cruess R, Cruess S, Johnston S. Renewing professionalism:
an opportunity for medicine. Acad Med. 1999;74:878–884.

427
 REFLECTIONS / KENNETH L. SHINE, M.D.

R E F L E C T I O N S
...

Medicine offers the physician a profession in which art,

science, compassion, and communication provide some
of the richest human experiences anyone can have.
K ENNETH I. S HINE , M.D.

Kenneth Shine, M.D., Founding Director of the RAND Corpora-

tion’s Center for Domestic and International Health Security, has
served as President of the Institute of Medicine, National Academy
of Sciences, and Professor of Medicine Emeritus at the University
of California, Los Angeles (UCLA) School of Medicine. He is UCLA
School of Medicine’s immediate past Dean and Provost for Medical
Sciences.
A cardiologist and physiologist, Dr. Shine received his A.B.
from Harvard College in 1957 and his M.D. from Harvard Medical

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School in 1961. Most of his advanced training was at Massachusetts

General Hospital, where he became Chief Resident in Medicine in
1968. Thereafter, he was Assistant Professor of Medicine at Har-
vard Medical School. In 1971, he became Director of the Coronary
Care Unit, Chief of the Cardiology Division, and, subsequently,
Chairman of the Department of Medicine at the UCLA School of
Medicine. As Dean at UCLA, Dr. Shine stimulated major initiatives
in ambulatory healthcare education, community service for medical
students and faculty, mathematics and science education in the
public schools, and construction of new research facilities funded
entirely by the private sector.
Dr. Shine is a Fellow of the American Academy of Arts and Sci-
ences and the American College of Cardiology and Master of the
American College of Physicians–American Society of Internal
Medicine. In 1988, he was elected to the Institute of Medicine. He
was Chairman of the Council of Deans of the Association of Ameri-
can Medical Colleges 1991–1992, and was President of the Amer-
ican Heart Association from 1985 to 1986.
Dr. Shine’s research interests include metabolic events in the
heart muscle, the relation of behavior to heart disease, and emer-
gency medicine. He participated in efforts to prove the value of
cardiopulmonary resuscitation after a heart attack and in the estab-
lishment of the 911 emergency telephone number in the multijuris-
dictional Los Angeles area. Dr. Shine is the author of numerous
articles and scientific papers on heart physiology and clinical
research.

430
 “That Was Frank’s Doctor”

Kenneth I. Shine, M.D.

Founding Director
Center for Domestic and International Health Security
RAND Corporation
Santa Monca, California

F rank* was a distinguished academic administrator, responsible

for a leading professional program at a major university. I had
participated in his care for over a dozen years, during which time he
underwent two cardiac coronary artery bypass operations and multi-
ple other procedures. He now had profoundly depressed cardiac mus-
cle function and a marginal cardiac output. He and his wife discussed
with me the various options available at this stage of his chronic ill-
ness. We talked about experimental medical therapy, cardiac trans-
plantation, taking a cruise to interesting places, and a variety of other
options. After some thought, he turned to me. “My wife and I both be-
lieve that my work is the most important part of our lives, and what I
would like from you is to do everything you can to help me function in
my profession until the time I die. I don’t want to be in the hospital or
have additional operations. I want to be allowed to continue to work.”
*a pseudonym

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In spite of his dire prognosis, he worked for another four years. I

pushed the limits of medical therapy to the point that he would get
dizzy from standing in the sun for more than two or three minutes. But
the treatment kept him functioning and out of the hospital. He worked
a full day before he collapsed one Friday evening at dinner. Although
a surgeon in the restaurant resuscitated him, it later became clear in
the coronary care unit that if he recovered, he would be badly dam-
aged neurologically. After several days of careful observation, his
family and I agreed that he should be removed from life support so
that nature could take its course. The memorial service was a remark-
able event, replete with mayors and scholars, a senator, and many
other dignitaries. Everyone going through the receiving line was iden-
tified by the other mourners. When I reached his wife, she hugged
and kissed me. I consoled her, and as I walked away, someone asked
her who I was. She said nothing about my being a Professor, Dean,
Provost, or Chief of Cardiology. She simply replied, “That was Frank’s
doctor.”
Professionalism means competence. Patients and their families
expect their physicians to be well informed and to be able to provide
the most effective healthcare available. Patients expect their physi-
cians to know the limitations of their professional competence and to
seek consultation or referral when that will provide the best possible
treatment. Professionalism means not being threatened when a pa-
tient or a family asks for a second opinion. Professionalism means
lifelong learning and continual education. Frank lived and worked for
four more years because he received excellent care.
Professionalism is about trust, about creating circumstances in
which patients and families can be open and honest with their physi-
cians and in which physicians reciprocate in kind. Trust is about be-
lieving that the physician will describe all the options fairly and
honestly and will make recommendations based solely on the patient’s
best interests, not on those of the physician, insurer, managed-care or-
ganization, or any other entity. Trust requires openness. A professional
cannot accept any limitation on discussions of the patient’s condition,

432
 REFLECTIONS / KENNETH I. SHINE, M.D.

prognosis, therapeutic choices, or other options. Frank and his wife

trusted me with their most private hopes, fears, and aspirations and
made good choices for themselves.
Professionalism means integrity. Integrity implies not only truth-
telling, but avoidance of conflicts of interest, such as referring pa-
tients for laboratory studies or procedures in which the physician has
a commercial interest, receives payment for referral, or participates
in procedures without being identified to the patient.
Trust and integrity require observing the confidentiality of
patient–physician communications. Frank was entitled to continue
his career in the knowledge that whatever I knew about his condition
would not be communicated to others, except at his instruction and
with his permission.
In medicine, professionalism also means being concerned about
the public health. This concern creates some of the most difficult
dilemmas for physicians. The law requires reporting of certain com-
municable diseases in the interest of the health of the community.
When the physician identifies tuberculosis, syphilis, gonorrhea, or
hepatitis, reporting is required, and the physician’s obligation is
clear. Much more challenging is the dilemma in which the patient is
infected with human immunodeficiency virus (HIV) and has not ad-
vised a spouse or other sexual partners. In this situation, without legal
requirements for reporting, it is even more important to build trust so
that patients understand their responsibilities to others.
In the past, physicians were compensated primarily on a fee-for-
service basis. Before the introduction of Medicare and Medicaid,
physicians often adjusted their fees according to a patient’s ability to
pay, and, particularly in rural communities, they were sometimes
compensated in nonmonetary ways. There was a strong tradition of
caring for the poor through volunteer services. Later, Medicare pro-
vided healthcare for Americans beyond the age of 65 years, and Med-
icaid covered many of the poor, particularly young mothers and
children. Volunteerism then declined. Fee-for-service identified the
patient’s interest with that of the physician, but there was the risk of

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unnecessary tests and procedures (performed by physicians know-

ingly or innocently) that increased the physician’s personal income
and raised the specter of a conflict of interest. Controlling healthcare
costs was not considered an obligation of the physician. Even if addi-
tional treatment had minimal incremental value, it was often recom-
mended.
As more and more technology became available, healthcare costs
began to grow at unsustainable rates, so that by the early 1990s, close
to one-seventh of the gross domestic product was being expended on
health. Despite these high expenditures, there was little evidence that
the overall quality of health in America was substantially better than
that found in other countries that spent only 50 to 60 percent of the
American expenditure. Unwilling to adopt a strong federal govern-
mental solution, purchasers of healthcare turned increasingly toward
managed care, in which market forces were supposed to help con-
strain costs. In this environment, patients are cared for either in cap-
itated systems in which physicians or institutions receive a flat fee
per patient per year to provide care or through systems of providers
receiving discounted fees. In such systems, physicians are rewarded
for doing less and are constrained from referring patients for specialty
consultations.
Professionalism requires that physicians always seek appropriate
care for their patients, even in the face of financial limitations im-
posed or of incentives to provide less care. Patients must also be fully
informed. Trust and integrity require that patients understand the
conditions under which their physicians are compensated. Profes-
sionalism means advocating systems of care that provide the best pos-
sible results for patients in a responsible, cost-effective manner.
At the same time, professionalism is knowing when enough treat-
ment is enough. Having accomplished his goal of working until the
end of his life, Frank’s family did not want to see him live in a per-
sistent vegetative state, nor did I. After careful consultation, support
systems were removed, and Frank passed away.

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 REFLECTIONS: KENNETH I. SHINE, M.D.

Medicine has a code of ethics that covers not only how profes-
sionals interact with patients, but how they accept responsibility for
their own behavior and that of their colleagues, including evaluating
the care given by others, identifying incompetent practicing physi-
cians or those with substance-abuse problems or improper behavior.
A physician’s failure to deal with a colleague’s unprofessional behav-
ior undermines the trust and integrity essential to a profession. Pa-
tients rely on physicians to apply the peer-review process to medical
staffs through their medical society or state licensing board. A profes-
sion that fails to police itself loses public confidence and invites out-
side control.
In the current rapidly changing environment, the relationships
between physicians and their patients, as well as physicians and their
colleagues, are undergoing substantial stress. The fundamental prin-
ciples of a profession, however, including competence, trust, integrity,
responsibility, and accountability, are essential. No personal distinc-
tion that I have received has ever quite measured up to Frank’s wife’s
explanation: “That was Frank’s doctor.” Medicine offers the physician
a profession in which art, science, compassion, and communication
provide some of the richest human experiences anyone can have.

435
 Afterword

...

O n the basis of our extensive interactions with highly skilled

physicians, we have certain recommendations for you as clini-
cians. One is that you understand the need for two kinds of life-
long study: (1) general and (2) specific, patient-oriented study. By
reading, listening to audiotapes, attending conferences and symposia,
viewing daily medical news from reliable Internet services, and con-
versing informally with experts and colleagues, you will become alert
to new developments and can obtain a nucleus of understanding upon
which to build. Toward that end, editorials in leading medical jour-
nals are particularly useful. Most newspapers and weekly magazines
report medical news fairly accurately, if briefly. So with just a little ef-
fort, you can be aware of recent medical developments and with the
current state of the art. Although essential, this is not enough. You
will also profit from nurturing your intellectual curiosity and from
assuming personal responsibility for answers to specific questions

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arising in your practice. Such answers require framing the question

precisely and, often, accessing pertinent medical information as well
as consulting colleagues.
Electronic databases have significantly simplified searching for
medical publications, which, in turn, helps optimize the care of your
patients. The possibilities that the computer offers for information re-
trieval, especially though the Internet, seem almost limitless. Tech-
nology will undoubtedly continue to facilitate and expedite access to
accurate, pertinent information. With current print and electronic in-
formation sources, there is no justification for being uninformed.
We do better what we do daily. You will therefore practice better
medicine if you engage in daily study and daily evaluation of your per-
formance. You need to acquire the discipline and diligence to read
and study every day and, because of time limitations and the flood
of mediocre publications, to screen articles critically for per-
tinence and validity. Current medical textbooks provide a quick
source of relevant information, although they are, by nature, somewhat
dated. A personal file of articles you have found useful in your prac-
tice, indexed either manually or on a computer, is extremely efficient
in satisfying information needs. Because electronic databases are in-
creasingly easy to access, there is little excuse for failing to obtain the
most reliable current information. If you do not wish to access the in-
formation databases yourself, medical librarians can fulfill almost any
such request provided you delineate your needs carefully. Choosing
one or two medical subjects for intense study, moreover, will heighten
your intellectual satisfaction, engage your curiosity, prepare you to
serve as a consultant, and thus enhance your self-confidence.
Participating in the collegial medical network permits you to
benefit from shared experience. Not only is this interaction an excellent
way to learn, but the camaraderie and sociability contribute to fulfill-
ment. Teaching is an added stimulus for learning, and even if you are
not affiliated with a medical school or teaching hospital, you can profit
from informal teaching sessions with your colleagues, other members of
your healthcare team, and your patients. You can eliminate ineffective

