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Medical Humanities Section Newsletter - June 2007, Vol 3, #3

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circle_arrow From the Section Chair
circle_arrow From the Editor
circle_arrow Is Clinical Empathy Teachable?
A Medical Humanities Initiative
circle_arrow Section Announcements
circle_arrow Photo: Royal Terns on Siesta Key, FL
circle_arrow Spring in Virginia
circle_arrow New Medical Humanities Publication Gets a Facelift
circle_arrow Novel Excerpt


Newsletter Index


Medical Humanities Section

 

From the Section Chair

By Michael D. Burg, MD, FACEP
UCSF- Fresno

Fair warning fellow Section of Medical Humanities members, this’ll be my first purely business-like column. Although, come to think of it, maybe I should have provided a warning for my attempts at more "artful" contributions. Either way, here goes.

It’s time to start considering who will lead the Section of Medical Humanities for the next two years. We’ll have elections for section chair during our meeting at Scientific Assembly in Seattle. You must be there to vote.

Meanwhile, please consider whether you have the skills to lead the section during its next two years. All you need is a vision about what the section can become (and an ability to communicate via e-mail). The section is like a car that drives itself, with only a touch of your hand on the wheel. Many of the section members are talented self-starters who only need to be asked to embark upon a section-related project.

If a role as chair of the section appeals to you (by the way – the term is for 2 years beginning with the Scientific Assembly in Seattle in October, 2007) please send an e-mail to me, Tracy Napper (Section Liaison), and Hans House (Newsletter Editor) c/o humanities.section@acep.org. Please express your interests, ideas, and qualifications in your e-mail. We’ll post the e-mails to the section’s listserv and run them in the section newsletter. You’ll also have an opportunity to briefly address the assembled throng at our annual section meeting in Seattle.

Thank you all for your support during the initial phase of our section’s development. Let’s make the next phase even better.

 

 


 

 

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From the Editor

By Hans House, MD, FACEP
University of Iowa

The May 15, 2007 edition of the New York Times Book section included the article, "Doctors Who Wield the Pen to Heal the Profession," by Abigail Zuger, MD. Dr. Zuger mostly highlights the strong work of New Yorker writers Dr. Jerome Groopman and Dr. Atul Gawande, and poses the question: why is there seemingly an explosion of writings by physicians? Dr. Burg will be pleased to read that Zuger makes a plug for the writing program at Sarah Lawrence College (although we all know that Iowa City is the center of the creative writing universe!). Mostly, Zuger argues, this physician prose carries a mission. Its authors do not seek to simply celebrate medicine, but "have come to a written word as a way to fix medicine." Zuger adds, "Humanists have long argued that when doctors cultivate the skills involved in constructing a written narrative- an ear for plot, images, and elisions [sic]- they become abler, more humane doctors."

I could not agree more. In fact, before I saw this article, I had already planned to include portions of Dr. Groopman’s book "How Doctors Think" to educate our new interns on the nature of medical mistakes and how to avoid them. To understand the use of the medical humanities in making more able, humane physicians, look no further than Dr. Carolyn Annerud’s brilliant piece in this issue of the newsletter.

To echo Dr. Burg’s plea for a successor, I also encourage the membership to nominate themselves to be the next newsletter editor. I will step aside at the next Scientific Assembly so that someone else can have all the fun with these pages. Do not be intimidated: the section membership is so creative and productive that I usually have a surplus of material. Tracy Napper works so hard for us, she makes assembling the final content really easy. This publication simply would not exist without her. Please submit your notes of interest to me, Mike, and Tracy c/o humanities.section@acep.org. I will not push you too hard for your "qualifications." My only qualification for what I have been doing the past two years is a liberal arts education and a passion for the humanities. Based on these criteria, anyone reading these words can qualify.

 

 


 

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Is Clinical Empathy Teachable?
A Medical Humanities Initiative

By Carolyn Riederer Annerud, MD, FACEP
John A. Burns School of Medicine (JABSOM) at the University of Hawaii

Introduction

"He found me very well; for me, I was still feeling sick," writes a patient in a letter to the famous 18th century Swiss physician, Samuel Tissot. Despite technical and scientific evidence-based improvements in the practice of medicine, the frustrations of today’s patient are much the same as those voiced over 200 years ago. The disparity between a patient’s perception of his own health, the physicians’ empathy (or lack thereof), and the physician’s perception of the patient’s problems, is the focus for continued miscommunication and dissatisfaction.i

Empathy, defined as the ability to understand and share the feelings of another,ii has been named as an essential learning objective by the American Association of Medical Colleges.iii Empathetic physician communication skills have been shown to significantly impact patient satisfaction, patient compliance, clinical outcomes, and professional satisfaction. iv  In the clinical setting, displaying the appropriate empathy has been defined as emotional labor requiring some degree of intentional modification or "acting."v

Can the study of medical humanities help physicians develop empathy?  