438
 AFTERWORD

and inefficient practice habits by inviting peers to observe you periodi-

cally, even during your routine clinical activities, such as taking a his-
tory or performing a physical examination or clinical procedure.
Our fervent hope is that all clinicians will adopt simple methods of
practice analysis to effect corrective changes in their practices. Billing
data can be used to maintain statistics on clinical problems seen, drugs
prescribed, and laboratory studies ordered. By indexing your medical
records by problem or diagnosis, you can examine your cumulative ex-
perience. Keeping notes by hand or computer on lessons learned from
instructive cases is equally beneficial. Lessons learned from the study
of practice are reinforced and expanded when discussed with well-
informed colleagues. Hospitals, medical societies, and medical schools
can help physicians evaluate their experience by advocating standards,
encouraging discussions of the validity of published material, and offer-
ing guidance in effective methods of practice analysis.
We also encourage you to be attentive to the changing social
and ethical issues in medicine. Here again, it is wise to remember
the two approaches: (1) general, for a framework upon which to build,
and (2) specific, including consultation, for solutions to problems par-
ticular patients present.
Although you need to be well informed, many problems in prac-
tice are unrelated to medical knowledge, but are caused by omission,
administrative or personnel inefficiency, lost data, or failure to react
to data obtained. These problems must constantly be combatted. With
patient care becoming more complex and with stronger emphasis on
the team approach, greater entrepreneurial involvement, and more
regulation to contain medical costs, systems problems will probably
multiply. To improve the quality of medical care, you must become a
more skilled manager of patient care rather than abrogate these re-
sponsibilities. In the words of Hippocrates: “The physician must be
ready, not only to do his duty himself, but also to secure the co-
operation of the patient, of the attendants and externals.1
Mastering many of the learning techniques and objectives
that we advocate in this book will help you achieve the competence

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promoted by the Accreditation Council for Graduate Medical Educa-

tion (ACGME) Outcome Project (Sept. 28, 1999). Such competence
will enrich residency training and may become a part of the certifica-
tion and maintenance of certification processes. The specific knowl-
edge, skills, and attitude to be required of residents are here modified
in these six components:

• patient care that is compassionate, appropriate, and effective for

the treatment of health problems and the promotion of health;
• medical knowledge about established and evolving biomedical,
clinical, and cognate (epidemiological and social–behavioral) sci-
ences and the application of this knowledge to patient care;
• practice-based learning and improvement that involves in-
vestigation and evaluation of their own patient care, appraisal of
assimilation of scientific evidence, and improvements in patient
care;
• interpersonal and communication skills that result in effec-
tive information exchange and teaming with patients, their fami-
lies, and other health professionals;
• professionalism, as manifested through a commitment to carry-
ing out professional responsibilities, adherence to ethical princi-
ples, and sensitivity to a diverse patient population;
• system-based practice, as manifested by actions that demon-
strate an awareness of and responsiveness to the larger context
and system of healthcare and the ability to effectively call on sys-
tem resources to provide care that is of optimal value.

If you approach the clinical puzzles in medical practice as intel-

lectual challenges; if you acquire the habit of reading and discussing
with colleagues the steady flow of new medical information issuing
from scientists and scholars; if you evaluate your clinical results reg-
ularly, framing precise questions and obtaining answers to the ques-

440
 AFTERWORD

tions arising in practice; and if you view each patient not as a clinical
case; but as a fellow human being whose unstated fears, anxieties,
and dependence associated with illness also require attention, you
will be rewarded with professional satisfaction and personal enjoy-
ment, and you will assuredly preserve the passion for medicine that led
you into this noble humanitarian profession.

PHIL R. MANNING, M.D.

LOIS DEBAKEY, PH.D.

REFERENCES
1. Hippocrates. Aphorisms. With an English translation by
W.H.S. Jones. New York: G.P. Putnam’s Sons, 1931, Vol
IV, p. 99.
2. ACGME Outcome Project [homepage on the Internet].
Accreditation Council for Graduate Medical Education;
c2001. Available at: http://www.acgme.org/outcome/comp/
compFull.asp.

441
 Interviewees and
Correspondents

...

Nancy Abdou Lailee Bakhtiar Garry G. Becker

Stephen Abrahamson Oscar Balchum John S. Beedie
Michael Ackerman James J. Ball Paul B. Beeson
James Aiyarrow Edwin V. Banta, Jr. Roy Behnke
Bobby R. Alford Barry Barber John G. Bellows
Clarence P. Alfrey Richard Barbers Howard Belzberg
Horace J. Anderson Emil Bardana, Jr. Jack Benhayon
Gary J. Anthone William Bardsley William M. Bennett
Susan S. Anthony Marloe Bareis J. Alfred Berend
Henry Aranow, Jr. R. Bareis Kenneth Berge
Juan A. Asensio Anne L. Barlow Stanley Berman
John Martin Askey Octo G. Barnett Betty Bernard
J. B. Aust Jeremiah A. Barondess Clarence J. Berne
Ruth Bain Howard S. Barrows Thomas V. Berne
Carol A. Baker Jacques Barzun Maurice Bernstein
Duke H. Baker Robert Beck Michael Bernstein

443
 M E D I C I N E : P R E S E R V I N G T H E PA S S I O N I N T H E 2 1 S T C E N T U R Y

Charles A. Berry Bernice Z. Brown D. Kay Clawson

Alice N. Bessman Janis Brown Clifton R. Cleaveland
Peter Best Sallye P. Brown Steven G. Clemenson
John E. Bethune F. Charles Brunicardi Linda Hawes Clever
Daniel C. Bird Barbara Buchanan William A. Clintworth
Marjorie Bird Francis S. Buck Nancy Coates
Gordon L. Black Charles S. Burger Walter S. Coe
Courtland Blake J. H. Burgess Jordan J. Cohen
David Blankenhorn Genevieve Burk Bradford Cohn
Andrew Bliss Joan Burns Lawrence H. Cohn
Harry A. Bliss Thomas W. Burns Morris Collen
Melvin A. Block George Herbert Walker Bush, Russell F. Compton
President
Marsden S. Blois Marilyn Cook
Peter Butler
Daniel K. Bloomfield William M. Cooper
Richard Byyny
Baruch S. Blumberg William G. Corey
C. A. Caceres
Morton Bogdonoff Mitchel D. Covel
Arthur A. Calix
Paul Bohannan Susan Covel
Thomas Callister
Eli L. Borkon David G. Covell
J. T. Campbell, Jr.
Louis G. Bove Joyce W. Craddick
Richard M. Caplan
Francis L. Bowler Cheryl M. Craft
Tor Carlsen
Marjorie A. Bowman Jean A. Creek
David B. Carmichael
Tom Bradley Peter F. Crookes
Susan T. Carver
Major W. Bradshaw Harold D. Cross
William J. Casarella
Robert M. Braude Martin H. Crumrine
William B. Castle
Mark Braunstein Robert Cullin
Cathleen Caton
Eugene Braunwald Martin Cummings
M. E. Chaffin
Donald F. Brayton Hiram Cury
Katherine R. Challoner
Thomas H. Brem David J. Dahl
Kit Chambers
Cedric Bremner David C. Dale
Wallace L. Chambers
D. J. Brennan W. Andrew Dale
Schumarry H. Chao
Gayne Brenneman Walter J. Daly
Robert Cheshier
Sandra Bressler William H. Daughaday
Arthur C. Christakos
Jeannie Brewer Nicholas Davies
Norman Christiansen
Garry Brody David A. Davis
Gail Clark
Dorothy Brooks Lawrence Davis
J. Philip Clarke
Arnold L. Brown William D. Davis, Jr.

444
 INTERVIEWEES AND CORRESPONDENTS

Pamela Day Marvyn L. Elgart Boy Frame

Catherine D. DeAngelis Neil Elgee Richard Friedman
John De Angelis George J. Ellis William F. Friedman
Michael E. DeBakey Mark L. Entman James F. Fries
Vincent A. DeLuca, Jr. Henry L. Ernstthal K. O. Fritz
Tom R. DeMeester Daniel Essin John Fry
Demetrios Demetriades T. N. Evans Atsuko Fujimoto
Scott Deppe Alison Ewing Ronald K. Fujimoto
Vincent DeQuattro Saul Farber Sherrilynne Fuller
N. A. Desbiens Gerald Farinola Jack J. Fulton
Kenneth Diddie Richard G. Farmer William B. Galbraith
Preston V. Dilts, Jr. Aaron Feder Augustin A. Garcia
Richard L. Dobson Daniel B. Federman Norman H. Garrett, Jr.
James E. Doherty James F. Feeney Paul J. Geiger
John Donald Ralph D. Feigin John P. Geyman
James Dooley Arthur W. Feinberg Ray W. Gifford, Jr.
Doris Doran Donald I. Feinstein Nelson J. Gilman
T. E. Doszkocs Theodore Feit Robert J. Glaser
J. Douglas William C. Felch Arnold W. Goldschlager
Dan Dover Alan W. Feld Nora Goldschlager
Andrew Dow Steven Feldon Charles Goldstein
Edgar Draper Benjamin Felson Robert M. Goldwyn
F. Dubeck Cotton Feray Joseph Gonnella
N. L. DuBlurg, Jr. Thomas B. Ferguson Lillian Gonzalez-Pardo
Eileen Duggan Daniel Ferrigno Brian W. Goodell
Harriett P. Dustan Richard Field J. F. Goodman
James M. Duvall William R. Fifer Alan L. Gordon
Donald Dworken Harry W. Fischer Babs Gordon
Eileen Eandi Joseph Fischer Antonio M. Gotto, Jr.
Allan J. Ebbin Winthrop Fish Arthur E. Grant
Robert E. Ecklund Charles Fitch Lawrence A. Green
William H. Edwards Edmond B. Flink Robert Green
Richard H. Egdahl Timothy Foley Stephen B. Greenberg
Roger Egeberg Michael Fordis Norton J. Greenberger
Hans E. Einstein Arthur Fox Robert Greenes
Robert S. Eisenberg Raul Fraide Lazar J. Greenfield

445
 M E D I C I N E : P R E S E R V I N G T H E PA S S I O N I N T H E 2 1 S T C E N T U R Y

Beverly June Gregorius Allen Hinman J. W. Johnson

Ward O. Griffen, Jr. Joan E. Hodgman Marvin E. Johnson
Janet Grignon Daniel Hoffman Harry S. Jonas
James A. Grimes Wu Hokwang Olga Jonasson
Paul Griner John H. Holbrook Lawrence W. Jones
David S. Gullion Hans Asbjorn Holm Albert R. Jonsen
Rolf M. Gunnar Grace Holmes P. B. Jorgensen
Warren G. Guntheroth Rita B. Hopper Desmond G. Julian
Michael Hagen Louis Horlick Ralph C. Jung
Jeffrey A. Hahn Sylvan H. Horwood Charles L. Junkerman
Daniel Hamaty Cyril Houle Maurice J. Jurkiewicz
David A. Hamburg James D. Houy Norman Kahn
Jean Hamburger Sidney Howard Mehwet Kam
James T. Hamlin, III James T. Howell Rokay Kamyar
Steven Hamman Willard J. Howland Thomas Edward Kane
C. Rollins Hanlon J. P. Hubbard W. Kane
Richard J. Hannigan Thomas Harrison Hunter Stanley Kaplan
Louise Hart J. Willis Hurst Manny J. Karbeling
William Hart F. Ikezaki Harvey R. Kaslow
A. McGehee Harvey James M. Ingram Jerome P. Kassier
Paul Harvey Thomas S. Inui D. Kassum
W. Proctor Harvey Julien H. Isaacs Laurence H. Kedes
James N. Haug Nicolas Jabbour Gary Kelsberg
Robert M. Hayes Marcia Jackson Robert Kerlan
H. Ralph Haymond Donald M. Jacobs Louis J. Kettel
R. Brian Haynes Karin E. Jamison Kaye Kilburn
L. Julian Haywood Charles L. Janes M. Kenton King
Katherine Hecht Stephen Jay Richard Kingston
Robert Hecht Harold Jeghers David M. Kipnis
Eugene M. Helveston Frederick R. Jelovsek Rebecca T. Kirkland
Bruce L. Henderson Thomas M. Jenkins Joseph B. Kirsner
Robert W. Henderson M. Harry Jennison Rodanthi Kitridou
Eva H. Henriksen Wu Jieping Margaret S. Klapper
John Bernard Henry Carol Johnson Johns Gerald Klatskin
Lester T. Hibbard Allen H. Johnson Suzanne B. Knoebel
Lawrence Highman Cage Johnson Malcolm Knowles

446
 INTERVIEWEES AND CORRESPONDENTS

Chris Kraft A. J. Lindgren Margaret McCarron

Richard O. Kraft Karen Lindsay Robert N. McClelland
Gabriel A. Kune G. Littenberg Ruth McCormick
Gustavo G. R. Kuster Nancy M. Lorenzi Clement J. McDonald
Robin B. Lake William Loskota C. E. McDonnell
Frank L. Lambert Leah M. Lowenstein Walter R. McFarland
Richard H. Lampert Richard Lubman Page M. McGirr
F. Wilfrid Lancaster Robert J. Luchi Charles H. McKinna
Donald G. Landale Frederick Ludwig John McMichael
Tom Landry George D. Lundberg I. R. McWhinney
Robert A. Larsen Joseph Lydon Sherman M. Mellinkoff
Jeffrey Latts Garrett R. Lynch Kenneth Melmon
Peter Lawin George Macer Robert C. Mendenhall
G. Hugh Lawrence Donald N. Mackay Pat Mensah
Aubrey Leatham Ian R. Mackay Henry S. Metz
Joshua Lederberg Robert Mager Thomas C. Meyer
Jeffrey S. Lee W. E. Malle David Micaelvitch
Peter V. Lee Susan B. Mallory William Millard
Philip R. Lee Robert T. Manning George E. Miller
John M. Leedom Charles M. March Jacqueline D. Miller
Wenzel A. Leff N. M. March Perry L. Miller
Howard A. Leibman Eugenia Marcus William Richey Miller
Thomas J. Lehar Alexander R. Margulis Don Harper Mills
John N. Lein E. Connie Mariano Donald S. Minckler
Michael A. Lemp Helen E. Martin Shri K. Mishra
Patrick D. Lester Maurice J. Martin Malcolm S. Mitchell
C. Robin LeSueur Ralph B. Martin Dan Mohler
Leo L. Leveridge Manuel Martinez-Maldonado R. W. Montgomery
Ceylon S. Lewis, Jr. Byron J. Masterson Pat Mooney
Jerry P. Lewis Nina W. Matheson Francis D. Moore
Richard P. Lewis James L. Mathis Dean H. Morrow
Walter M. Lewis Gastone Matioli David H. Morse
Fred V. Light William Matory Robert H. Moser
William Liley Betty H. Mawardi James M. Moss
Thomas Lincoln Paul E. Mazmanian Edward Movius
Donald A. B. Lindberg Andrew McCanse Richard H. Moy

447
 M E D I C I N E : P R E S E R V I N G T H E PA S S I O N I N T H E 2 1 S T C E N T U R Y

Cheryl A. Moyer R. H. Palmer Rangasamy Ramanathan

Donald R. Moyes Robert L. Palmer Eli A. Ramirez-Rodriguez
John F. Mueller P. J. H. Pansegrouw Elizabeth Ramirez-Rodriguez
John H. Mulholland Theodore Pappas K. J. Rao
W. V. Murowsky John Parboosingh Samuel I. Rapaport
Daniel M. Musher Dilip Parekh C. Thorpe Ray
Alvin I. Mushlin Charles E. Parker Joe Redding
Jack D. Myers James L. Parkin Frank Reed
Richard Nabours Richard P. Parkinson Peter L. Reichertz
Frederick Naftolin William W. Parmley J. S. Reinschmidt
Richard H. Nalick Joseph Paterno Richard J. Reitemeier
Stephen Nazarian E. Mansell Pattison Linda J. Rever
William D. Nelligan Stephen G. Pauker Ralph D. Reynolds
Eugene C. Nelson Beverly C. Payne Telfer B. Reynolds
Janet Nelson Meredith J. Payne William A. Reynolds
Victor Neufeld Gee Pei Richard D. Richards
Anita Newman Jeffrey H. Peters Robert Richards
Edward Newton Ruth K. Peters Benjamin M. Rigor
Charles H. Nicholson Robert G. Petersdorf Jesse D. Rising, III
John T. Nicoloff Hans E. Peterson Brooke Roberts
Nancy Nielson-Brown Roger Peterson James M. Robertson
Lilia F. Nikolaeva Donald Petit Carroll M. Robie
Robert A. Nordyke Thomas A. Petro L. Rodney Rodgers
Jackson Norwood Ronald J. Pion Jonathan E. Rodnick
Celia M. Oakley Nicholas Pisacano John Romano
Claron L. Oakley Lynn Pittier Robert Rosati
Byron Oberst Gerald I. Plitman Donald H. Rose
Richard L. O’Brien Hiram C. Polk, Jr. Margaret Rose
Alton Ochsner Bernard Portnoy Noel R. Rose
Frederick C. O’Dell, Jr. John Premi Robert M. Rose
Kunio Okuda Gretchen P. Purcell Edward C. Rosenow, Jr.
Wesley M. Oler Barbara Quint Joseph F. Ross
D. E. Olson George J. Race Herbert J. Rothenberg
Claude H. Organ, Jr. Derek Raghavan Edward Rubenstein
Edwin L. Overholt Robert C. Rainie Robert Rude
Irvine H. Page Robert E. Rakel Ian E. Rusted

448
 INTERVIEWEES AND CORRESPONDENTS

Robb H. Rutledge Mark E. Silverman Oscar Streeter

David C. Sabiston, Jr. George M. Simpson Jeffrey K. Stross
David L. Sackett Maureen Sims Patricia J. Stuff
Paulette Y. Saddler Marjorie S. Sirridge Stephen Sullivan
Alfredo A. Sadun S. E. Sivertson James M. Swain
Murray Salkin Harold Skalka Donald M. Switz
Paul J. Sanazaro David Slawson Lee R. Talbert
Marilyn Sanders Henry Slotnick Dorothy Tatter
Jay P. Sanford J. Orson Smith Clive Taylor
Yoichi Satomura Lloyd H. Smith, Jr. Annabel J. Teberg
Ragheb Sawires Robert B. Smith, III Jack E. Tetirick
John L. Sawyers Ronald E. Smith John Thayer
Andrew I. Schafer Eric W. Sohr Joe Theil
Irwin J. Schatz Bjarte G. Solheim Leigh Thompson
Robert Scheig Jane Somerville George W. Thorn
DuWayne Schmidt Walter Somerville John Toews
Harold M. Schoolman Eli Sorkow David Torin
Alvin Schultz Robert D. Sparks Gary Toule
M. Roy Schwarz Robert L. Spears Richard Treiman
Hervey D. Segall Harold M. Spinka Donald Trunkey
Milton M. Seifert, Jr. John A. Spittell, Jr. Suzanne Trupin
R. Rick Selby Steven Stain Susan B. Tully
Donald Wayne Seldin Eugene A. Stead, Jr. Philip A. Tumulty
Hugh Shade William Stead Marvin Turck
Edward Shapiro Knight Steel Fred Turrill
Om Sharma David Steinman Edmund E. Van Brunt
Jiaqi Shen G. Gayle Stephens Stanley van den Noort
Sheila Sherlock Lorin Stephens Joseph P. Van Der Meulen
Kenneth I. Shine W. Eugene Stern J. Van Dyke
William C. Shoemaker Roger Stickney John F. Viljoen
Edward Shortliffe Margaret T. Stockstill Richard W. Vilter
Linda D. Shortliffe Gene H. Stollerman Jean-Louis Vincent
Jerry M. Shuck Daniel C. Stone Jan Vleck
Ira A. Shulman Patrick B. Storey Robert Volpe
A. A. Siddiqui C. F. Stout Kenneth Walker
Jill K. Silverman John S. Strauss Gary L. Walkup

449
 M E D I C I N E : P R E S E R V I N G T H E PA S S I O N I N T H E 2 1 S T C E N T U R Y

Marsha Wallace Claude E. Welch Frank Woolsey

Betty Wallerstein Dennis K. Wentz Harold Wooster
Ralph Wallerstein Murray Wexler Eton W. Wright
Lila Wallis G. M. Whitacre Kerry E. Wylke
Alexander J. Walt G. E. Wiebe Milford G. Wyman
Richard F. Walters George D. Wilbanks James B. Wyngaarden
Waltman Walters Hibbard E. Williams Rosalyn S. Yalow
John Walther Martha E. Williams Sadahiro Yamamoto
Paul H. Ward Warren Williams Myron Yanoff
William C. Waters, III John Williamson J. Young
David E. Waugh Robert J. Williamson James B. Young
Fred A. Weaver Marjorie Price Wilson Lawrence E. Young
Lawrence L. Weed Deborah A. Wing Stuart C. Yudofsky
Paul F. Wehrle George Winokur Rex C. Yung
Laurel Weibel Alice Witkowski Martin Zane
Max H. Weil John E. Wolf, Jr. Christopher K. Zarins
Horst D. Weinborg Francis C. Wood Bruce E. Zawacki
John M. Weiner Thomas C. Wood Samir M. Zeind
James M. A. Weiss Sherwyn M. Woods Israel Zwerling
Mark W. Weiting

450
 Name Index

...