The practice of medicine delicately balances both humanism and science. The American Society for Bioethics and Humanities was established in 1998 to "promote the exchange of ideas and foster multidisciplinary, interdisciplinary, and inter professional scholarship, research, teaching, policy development, professional development, and collegiality among people engaged in all of the endeavors related to clinical and academic bioethics and the health-related humanities." vi

The study of medical humanities facilitates personal development of core values, balance, and societal contract. Dr. Delese Wear states:  "The possibilities of the humanities in the undergraduate medical curriculum remain unchanged: to deepen, enlarge, and sharpen one's sensibilities as students move through an increasingly complex life in medicine, examining themselves, their patients, their profession, and the culture in which they serve.vii

In his history of medicine, "The Greatest Benefit to Mankind," Roy Porter emphasizes the common ground in Greek thinking of the later separate disciplines of philosophy, medicine and ethics. With evidence-based medicine and the dominance of science, there is a need to re-establish balance.viii  

In addition to strengthening the patient-physician relationship, these traits contribute to development of the core competencies of the Accreditation Council for Graduate Medical Education (ACGME).ix

Table 1. Core competencies for ACGME

1. Patient care
2. Medical knowledge
3. Practice-based learning and improvement
4. Interpersonal communication skills
5. Professionalism
6. Systems-based practice

The study of medical humanities stimulates the development of communication, professionalism, patient care and empathy, and the ability to maintain an interest in continued self improvement and education. Learned skills such as teamwork, partnership, interdisciplinary collaboration contribute to the system-based practice of medicine. Finally, patient perception of medical knowledge and expertise is often at least partially based on the quality of the physician’s empathy and ability to "connect" with the patient. Teaching and learning such ideals is challenging, requiring diverse techniques and self reflection.x   

J. Macnaughton states "the communication (between doctor and patient) is positive, life-affirming, and often creatively productive. What is offered in the medical humanities is the education of the creative imagination of doctors."xi  

In an era of ever increasing sub specialization in medicine, the role of medical education must be to guide physicians (and physicians in training) to see, interact and treat the patient as a whole person and an integral part of a family, a culture, and society. Physician and patient together, in building this intimate relationship, must view difficult issues such as death and dying as a part of the continuum of birth, life, and living. Their decisions impact not only themselves, but also those in their extended family unit and community.  

Current Status of Medical Humanities

0607clinempathy
Clinical Empathy - Dr. Piamnok & Kila Aita,
Papua New Guinea. Kila died the following
day of HIV AIDS. Photo with her
permission, taken by Dr. Annerud

More than three-fourths of U.S. medical schools now have medical humanities courses as part of their core curriculum.xii Multicultural patient, family and physician encounters are the frequently the rule rather than the exception. The demands of practicing medicine in this increasingly complex discipline and cultural environment stimulates one to ask if the  young medical student has sufficient life experiences to survive, even with good clinical knowledge. Understanding and incorporating humanities into daily practice perhaps is what defines the doctor who positively contributes to the well-being of his patient and confidently addresses the needs of our diverse island communities.

Student response is positive to potential courses in the medical humanities and the "art of medicine." Discussions with transitional residents in the University of Hawaii program in Honolulu, and residents of the University of Hawaii Postgraduate Medical Education Program at the Okinawa Chubu Hospital revealed a keen interest and desire to learn more about medical humanities, specifically end of life ramifications. Discussions at James Cook University (Queensland, Australia), University of Papua New Guinea School of Medicine and Health Sciencesxiii and John A Burns School of Medicine in Hawaii (JABSOM), reflect a high level of student interest internationally. The University of California Irvine School of Medicine in particular has developed an integrative program of medical humanities in a third-year clerkship.xiv   Certainly threads of medical humanities are introduced in group discussions in the Problem Based Learning curriculum at many schools; reflection suggests that a more comprehensive approach would be beneficial. 

Clinical educators, in their daily practice, and by example, should teach passion and empathy.xv   Encouragement and acceptance of some premedical students with a background of "humanities" or ethics and philosophy rather than the narrower premedical degrees could foster this environment.xvi Broadening the scope of a medical humanities course to include humanities students as well as medical students in the same university setting could increase diversity of the course interaction as well as the funding base. Lund University in Malmo Sweden has suggested this in further planning of their existing curriculum.xvii

Prospects for the Pacific

A medical humanities pilot project for third year medical students is a proposed format for an initial introduction of this discipline at JABSOM.

Topics for small group discussions and participation include but are not limited to:  history of medicine, philosophy, psychology, sociology, comparative religions and the impact on patient-doctor decisions, art and music as disciplines for expression and for enhancing observational skills, writing from different perspectives (doctor, patient, and family), drama, and dance.