Ackerman, Michael, 147–148 Bernstein, Maurice, 316

Adler, Mortimer, 9, 53 Bessman, Alice, 392, 398–399
Alford, Bobby R., 89– 90 Best, Peter, 231
Alfrey, Clarence P., 192 Billings, John Shaw, 59–60
Askey, John, 259 Bird, Daniel, 235–236
Avery, Oswald T., 68 Blackburn, John, xxvii–xviii
Bloomfield, Arthur, 336
Bacon, Francis, 145 Blumberg, Baruch, 4
Bain, Ruth, 393, 395 Bohannan, Paul, 349
Bakhtiar, Lailee, 387–388 Boone, Joel, 415
Balchum, Oscar, 212–213 Bowey, Walter, 353
Balint, Michael, 318 Braunwald, Eugene, 72, 77–78
Bardsley, William, 350 Brook, R.H., 340
Barge, J. Arnold, 312–313 Brown, Bernice, 392, 396
Barnett, George De Forest, 335–337 Bruch, Hilde, 312
Barondess, Jeremiah, 274 Brunicardi, Charles, 7, 64, 238–239
Barr, David, 320–321 Brunner, J.S., 93
Bauer, Julius, 261 Buchanan, Barbara, 391
Beck, Robert, 194, 197 Buck, Francis, 351
Beeson, Paul, 48–49, 208, 236 Buckley, William F., Jr., 305
Behnke, Roy, 17 Budd, William, 268
Bennett, Bill, 321 Burger, Charles, 160–161
Berge, Kenneth, 206–207, 235 Burk, Genevieve, 392

451
 M E D I C I N E : P R E S E R V I N G T H E PA S S I O N I N T H E 2 1 S T C E N T U R Y

Burnett, Leo, 154 Ebbin, Allan, 65

Burns, Thomas, 258 Eichna, Ludwig, 81
Burwell, C. Sidney, 109 Eijkman, Christjaan, 94
Bush, President George, 413 Elgart, Marvyn, 320–321
Bush, President George Herbert Walker, 407 Elgee, Neil, 204
Byyny, Richard, 69–70, 205
Farber, Saul, 7, 259, 261, 263, 301
Callister, Thomas, 64 Farinola, Gerald, 231
Caplan, Richard, 229, 232 Feder, Aaron, 220–221
Carlsen, Tor, 285 Feigenbaum, E.A., 179–180
Castel, William, 260 Feigin, Ralph, 146, 256
Caton, Cathleen, 346 Feinstein, Alvan, 138
Chambers, Kit, 389–390, 395–396 Feinstein, Donald, 235
Chambers, Wallace, 204 Feray, Cotton, 351
Cherny, Walter, 315 Field, Richard, 65, 262, 264
Christakos, Arthur, 315 Fischer, Paul, 124
Churchill, Winston, 209–210 Fleming, Alexander, 94
Clark, Gail, 392–393 Folkman, Judah, 64
Cleaveland, Clifton, 257 Fordis, Michael, 170–171
Clemenson, Steven, 327 Fowler, James, 54–55
Clever, Linda, 259 Fox, Arthur, 261
Clintworth, William, 191, 195–199 Freud, S., 137 – 138
Cochrane, Archie, 138 Friedman, William F., 78
Codman, E.A., 279–280 Fry, John, 269 – 270
Cogan, David Glendenning, 5–6
Cohen, Jordan, 12, 371, 421 – 422 Gage, Mims, on Michael DeBakey, 28
Cohn, Lawrence, 155–156, 206, 285 Geyman, John P., 124, 132 – 134, 319
Confucius, 58–59 Glaser, Robert, 300
Cooper, William, 270 Goldschlager, Arnold, 284
Cotsonas, N.J., Jr., 340 Goldschlager, Nora, 401–402
Covell, David, 66–67, 210 Gonnella, Joseph, 215, 340
Creek, Jean, 205 Gonzalez, Pancho, 322
Cruess, Richard, 426 Goodell, Brian, 215, 264
Cruess, Sylvia, 426 Goran, M.J., 340
Cushing, H., 64–65 Gordon, Alan, 71, 262
Green, Lawrence, 65
Da Costa, Jacob M., 57 Greenberg, Stephen, 164, 169, 256
Dale, Andrew, 208 Greenberger, Norton J., 7, 14, 65–66, 107,
Davis, David A., 243 275 – 276
Davis, William, 239 Greenes, Robert, 162
DeAngelis, Catherine D., 251–252 Greenfield, Lazar, 5–6
DeBakey, Lois, ix–x, xiv, xvii–xviii, 1, 60, Gregorius, Beverly, 397
123, 145, 191, 297, 417 – 418 Grossman, Morton, 336
DeBakey, Michael, 4, 8, 21–24, 280–281, Guyatt, Gordon, 141
297, 418
de Chauliac, Guy, 95 Halle, John, 217
Donaldson, R., 340 Hamburg, David A., 180
Dooley, James, 219 Hamburger, Jean, 5
Duggan, Eileen, 387 Hamman, Steven, 349
Durant, Will, 260 Hanlon, C. Rollins, 303

452
 NAME INDEX

Harper, Harry, 44 Lantz, K.H., 274

Hart, William, 347 Larson, Scott, 272
Harvey, A. McGehee, 291, 336, 337 Latham, Peter Mere, 227, 267, 282, 355
Harvey, Paul, 222 Lawrence, Hugh, 237
Haymond, H. Ralph, 208, 262 Lederberg, Joshua, 179–180
Haynes, R. Brian, 135–136 Lee, Peter, 322–323
Herrick, W.W., 202 Lee, Philip, 298–300
Highman, Lawrence, 232 Leff, Wenzel A., 231, 233
Hippocrates, 201, 224, 439 Lein, Jack, 229
Hodgman, Joan, 392–393, 395 Lempert, Julius, 95–96
Hoffman, Daniel, 231 Leriche, RenÈ, 28
Holmes, Oliver Wendell, 9–10, 39, 229 Levine, Maury, 13
Houle, Cyril, 11 Levine, Sam, 221
Howard, Sidney, 263 Lewis, Howard P., 321
Hubbard, Bill, 81 Lewis, Richard, 311, 320, 336 – 337
Hui, S.L., 342 Lewis, Sir Thomas, 44, 60
Hunter, Kathryn Montgomery, 306 Lincoln, Thomas, 154, 170, 419
Hunter, Thomas, 300 Lindberg, Donald A.B., 187, 193 – 195, 199
Hurst, Willis, 7–8, 15 Lock, Stephen, 140
Huth, Ed, 139–140 Locke, John, 3
Logue, Bruce, 48–49
Issenberg, S. B., 171 Longcope, Warfield T., 311
Longmire, William P., Jr., 307–308
Jacobs, Donald, 231 Luchi, Robert J., 113 – 114
Jamison, Karin, 229, 387–388, 397 Ludwig, Frederick, 67, 207, 213, 234
Jeghers, Harold, 12 Lundberg, George, 185
Johns, Carol Johnson, 333 Lydon, Joseph, 213
Johnson, Samuel, 157, 209 – 210 Lynch, Garret T., 2 – 3, 256, 274
Jonasson, Olga, 258
Jonsen, Albert, 298 MacCallum, W.G., 307
Jorgensen, P.B., 231 McCormack, J. N., xxvii
Julian, Desmond, 204–205, 214–215, 222, McDonald, Clement, 156–157, 342, 354
224–225, 238 McGirr, Page, 347, 352
Mackay, Ian, 69, 123, 125, 129 – 130, 212,
Kamyar, Rokay, 231 224 – 225, 237 – 238, 287
Kelsberg, Gary, 130–132 MacKenzie, Sir James, 44, 268
Kettel, Louis, 322 MacKinley, Charles, 322
King, Kenton, 350 Macleod, Colin M., 68
Kirkland, Rebecca, 315 McMichael, Sir John, 212
Kirschner, Martin, 28 McWhinney, I.R., 319
Knoebel, Suzanne, 66 Maimonides, 91
Knowles, John, 7 Manning, Phil R., ix–x, xiii–xv, xvii, 123, 145,
Knowles, Malcolm, 11 191, 417
Koeher, Theodor, 94 Manning, Robert, 9, 262
Kraft, Chris, 341 Mariano, Connie, 407–408
Kuster, Gustavo, 213, 281 Martinez-Maldonado, Manuel, 205
Matioli, Gastone, 68
Laidlaw, Jack, 138 Matory, William, 372–373
Lambert, Frank, 342 Maugham, Somerset, 10, 306
Landry, Tom, 278–279 Mayo, Charles, 213, 255–256

453
 M E D I C I N E : P R E S E R V I N G T H E PA S S I O N I N T H E 2 1 S T C E N T U R Y

Mayo, Will, 213 Pope, Alexander, 95

Mazmanian, P. E., 16 Postman, L., 93
Mellinkoff, Sherman, 14, 83, 223 – 224, 291, Premi, John, 211
333–334 Price, Philip B., 308
Meyer, Thomas, 273–274
Miller, George, 11, 339 Race, George, 229
Miller, Jacqueline, 386, 389, 391, 393 – 394, 398 Ralston, Dennis, 322
Mills, Don Harper, 357 Rankin, W. S., xxviii
Mohler, Dan, 67 Rapaport, Samuel, 236, 261
Moore, Carl, 350 Rappleye, Willard C., xxviii
Moore, Francis, 202, 207, 238, 313 – 314, Ravitch, Mark, 336
349–350 Ray, Thorpe, 258
Morehead, M.A., 340 Reid, R.A., 274
Morse, David, 194–195, 197–199 Reitmeier, Richard, 312–313, 353–354
Moser, Robert, 58, 66, 317–318, Reynolds, Sir Joshua, 209–210
417–420 Reynolds, Telfer, 276
Moss, James, 71, 203, 237 Rich, Arnold R., 307
Moynihan, Sir Berkeley, 8 Richards, R.D., 220
Musher, Daniel, 147 Rising, Jesse, 228
Rodgers, Rodney, 262
Nazarian, Stephen, 148 Rodnick, Jonathan, 319–320
Nossal, G., 179–180 Rosen, Sam, 95 – 96
Rubenstein, Arthur, 69–70
Oakley, Celia, 276–278 Rubenstein, Edward, 232
O’Brien, Richard, 64
Ochsner, Alton, 22, 31 – 32, 64 – 65 Sabiston, David, 24, 71, 214
O’Dell, Frederick, 213 Sackett, David, 60 – 62, 124 – 125, 138 – 139
Okuda, Kunio, 211, 313 – 315 Sadun, Alfredo, 5
Organ, Claude, 228, 238 – 239, 324 Salkin, Murray, 346–347
Osler, William, 3, 9, 59, 64 – 65, 278, 352, Sampson, John, 105
381–382 Sanazaro, Paul, 3
Overholt, Edwin, 257 Sarton, Gene, 73
Satomura, Yoichi, 148
Page, Irvine, 4, 68, 202 Sawires, Ragheb, 231
Palmer, Robert, 234 Schafer, Andrew, 117
Parboosingh, John, 163 Scheff, D., 340
Parker, Charles, 315–316 Schultz, Alvin, 203
Parkinson, Richard, 264 Seldin, Donald, 68, 72
Parmley, William W., 99–100, 219 Seneca, 253
Pasteur, Louis, 5, 91, 93, 95 Shapiro, Edward, 212 – 213, 220
Paterno, Joseph, 279 Shaw, George Bernard, 3–4
Pattison, Mansell, 13 Shen, Jiaqui, 58
Paz, Octavio, 17 Sherlock, Dame Sheila, 390, 393
Peabody, Francis, 83 Shine, Kenneth I., 429–430
Pepper, O.H. Perry, 259 Shortliffe, Edward, 72, 153–154
Percy, Walker, 306 Shortliffe, Linda, 388, 394, 397
Petit, Donald, 232–233 Sibley, J.C., 245
Pickles, William, 268 Sigerist, Henry, 308
Plitman, Gerald, 59, 67 Sims, Maureen, 393
Pollack, Seymour, 322–323 Sivertson, S.E., 273 – 274

454
 NAME INDEX

Slawson, David, 127–129, 133 Van Der Meulen, Joseph, 58, 257
Smith, F.E., 210 Vilter, Richard, 9
Smith, Lloyd, 260–261 Vleck, Jan, 126, 131
Smith, Robert, 277 Volpe, Robert, 204
Somerville, Jane, 278
Somerville, Walter, 221, 276 Walker, Kenneth, 42
Spinoza, Benedict de, 125–126 Wallace, Marsha, 240
Starfield, R., 340 Wallerstein, Ralph, 260
Starr, Paul, 424 Walther, John, 283–284
Stead, Eugene, 4, 14–15, 24, 164 Waters, William, 70, 257, 261
Stephens, Gayle, 318 Weed, Lawrence, 14–15, 160
Stephens, Lorin, 204 Weed, Lincoln, 160
Stevenson, R.L., Jr., 340 Wehrle, Paul, 69, 217, 238
Stickney, Roger, 348, 352 Weibel, Laurel, 386–387, 393
Stollerman, Gene, 311 Weiner, M., 342
Stone, Daniel, 65, 223 Welch, William Henry, 294
Storey, Patrick, 229 Wells, H.G., 210
Streeter, Oscar, 154 Wentz, Dennis, 371–372, 379–380
Sullivan, Stephen, 148–149, 168 Wesselhoeft, Conrad, 349–350
Switz, Donald, 67 White, Paul Dudley, 44–45, 275
Sydenstricker, V.P., 44–45 Whitehead, Alfred North, 9, 14
Williams, Warren, 220, 269 – 273, 343
Tawney, R.H., 53 Williamson, John, 60, 339–340
Thayer, William, 336 Williamson, R.J., 207
Thompson, Leigh, 256, 258 Wilson, Marjorie Price, 386, 395
Thorn, George, 218 Wolf, John, 146
Toews, John, 164–165 Wood, Paul, 221, 276, 288
Travell, Janet, 413, 415 Wood, Thomas, 202
Treiman, Richard, 203–204 Woodward, Theodore E., 381–382
Tully, Susan, 391 Wu Jieping, 10, 230
Tumulty, Philip, 83, 85 – 90, 336 – 337 Wyngaarden, James, 263–264
Turck, Marvin, 261–262
Turrill, Fred, 214, 349 Yamamoto, Sadahiro, 204
Tuttle, Judge Elbert, 53 Youmans, John B., xxviii
Twain, Mark, 146 Young, James, 10 – 11, 63 – 64, 234, 263
Yudofsky, Stuart, 312
Udvarhelyi, George, 87
Zawacki, Bruce, 277 – 278, 281, 298, 300

455
 Subject Index

...

Academia, learning by members of, 205–206 American Academy of Ophthalmology (AAO)

Access to information, as an attribute of its publications of, 375
utility, 127 Web site of, 376
Accreditation Council for Continuing Medical American Academy of Orthopaedic Surgeons
Education (ACCME), 92–93 (AAOS), 323
reorienting to evidence-based courses, 133 on continuing education, 373
on sponsored education programs, 253–254 Web site of, 376
Accreditation Council for Graduate Medical American Academy of Pediatrics (AAP), Web site
Education (ACGME), 439 of, 376
Accuracy of information, checking, 127 American Board of Family Practice
ACP Journal Club, 128, 133 office record review, as part of certification, 286
origins of, 140 recertification-using online, patient-centered,
Administration, academic, 48–49 problem-solving tests, 173–174
Advice, experts’ need for, 321 American College of Cardiology (ACC)
Alternative medicine, Web-based information continuing medical education at the meetings
about, 184 of, 104, 374
Altruism, as an attribute of a good physician, 424 Heart House of, 376
American College of Physicians, derivative self-directed, practice-oriented education
journal concept of, 140 programs of, 377
American Academy of Family Physicians (AAFP) American College of Obstetrics and Gynecology
continuing education commitment of, 373 (ACOG)
Web site of, 376 educational opportunities offered by, 375

457
 M E D I C I N E : P R E S E R V I N G T H E PA S S I O N I N T H E 2 1 S T C E N T U R Y

ACOG (continued) Attitudes, of patients toward medicine, changing,

ratings of the quality of recommendations of, 318 – 319
131 Attributes, of physicians, nurturing, 4–8
American College of Physicians (ACP) Audit
founding of, 373 for identifying problem areas for discussion,
listing of pertinent Web sites, 153 238 – 239
Medical Knowledge Self-Assessment Program invisible, as a technique for consultation,
(SESAP) of, 308 221 – 222
American College of Physicians-American Soci- self, for evaluating a patient or teaching
ety of Internal Medicine, Web site of, 376 encounter, 319–320
American College of Surgeons, Surgical Educa-
tion and Self-Assessment Program Baylor University College of Medicine, 89
(SESAP) of, 308 Benefits
American Heart Association (AHA), continuing assuring, from formal courses and conferences,
medical education at the meetings of, 104 234 – 236
American Journal of Medicine, 120 expected, of formal courses and conferences,
American Journal of Physiology, 103 229 – 231
American Medical Association (AMA), 372 of teaching, 255–265
Institute of Medical Ethics of, 383 Best Evidence, 142
MEDIS journal text on the Internet, 188 Bibliographic technology, 32–36
policy studies of, 300 Billing data, using for practice analysis, 268
American Society of Bioethics and Humanities, Bookmarks, of Web sites on personal computers,
299 133
Angiotensin converting enzyme (ACE) inhibitors, Brigham and Women’s Hospital, 285
data considered by computer rules about, British Medical Journal, 140
157
Annals of Internal Medicine, 139 – 140 Cambridge Quarterly of Healthcare Ethics, 299
Annual meetings, educational value of, 239–240 Canadian Medical Association Journal, 139
Anomaly, curiosity and observation leading to Cardiac diagnosis, complete, Paul Dudley
recognition of, 94 White’s form for, 45
Aortocoronary artery bypass, Dr. Michael E. Career
DeBakey’s role in development of, 22 fulfilling, preparing for, 85–90, 403–405
Archives of Internal Medicine, 299 military, for a physician, 409–415
Archives of Otolaryngology, 90 triple, physician, wife, mother, 403
Arthroscopy Association of North America, 376 Carotid endarterectomy, Dr. Michael E.
Artificial heart research, Dr. Michael E. DeBakey’s work on, 22
DeBakey’s role in, 22 Case-control studies, critical reading of reports
Art of medicine, 321 of, 62–63
biographies of pioneering physicians, 337 Case presentations, at hospital conferences, 236
Art of self-defense, the physician’s, 359–370 Case-study method, education using, 80
Association of American Medical Colleges Case Western Reserve University, 107
(AAMC) Change
on continuing medical education, 12–13 in the delivery of medical care, 49
Medical School Objectives Project (MSOP), organizational, delivery of care affected by,
424 16
on women in the medical profession, 385–391 Charting, improving, 346
Atlanta Constitution, article from, “Medical Chiba National Hospital (Japan), 314–315
Mistakes Are Killers,” 52 Childbirth and child-rearing, as an interruption
Attendance, at formal courses and conferences, of practice, 388–394
reasons for, 228–231 Circulation, 103
Attention span, and setting for reading, 110 Clinical biographies, 318

458
 SUBJECT INDEX

Clinical Evidence, 128, 142 in establishing informed consent,

Clinical experience 363 – 364
analysis of, 33–34 personal, 317–318
of colleagues, as a tool for identifying reviewing online medical records, 150
problems, 47 skills required of residents, 440
documenting the patient mix, and recording for teaching, 261
procedures and outcomes, 133 using the Internet for, 188
integrating clinical evidence with, 132 Community health, promotion of, as an attribute
as self-education, 86–87 of a good physician, 424
Clinical laboratory, learning from, Community service, commitment to, by
212–213 physicians, 425–426
Clinical Management State (CMS), 162 Companionship, in medicine, 13–14
Clinical practice DeBakey Heart Center example, 31
application of material from continuing departmental conferences, 35
medical education, 247–249 effect on the delivery of care, 16
puzzle-solving in, 440–441 Compassion
Clinical problems as an attribute of a good physician, 424
notation of, 275–278 of physicians, 7–8, 46
teaching reasoning and discipline in the Compensation, of physicians, 433–434
approach to, 258 Competence
Clinical research support, 79–80 avoiding errors through, 342
Clinical screening-tool questionnaires, 149 risks from infrequent practice, surgical
Clinical skills example, 366
and medical technology, 311–312 as evidence of compassion, 7–8, 46
methods that hone, 318–320 as evidence of professionalism, 432
Clinical trials, data from the Cochrane Library, Computerized patient record, 148
131 Computer skills, acquiring, 306
Clinton, President William, 408, 412 Computer viruses, 182
Cochrane Library, evidence-based medicine Conferences, 227–241
articles at, 128, 131 Conference summaries, on Medscape, 1
Collaboration, in teaching, 263 51 – 152
Colleagues Confidentiality, of the physician-patient
learning with, 203–208 relationship, 433
relationships among, 352–355 Conflict of interest
Collegiality in medicine, 13–14 organizational, resulting from the cost of
Collegial network, 201–216 healthcare, 51–55
developing at medical society meetings, and physician education, 253–254
382–383 Consent, for treatment, 363–364
in medicine, 335–338, 438–439 Consultants
support from, 393–394 decisions about calling, 365–366
Common sense, early influences on development one-on-one training from, 414
of, 26 questions to ask of, 219–220
Commonwealth Fund, sponsorship of evaluation for using evidence-based approaches, 133
of continuing medical education, xxviii Consultations
Communication communication about, in conversation, 337
formal and informal exchange of information complicating, 367–368
about meeting presentations, about ethical questions, 299–300
374–375 ideal, 225–226
misunderstanding a physician’s instructions, learning from, 217–226
348 providing, 221–225
between physician and patient reasons for, 218

459
 M E D I C I N E : P R E S E R V I N G T H E PA S S I O N I N T H E 2 1 S T C E N T U R Y

Consumers Critical appraisal, of medical publications,

of healthcare, implications of designation as, 141 – 142
424 Critique, of mortality and morbidity data, 281
patients as, 37 Cumulative data, comparing an individual physi-
Content, as a criterion for selecting a conference, cian’s diagnoses and prescriptions with
232 the average, 275
Continuing education Curbstone conferences, 206–207, 367–368
through collegial relationships, 335–338 Curiosity
current information from, 34–36 importance of, 4–6
general, 437–438 as a reason to keep up in retirement, 115–116
Michael E. DeBakey’s views on, 31–32 stimulating, 6
shipboard lectures for medical corpsmen,
411–415 Daily Prayer of a Physician (Maimonides), 91–92
Continuing Medical Education (CME), 187–189, Data
426 abnormal, from laboratory tests, failure to note
American Medical Association standards for, or act on, 345
372 clinical, available from managed-care
future format for, 104 organizations, 282
for keeping up, by a woman professional, 405 insufficient, acting on, 352
traditional, 245–252 leasing access to, 198
Contraindications, focus on, in treatment, 365 recording, 275
Contributions, social, of physicians, 398–399 Database, electronic, as a source of knowledge,
Conventions 438
ethical considerations discussed at, 299 Database system
selecting material from the schedule at, 374 to help physicians pose clinical questions, 377
Cornell University, 320 hospital, advantages of, 285–286
Coronary artery disease, online screening for, 149 DeBakey Left Ventricular Assist Device, 22
Coronary atherosclerotic disease, risk factors in, Defensive medicine, as an irrational response to
early work, 45 threats, 359
Correspondence, for exchanging information, Delivery of care, studies of changes in, 16–17
208 DENDRAL, early work on artificial intelligence
Correspondents, list, 443–450 with, 179–180
Cost Denial
of e-mail communication, 170 by patients, 348–349
of healthcare by physicians, of significant data, 351–352
growth with technology, 434 Derivative periodicals, new, 142
as a reason for concern in medicine, 51–55 Determination, in lifelong learning, 7
Cost data, report cards for physicians, 284 Diagnostic tests, example of screening written
Cost-effectiveness material for validity, 62
versus cost-saving, 37 Didactic material, on the Web, 183–184
of physical examinations, in eliminating Difference, as an advantage, for a woman and a
unnecessary testing, 320 minority member, 412–413
versus physician’s satisfaction with clinical Diligence, in lifelong learning, 7
work, 316 Dimethylsulfoxide (DMSO), “Sixty Minutes”
Council on Ethical and Judicial Affairs, of the report on, 71
American Medical Association, 383 Discipline, in lifelong learning, 7
Course design, as a criterion for selecting a Disclosure, in communicating with patients, the
conference, 233 art of self-defense in, 364
Credibility, of sponsored continuing education, Discoveries, examples of application of
247 knowledge with observation, 93–94

460
 SUBJECT INDEX

Discussion, about a consultation, 223–224 ePocrates, drug database, 155, 272

Discussion groups, information exchange at, Error
209–212 defensible, 366–367
Distractions, during a physician-patient learning from mistakes, 278
conference, 350–351 reporting, 353–354
Doctors’ Stories (Hunter), 306 Ethics
Documentation, of observing the duty to warn, changing, general and specific attention to,
361 439
Drugs medical code of, 435
information about of physicians, conflicts in evaluating drugs, 52
in connection with World Medical Leaders teaching of, 298
lectures, 152 Evaluation, of continuing medical education
warning patients of the dangers of, 360 factors to weigh for, 248–249
notifying patients of changes in approval of, measures used, 245 – 252
from files, 272 Evidence, meanings of, 141
Duty to warn, of side effects and adverse effects Evidence-based medicine, 123–136, 142
of treatment, 360–363 defined, 141–142
learning from healthcare research, 137–143
Eagle Patient Simulator, 172 Evidence-based Medicine Working Group, 136
Editorials, reading of, in professional journals, guides for critical reading from, 128
69–70 Excel files, 270
Educational activities Excerpta Medica, 70
changes in delivery of care due to, 16 Expected value, as a criterion for selecting a
discussion of practice data, 284 conference, 234
The Effective Clinician (Tumulty), 83 Experience
Effectiveness learning from, 8–13
of continuing education courses, 247 notes on, 276–278
diminished, in complex organized systems, 342 relating reading to, 59
of health care, follow-up of laboratory or Experience-based medicine, complementing
roentgenographic reports, 340–341 evidence-based medicine with, 125
of the physician, factors limiting, 349–352 Experts, advice about fundamentals for, 321
Electronic mail (e-mail), 168–170, 329–331
for enriching the physician-patient Faculty
relationship, 329–331 as an attraction in selecting a conference,
Electronic resources, 152–154 232 – 233
electronic medical records (EMRs) full-time, 259–262
improving healthcare delivery with, 327 See also Teachers
services for physicians, 150 Family
Web-enabled, for ambulatory care, 197 parents as an influence in choice of career,
E-mail. See Electronic mail 25 – 27, 43 – 44
Emory University School of Medicine, 48–49 and professional careers, 403–405
Employees, to help in the home, 391, 403–404 Family physicians, choice of course subject in
Encyclopaedia Britannica continuing education, 245
11th edition, 307 Feedback, from patients about treatment, 33
online information from, 153 Flow sheets, 345
links to, 184 Follow-up
Endoscopic sinus surgery (ESS), simulator for, after consultation, 224–225
171–172 lack of, as a source of error, 346–347
Enjoyment, of physicians in their work, 3–4 patients who fail to appear, duty to warn,
Enoch Pratt Free Library, 307 362 – 363

461
 M E D I C I N E : P R E S E R V I N G T H E PA S S I O N I N T H E 2 1 S T C E N T U R Y

Foraging, for information to keep up, 129, Health professional, non-physician, learning
132–133 from, 215
Formal courses, 227–241 Healthy PalmPilot (Web site), 154
Form-Based Clinical Guidelines, 327 Hearing impairment, from otosclerosis, treating,
Free-market healthcare economics, burdens of, 95 – 96
120–121 The Heart (Hurst), 42
Fundamentals, experts’ need for advice on, 321 student-enlisted help in preparing a self-
Future, of evidence-based medicine, 142–143 assessment book for, 47–48
Heart Disease (Braunwald), 79
Gag rule, preventing physicians from communi- Heart House, of the American College of
cating managed care decisions to Cardiology, 376
patients, 418 Hippocrates Web site, 154
G-care language, 157–158 Hippocratic Oath, 423
Generalized Anxiety Disorder (GAD), example of Historical perspective, reading with, 68–69
using the computer and questions in History, sense of, 29–30
clinical practice, 166–167 Honesty, as an attribute of a good physician, 424
General reading, aids to, 69–70 Honors and awards, Michael E. DeBakey’s,
Goals 23 – 24
for obtaining or reviewing information, 129 Hospitalist, development of profession as in the
of the Regenstrief Medical Records System, United States, 317
156 Hospitals
Grand Rounds, for a practice, 272–273 conferences offered by, 236–240
Grateful Med searching strategy, 193 databases of, 155–156
Group practice, communication among HotSync, of Palm to a computer, automatic
physicians in, 203–205 update of ePocrates, 155
Group study Household management, women’s responsibility
evaluation of knowledge gained in, 212 for, 387
outcome of, and group size, 246–247 Humanitarianism, in medicine, 38
Guidance, moral and spiritual, from parents, 27 Huntington Hospital, study group at, 210
Guidelines, selecting and using, 368–369 Hypothyroidism, recognizing, 94

Habits, influential, 305–309 Illegibility, of medical records, 345–346

Hammersmith Hospital (London), 205 Inattention, of the physician, as a barrier in the
Hardware, obsolescence of, and preservation of physician–patient relationship, 349
data, 182 Independent Physicians Association (IPA),
Harrison’s Principles of Internal Medicine, 79, 81 review of recent practices, 284
online availability of, 155 Index Medicus, information from, 32
Harvard Medical School, 421–422, 429–430 Infectious Disease Alert, 70
Harvard Medical School Health Letter, 71 Inflammatory bowel disease, the physician–
Hastings Center Report, 299 patient relationship as a therapeutic tool,
Healthcare ethics committee (HEC), self- 312 – 313
education of members of, 299 Influences
Healthcare Ethics Committee Forum, 299 early, in preparing for a career in medicine,
Health Care Financing Administration (HCFA), 25 – 28
audit of health plans, 282–283 of Paul Dudley White on medical students and
Healthcare providers, physicians as, 37 colleagues, 45
Healthcare research, learning from, 137–143 InfoRetriever, 131, 133
Health Maintenance Organizations (HMOs), 426 Informatics, potential approaches using,
Health Plan Employer Data and Information Set 162 – 163
(HEDIS), evaluation of managed-care Information
organizations by, 282–283 accessing, 116

462
 SUBJECT INDEX

computer-generated, 110 Japan, organization of group practice in, 204

evidence-based, utilizing, 16 Japanese Association of Medical Informatics, 148
making use of, responses to abnormal John Bull’s Other Island (Shaw), 3
laboratory reports, 339 Johns Hopkins University, 83, 303
from medical societies, 382–383 Johns Hopkins University Medical Institutions,
about patients, from a reporters’ set of interdisciplinary informal program at, 87
questions, 47 Johns Hopkins University Medical School,
from professional organization bulletins and 99 – 100, 291
newsletters, 301 Journal of Applied Physiology, 103
thinking as the realignment of, 50 Journal of Clinical Ethics, 299
useful, attributes of, 127 Journal of Family Practice, Evidence-Based
Information management, future of, in integrating Practice, 129
and utilizing data from different sources, Journal of the American College of Cardiology,
197 100, 103
Information technology Journal of the American Medical Association,
burdens of innovations in, 120–121 63 – 64, 92, 141, 299, 372 – 373
for implementing self-directed continuing Journals
medical education, xxix advertising in, ethical considerations, 253–254
Institute of Medical Ethics, of the American availability of, online, 195
Medical Association (AMA), 383 Judgment
Institute of Medicine, 342 decisions dependent on, 364–367
Intangibles of health care, 419–420 education for, by interacting with colleagues,
Integrity, as an attribute of professionalism, 48
433
Interactive phase, of continuing medical educa- Keeper, the physician as, 359–360
tion programs, 104 Keeping up to date, 101–105
materials for, 375 with a specific area of interest, 129
Interdisciplinary interactions, in continuing Kellogg, W. K. Foundation, grants to develop
education, 35 continuing medical education, xxix
Internet Knowledge
effect of, on the physician–patient relationship, acquiring, 92
315 acquiring from colleagues, as medical
information from, 32–33, 93 education, 102–103
for physicians in retirement, 116 changes in the processing of, 182–183
quality of, 146 first-hand, 9–13
Joshua Lederberg work on, 181 medical, problems unrelated to in practice,
as a source of information for guidance in 339 – 356
medical dilemmas, 306 of participants in a small group study program,
use of, by medical societies, 376 evaluation of, 212
Internet Grateful Med, 193 political interpretation of possession of, 58
Interpersonal skills, required of residents, required of residents, components of, 440
440 for teaching, matching with communication
Intervention skills, 261
comparison of choices, 132 Knowledge Coupler, 175
framing questions in terms of, 131
Interviewees, list, 443–450 Laboratory Automation Project, Los Angeles
Involvement County-University of Southern California
individual, 298–300 Medical Center, 187
opportunities for, 297–298 Laboratory data, 344–345
“I View with Alarm” (J. Willis Hurst), the direc- inconsistent, identifying and correcting errors,
tion of medical training, 50–51 353

463
 M E D I C I N E : P R E S E R V I N G T H E PA S S I O N I N T H E 2 1 S T C E N T U R Y

Laboratory work, limiting use of, in consultation, backlash against, 425

222 rewards for physicians limiting patient costs,
The Lancet, 63–64, 70 418
Language, importance of, to physicians, 30–31 Managed-care control, and the quality of
Learning teaching, 50–51
active, in continuing education, 35 Managed-care organizations, clinical data avail-
from consultations, 222–223 able to, from claims data, 274
from healthcare research, 137–143 Managed costs, 36–37
lifelong, 245–252 Manager, the physician as, 343
medical information technology as an instru- Mars Climate Orbiter (MCO), error leading to
ment for, 145–178 failure of, 341
from mistakes, 278 Massachusetts Institute of Technology, electronic
motivation for, 397–398 scientific journal at, 188
passion for, in continuing medical education, Mathematics, importance of, 30
104–105 Mayo Clinic Health Letter, 71
personal responsibility for, 293–295 MDConsult, information from textbooks and
practice as a component of, 50 journals online, 158–159
self-directed, 11–13 Media, reading in, 71
from teaching, 253–265 Medical Alert, 70
lecture revision, 261–262 Medical and Chirurgical Faculty of Maryland, 382
Learning centers, of medical societies, at their Medical College of Ohio, 185
headquarters, 376 Medical errors, 339–356
Learning diary, 164–168 MedicalInfoPointer, daily e-mail update of
Lecture courses, on the Internet, 152 current primary-care articles, 129
Letters to the editor, reading, in journals, 70 Medical Informatics, defined, 327
Librarian, medical Medical Information Service via Telephone
for help in learning to use search tools, 133 (MIST), University of Alabama service,
for identifying relevant information, 128 207 – 208
Libraries, role in linking information with Medical information technology, 145–178
customers, 194–195 Medical knowledge, required of residents, 440
Lifelong learning Medical Knowledge Self-Assessment Program
kinds of study for, 437–438 (MKSAP), 70, 210
need for, 2–3 Audio Companion for, 375
Limitations, of annual meetings, 239–240 The Medical Letter, 70, 92
Links, among Web sites, evaluating, 184 Medical library, 191–199
Literature, learning from, 29–30 Medical Matrix, 153 – 154
on-site peer review at, 196
McMaster approach, framework of steps for, Medical organizations, participation in, by
126–127 women, 395
McMaster University, 135, 243 Medical practice
Department of Clinical Epidemiology and incorporating new information into,
Biostatistics, 143 247 – 249
Maintenance of Certification Program, of the incorporating valid information into, 129
Royal College of Physicians and Surgeons Medical publications, critical appraisal of,
of Canada, 167–168 139 – 141
Maintenance of Competence Programs Medical records
(MOCOMP), to facilitate practice-based coding the quality of evidence-based medicine
learning, 163– 167 decisions on, 130
Mammograms, computer rules about, variables as a source of error, 345–346
included in, 157 Medical schools, selecting students with the
Managed care, 36–38 attributes of effective clinicians, 86

464
 SUBJECT INDEX

Medical technology, rapid changes in, Joshua Lederberg role in missions to Mars, 180
181–189 National Center for Biotechnology Information,
“Medical truths,” 101–102 development of PubMed at, 193
Medicine, integrating the art and science of, National Committee on Quality Assurance
119–121 (NCQA), 282–283
MEDIS, journal text from the Journal of the National Health and Medical Research Council
American Medical Association, 188 (NHMRC), taxonomy of evidence
MEDLINE developed by, 129–130
accessing through Medscape and WebMD, National Heart Institute, 99–100
151–152 National Library of Medicine (NLM), 306
development and use of, 192 development of MEDLINE at, 192
and speed of publication, 183 PubMed Central (PMC) of, 183
Medscape, 151–152 Visible Human Database of, 171–172
on-site peer review at, 196 National Medical Association (NMA), 372–373
Medscape Select, 151 National Mental Health Association, screening
“Medscape Wire” news service, 152 tool for depression developed by, 149
Memory, reducing reliance on, 14–15 National Reference Center, 299
Mental summaries, of reading material, as a Nature, 120
learning tool, 64 Nearer My God (Buckley), 305
The Merck Manual, online, 153 Needs, learning, determination of, 246
METI simulator, 172 Network
Microsoft Access files for manipulating data, of information among physicians, 202
Food and Drug Administration, 270 telephone, 207–208
Mind, prepared, 91–98 The New England Journal of Medicine, 64, 71,
Mobile Army Surgical Hospitals (MASH units), 92, 120, 299
Michael E. DeBakey’s role in develop- New procedures, learning, 323–325
ment of, 22–24 New York Heart Association, cardiac diagnosis
Monoclonal antibodies, development of, classification for, 45
179–180 The New York Times, 299
Moore’s law, 181–182 article, “When Physicians Double as
Morbidity and mortality rounds Businessmen,” 51–52
data for discussion at, 281 New York University, 81
learning in, 236 Nobel Prize
value of, 237–238 to Josha Lederberg, for work on genetic
Morbidity and Mortality Weekly Report (MMWR), material in bacteria, 179–180
of the U.S. Department of Health and to Theodor Kocher, for work on the thyroid
Human Services, 92 gland, 94
Morning Report Noncompliance by patients, 347–348
shared learning in, 96 Norwegian Medical Association,
talking about recently read materials in, 110 284 – 285
Motivation Note-taking, while reading, 64
of physicians by patients, 17 Nurses, learning from, informal, 215
to work, 80–81
Multiple roles Objectives, of reading, 59
of physicians, satisfaction with, 79–81, Observation, learning from being the subject of,
395–399 322 – 323
professional, 79–81 Office staff
social, of women, 385–391 checking for the results of tests ordered,
344 – 345
National Aeronautics and Space Administration teaching, 264–265
(NASA), 341 Omissions, reporting, 353–354

465
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Ophthalmology Monographs, 375 information for, quantity and quality of, 194
Opportunities informed, the decisions of, 156
education leading to, 412 noncompliant, 347–349
for involvement, 297–298 other physicians’, learning from, 209
Optimism problems of, judging what can and should be
from the dissatisfaction with managed care, done, 48
55–56 reporting to, after a consultation, 224
reasons for, in a profession at risk, 43–56 specific, reading about the problems of, 72–74
Organization of patient information for study, teaching of, 45–46
269–270 understanding the point of view of, 313–318
Organizational changes, delivery of care affected See also Physician–patient relationship
by, 16 Patterns of disease, recognizing from clinical
Organized medicine, 300–301 experience, 34
and lifelong learning, 371–377 PCDiary, 163
Otosclerosis, example of change in treatment, Peer review
95–96 as the gold standard in scientific publication,
Outcomes 93
adverse, managing, 369 utility of, for screening information, 183
questions about, 132 Peers, effects of, on fostering change, 16–17
tracing and reacting to, 278–282 Pen Computing (magazine), on handheld
Overload, misinformation, 141 computers, 155
Oversight, as a source of problems in medical Penicillin, discovery of, 94
care, 175 Percutaneous transluminal coronary angioplasty
Ovid, access to MEDLINE through, 152 (PTCA), example of record keeping,
276 – 278
Palm.Net wireless communication service, 155 Performance
Palm Pilot, for office practice information, 272 comparison with compensation, 53
Participation, active physician’s, value of continuing medical
in learning from a course, 235 education in, 245
and value of a course, 232, 246–247 Personal digital assistants (PDAs), 154–155
Pathology departments, learning from, 212 to access medical information, 196
Patient care Personal Health Diaries (PHDs), on the Internet,
analyzing in conferences, 237 149
investment of the patient in, 419 Personal physician, satisfaction of being,
required knowledge for physicians to manage, 431 – 435
440 Pharmacists, learning from, 215
Patient Keeper, software for storing patient Philosophy, study of, 30
history, 155 Physical examinations, 320–323
Patient-Oriented Evidence that Matters (POEM), and error, 343
128–129 Physician, e-mail information form for patients,
Patients 330
characterizing a practice from records of types Physician/Hospital Organizations (PHOs), 426
of patients, 274 Physician–patient relationship, 311–320
as a driving force in physicians’ use of the inattention of the physician as a barrier to,
Internet, 148–149 349 – 350
ethical problems regarding, consultants’ roles, the physician as the patient’s keeper, 359–360
299–300 videotaping or audiotaping encounters to
expectations of, in medical care, 317–318 review, 319
imagining the thoughts and feelings of, 221 Physicians
inattention of, 348 as catalysts, 342–343

466
 SUBJECT INDEX

e-mail information form for patients, 330 Problems

emotional responses of, to patients, 318 puzzling cases, 294–295
fraternity of, international, 201–202 questions for identifying, 46–48
knowledge needed for patient care, 440 social, ethical, and economic, 297–301
orders of, computer-generated suggested specific, reading to solve, 71–74
alternatives, 158 studying, to make the most of consultations,
protocol-based reminders for, computer- 218 – 220
generated, 354 Problem-solving, courses offering, 233
requisite attributes of, 423–427 Procedural audits, by office staff, utility of, 343
retired, preserving the passion for medicine, Profession/professional
115–116 attributes of, 52–55
Physician’s Desk Reference, drug package insert defined, 53, 423
to, 368–369 Professionalism, 417–427
Physician to the President, duties of, 413–414 and appropriate care for patients, 434
Plan-Do-Study-Act (PDSA) cycle, 284–285 intellectual and ethical components of, 38–39,
Platforms for personal digital assistants, 154 381 – 383
Pleasure in work, 39–40 required of residents, 440
POEMs for Primary Care, subscription service, Professional lives, multiple, Eugene Braunwald
129 on, 79 – 81
Point-of-care Professional meetings, value of, for acquiring
information at, 158–163 knowledge, 92–93
learning at, 133 Professional position, after department
Population, from which the patient could be chairmanship, 49–50
drawn, 131 Profiting from learning, 218–220
PowerPoint presentations, abstracting information Prostate cancer, as an example of the relevance of
for from patient databases, 276 information, 127–128
Practice Publications
analysis of, 267–289 proliferation of, and choice of reading material,
to maintain skill, 438 60
self-monitoring of, 11 of specialty societies, 375
Practice-based learning Public health, concern about, dilemmas of, 433
promoting, 163–168 Public service, in medicine, 38
required of residents, 440 PubMed, for searching for information in
Practice Based Small-Group (PBSG) program, cardiology, 103–104, 133
modules, 211 PubMed Central (PMC), 104
Practice-oriented education programs, of the of the National Library of Medicine, 183
American College of Cardiology, 377
Practice profile, from organizing records, 271 qID infectious disease database, 272
Practitioners, full-time, teaching by, 262–265 Questioning, value of, in medical learning, 47
Predigested information, for keeping up, 133 Question Library, 164
Preferred Provider Organizations (PPOs), 426 Questionnaires, patient, for improving practice,
Preparation 281
for a career in medicine, 25–40 Questions
for course or conference attendance, answering from rambling information,
234–236 336 – 337
Primum non nocere, consideration for decision- about the care for individual patients, 300
makers in health policy, 418 critical thinking, using with PCDiary, 164
Print collections, of libraries, importance of, dependence on others for answering, problems
197–198 with the curbstone conference, 206–207
Problem knowledge couplers, 160–161 encouraging while teaching, 261

467
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Questions (continued) Relationships, strained, within the health team,

framing, 15, 165 352. See also Physician–patient
databases to assist in, at the point of care, relationships
377 Relaxation, for a woman who is a physician,
for e-mail communication, 168–170 386 – 387
to get the most from consultation, example, Relevance
219–220 of information about patients, 127
to identify problems, 46–48 screening reading material for, 61
to select information for a specific clinical Reminder systems, avoiding problems due to
problem, 73 oversight with, 156–158
searchable and answerable, elements specified Reports
for framing, 131–132 consultant’s, 222 – 223, 225 – 226
seeking consultation to answer, 218 lost, organization to reduce the number of, 344
for following the success of treatment, 280 Residency, formative experiences in, 44–45
teachers’ updating knowledge in response to, Resources, access to, in managed care,
263 316 – 317
Retracing, previously learned information, for
Radiology departments, learning from, 212–213 evaluating new information, 129
Randomized clinical trials, critical reading of Revelle College, University of California at San
reports of, 62–63 Diego, 407
Randomized controlled trials, of continuing Rewards, from learning from experience, 3–4
medical education, 246–247 Risk, to the profession
Rank, concept of, as a deterrent to learning, 264 reasons for, 51–55
Rationalizations, of treatment, keeping separately and reasons for optimism, 43–56
from the patient’s chart, 369 Risk factors, for coronary atherosclerotic disease,
Reading early definition of, 45
critical, remarks on by Sir Thomas Lewis, 60 Rockefeller Institute for Medical Research, 68
early experiences enjoyed, 44 Roller pump, development of, by Michael E.
general, 69–71 DeBakey, 28
as a habit, 305 Royal College of Physicians and Surgeons of
to keep current, 57–75 Canada (RCPSC), education program of,
a time and place for, 109–110 163, 166
Reading retreat, 67–68 Rules, computerized, to relate patient states with
Reappraisal, in teaching, 260 clinical actions, 157
Reason, early influences on development of, 26
Reasoning, value of, 29–30 Sabbatical policies, of group practices, 205
Records Saint Louis University School of Medicine, 327
altering, advice about, 365 Satisfaction, of physicians from multiple roles,
lost or misfiled, 346 395 – 399
summarizing, to benefit from consultation, 219 Scheduling, personal, of time for reading,
Recreational sites, for exchanging information, 65 – 68
214 Science, 120
Redundancy checks, to reduce error, space Scientific American Medicine (SAM), 159
shuttle example, 341 Screening
Referring physician, presence during of information for relevance and validity,
consultation, 220–221 128 – 129
Refusal of recommendations, documentation of, of reading material, 59–64, 438
361 services for, 70
Regenstrief Medical Records System (RMRS), 156 selection of a course or conference, 232–234
Regenstrief policy, on using rules to determine Searching, for information related to a specific
clinical actions, 157 patient, 129

468
 SUBJECT INDEX

Seizure disorders, duty to warn state bureaus Speaking, education from, 264
about, 360 Special interest
Self-assessment developing knowledge about, self-education
during a patient encounter, 319–320 for, 87–88
programs for, 70 reading on a topic of, 72
offered by specialty societies, 375 Specialization, due to growth of clinical
Self-confidence, from an expanded intellect, 3 knowledge, 150
Self-defense, the physician’s art of, 359–370 Specialty, education outside of, 48
Self-directed, practice-oriented education Sponsor, identity of, as a criterion for selecting a
programs, 377 conference, 232–233
Self-directed education programs, of the Ameri- Starling’s Law, Eugene Braunwald’s work on, 77
can College of Cardiology, 377 State-of-the-art medicine, at the White House,
Self-directed learning, 11–13 414
Self-discipline, for continuing education, 28–31 Statistics, on clinical problems, by physicians,
Self-education 273
clinical, components of, 86–87 Structured abstracts
through membership in an healthcare ethics call for, 139
committee, 299 development of, 135–136
Self-interest, and professionalism, 426 Struggle, enjoying, 1–20
Self-regulation, as an attribute of a professional, Students, life-long, physicians as, xxvii
54 Study
Self-study follow-up, after course attendance, 235–236
to learn about patients’ attitudes, 319 patient-oriented, 437–438
programs for, as the focus of a study group Support, enlisting, for a woman physician,
meeting, 210 391 – 392
Seminars, to hone clinical skills, 318 Surgical Education Self-Assessment Program
Senior Clinical Educators, proposal for, 263 (SESAP), 70
Service System-based practice, required of residents, 440
as the defining characteristic of a professional, Systems
53, 55 errors in, 370
definition on, by Judge Elbert Tuttle, 53 providing point-of-care information, 158–159
sense of, in physicians, 7–8 Systems flow, teaching in continuing medical
Short course, alternatives to, 249 education workshops, 187–188
Simulation, for practicing skills, 170–174
Single women, as physicians, 395 Tavistock Clinic (England), 318
Sites Teachers
of collegial conversations, 208–214 effective, attributes of, 256–259
consideration of, in selecting conferences, as an influence in choice of career, 43–44
233–234 roles of, in developing curiosity, 27–28
SKOLAR, M.D., integrated information system, Teaching
159 clinical, 320
Social issues comeback of, 55–56
changes in patients and students, 45–46
general and specific attention to, 439 as a stimulus for learning, 438–439
in the physician–patient relationship, 315 “teaching surgeons to teach” seminars, 309
in the provision of health care, 433–434 Techniques, for selective reading, 61
the multiple roles of women, 385–391 Technology, and the costs of health care, 434
Social Transformation of American Medicine Telephone consultation, 207–208
(Starr), 424 alternative to travel to a medical center, 273
Solo practice, and collegial relations with other Television, and passivity, 29
physicians, 205 Textbooks, information lag in, 102–103

469
 M E D I C I N E : P R E S E R V I N G T H E PA S S I O N I N T H E 2 1 S T C E N T U R Y

Therapeutics, review of, example of framing Veterans Administration hospital, practice in,
questions about a patient, 166 staff meetings for exchanging information,
Therapeutic tool, the physician-patient 205 – 206
relationship as, 312–313 Videotaping, of interviews with patients, 319
Thrombolysis in myocardial infarction (TIMI), Virtual operation, with computer modeling,
work of Eugene Braunwald on, 77–78 learning from, 96–97
Time, limitation of physician’s Visible Human Database, National Library of
when family duties interfere, 386 Medicine, 171–172
with patients, 316, 351 Visiting other medical centers, gaining knowl-
To Err is Human: Building a Safer Health System, edge from, 213 – 214
342 Vocabulary of health care, consumers, providers
Translating Research Into Practice (TRIP), and products, 418
130
Transplantation, multiple, DeBakey work on, 22 The Wall Street Journal, 71
Trauma Life Support, Advanced, 309 “Health Journal” column of, 149
Treatment, warning patients of potential adverse WebMD, 151
effect of, 362 Web portals, for patients to review medications
Treatment Updates (Medscape), 152 and problems, 330–331
Triage coupler, use by receptionists, 160–161 Web sites, significant, identifying, 153–154
Trust “When Physicians Double as Businessmen,”
as an attribute of professionalism, 432–433 comments on article from The New York
in professionals, 54 Times, 51 – 52
Tulane University, 22 White House Physician, 411–412
Whole-body simulators, 172–173
Understanding, levels of, 125–126 Wireless palm devices, 154
Uniformed Services University School of Wishard Hospital, 156
Medicine, 409 Women physicians, 385–399
University of Alberta, 135 Words, effects of, on attitudes, behavior and
University of California at Los Angeles School actions, 418
(UCLA) of Medicine, 333 WordWatch, for patient tracking and maintaining
University of Chicago, 379–380 to-do lists, 155
University of Cincinnati, 357 Work
University of Pennsylvania School of Medicine, of identifying useful information, 128
113, 117 pleasure in, 39–40
University of Pittsburgh School of Medicine, 251 World Medical Leaders, broadcast of lecture by
University of Toronto, 243 medical educators, 152
University of Western Ontario, 243 World Wide Web, 147–148
UpToDate, internal medicine CD-ROM, 103, 159 Writing
continuing education through, 31–32
Vaccination, discovery of, through curiosity, 5 as education, 263–264
Validation, of a simulator model, 172 quality of, and reasons of the author for, 60–61
Validity in retirement, 121
of information, assessing research articles for, Writing, professional, personal value of, 45–46
127–128
screening reading material for, 61–64 Yearbook of Medicine, as a screening tool for
worthwhile reading, 70

470
 Phil R. Manning, M.D.

...

P hil Richard Manning has had a long and illustrious career at his
Alma Mater, the University of Southern California School of Med-
icine, beginning in 1954. He was a Professor of Medicine from 1964
to 2002, when he retired. In 1981, he was named Paul Ingalls
Hoagland-Hastings Professor of Continuing Medical Education, and
until June 2002, he was Associate Dean in charge of Postgraduate
Medical Education and Associate Vice President for Postgraduate
Affairs.
His interest in medical education was apparent from the begin-
ning of his career, evidenced by a deep involvement in undergraduate
and postgraduate instruction, including active bedside teaching,
course organization and evaluation, and publications dating back to
the mid-fifties.
Dr. Manning has been organizing and directing national and in-
ternational postgraduate medical programs since 1955. Considered
 PHIL R. MANNING, M.D.

the master of continuing medical education, he has done more to in-

fluence this field than any other single person. Some of his more re-
cent efforts have been directed to the role of computers in continuing
education, development of the community hospital as a teaching cen-
ter, and methods allowing the practicing internist, in his or her private
office, to keep abreast of ongoing developments.
His Mastership from the American College of Physicians was ac-
companied by the following statements: “If one were to count
achievement in medicine in terms of influencing the thinking and
manner of practice of countless thousands of health professionals, Dr.
Manning has no peer. He has never lost his own passion for the art
and science of medicine and has rekindled it in many others by his
example, knowledge, teaching, writing, and research.”
 Lois DeBakey, Ph.D.

...

L ois DeBakey, Professor of Scientific Communication at Baylor

College of Medicine in Houston, Texas, received her B.A. degree
in mathematics with honors from Newcomb College, and her M.A.
and Ph.D. degrees in literature and linguistics from Tulane Univer-
sity. A pioneer in the teaching of biomedical communication, she de-
signed and conducted the first curriculum-approved courses in this
subject in a medical school. The success of her oversubscribed
courses, including those sponsored by prestigious medical societies,
has been attributed to her approach through critical reasoning first
and lucid language second, and to her use of cartoons to illustrate
illogicalities, infelicities, pomposities, and inadvertent humor in
medical publications.
Described by distinguished physicians as “the medical world’s
great communicator,” “the unchallenged champion of the proper use
of medical English,” and “the preeminent defender of integrity in
 L O I S D E B A K E Y, P H . D .

American medical letters,” Dr. DeBakey is recognized as the leading

scholar and authority in this discipline. She has published prolifically
in medical and lay periodicals on biomedical communication, med-
ical ethics and socioeconomics, language, literacy, and education.
Her definitive edition, The Scientific Journal, has been adopted by
editorial staffs of major medical journals.
Dr. DeBakey has served on the Board of Regents of the National
Library of Medicine, on the Usage Panel of The American Heritage
Dictionary, as a team leader consultant to the Encyclopaedia Britan-
nica health and medical database, and on numerous national and in-
ternational committees, university accrediting agencies, and
government consulting bodies, as well as on the editorial and advisory
boards of the Journal of the American Medical Association and other
prestigious medical journals.
Among honors recognizing her achievements are Phi Beta Kappa,
scholastic excellence society; the Golden Key National Honor Soci-
ety; Distinguished Service Award of the American Medical Writers
Association; the first John P. McGovern Award of the Medical Library
Association; Newcomb College Distinguished Alumna; and Fellow-
ship in the American College of Medical Informatics.
Dr. DeBakey has been called “the conscience of medical journal-
ism” and has been credited with doing more to bring literacy, clarity,
and validity to medical writing than any other person in the country.