Collaboration between JABSOM and UH Manoa Department of Arts and Humanities would seem an appropriate and complementary use of expertise and resources.

Desired outcomes of a humanities curriculum would eventually include other important members of the medical team in team approach sessions – nurses, health and social workers. 

Continuing medical education courses (CME) for physicians is an extension of this vision. Some state that the majority of physicians are only interested in CME that is helpful in the recertification of their specialties. I believe there is room for growth, and interest in a certain population of physicians that would support CME in medical humanities. University of San Francisco currently offers a "Healer’s Art Retreat" for medical faculty development, and medical students, as well as other health professionals.

Perhaps this is part of what incorporating the humanities into the role of medicine can accomplish. The practice of medicine delicately balances humanism and science. The goal is to foster a greater understanding of the human condition; how health, illness and suffering are experienced by both patient and physician. As such, humanism can be modeled by teachers, but is also reflected in philosophy, ethics, theology, history, literature, art, music, language, and the social sciences. It is hoped that a balance of science and humanism will help to create physicians with an enhanced understanding of the holistic nature of good medicine, public and social issues in health care, and the need for cooperation with patients, families, allied health professionals and alternative care providers.xviii

Life and medicine are not only about the collection and synthesis of facts, but the ability to explore. In the global perspective, we are geographically, culturally, academically, and philosophically ripe for development of such a program. 

And perhaps our patients might write: "He found me very well, and I am well."

Acknowledgements: Dr. Richard Kasuya and Dr. Satoru Izutsu,  (JABSOM, University of Hawaii)

Dr. Annerud is an Assistant Clinical Professor in the Department of Surgery, Division of Emergency Medicine at the John A Burns School of Medicine (JABSOM) in the University of Hawaii.

  1. Louis-Courvoisier M Mauron A. 'He found me very well; for me, I was still feeling sick': The strange worlds of physicans and patients in the 18th and 21st centuries. Med Humanit. 2002 Jun 28(1):9-13.

  2. Oxford dictionary of current English, 3rd edition. C. Soanes ed. Oxford University Press. 2001.

  3. Stepien, KA and A Baernstein. Educating for Empathy. J Gen Intern Med 2006 21:524-530.

  4. Kim SS., Kaplowitz, Johnston J. The effects of physician empathy on patient satisfaction and compliance. Evaluation & the Health Professions 2004. 27(3): 237-251.

  5. Larson EB, Yao X Clinical empathy as emotional labor in the patient-physician relationship. JAMA. 2005 293:1100-1106.

  6. www.asbh.org

  7. Wear, D., Viewpoint: "Trends and Transitions in the Medical Humanities", AAMC Reporter: October 2006, http://www.aamc.org/newsroom/reporter/oct06/viewpoint.htm

  8. Porter R. The greatest benefit to mankind. London. Carper Collins 1997 pp 64.

  9. Larkin, G, Binder, L, Houry, B. and Adams, J. Defining and Evaluating Professionalism: A core competency for graduate emergency medicine education. Acad Emerg Med 2002, 9(11):1249-1256.

  10. Krych E and J Van der Voort. Medical Students Speak: A two voice comment on learning professionalism in medicine. Clinical Anatomy 2006 19:415-418.

  11. MacNaughton, J. Arts and Humanities: A new section in Medical Education. Med Ed 2002, 36:106-107.

  12. Curriculum Management and Informational Tool (CurrMIT). www.aamc.org/meded/curric search on Medical Humanities. Advisor, Consultant Dr. Jay Jacobs, University of Hawaii John A. Burns School of Medicine. 2007.

  13. Curry C, Annerud C, Jensen S, Symmons, D, Lee M, Sapuri M. The first year of a formal emergency medicine training programme in Papua New Guinea. Emerg Med Australasia 2004 (16):343-347.

  14. Rucker L and J Shapiro. Becoming a Physician: Students' creative projects in a third year IM clerkship. Apr 2003 78(4):391-397.

  15. Campo R. "The Medical Humanities," for lack of a better term. JAMA 2005. 294(9):1009-1011.

  16. Spiro H. The Medical humanities and medical education. Letters Section and Reply.
    JAMA 2006. 295:997-8.

  17. Wachtler, C, S. Lundin, and M. Troein, Humanities for medical students? A qualitative study of a medical humanities curriculum in a medical school program. BMC Med Educ 006. 6: 16. Published online 2006 March 6.

  18. umanitoba.ca/faculties/medicine/medical_humanities/

 

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Section Announcements

The ACEP Artistic Expressions Gallery at Scientific Assembly will return in Seattle in October 2007. The application is available online.

    Fourteen Stories Book Cover
View larger image

Section member Jay Baruch, MD has published a book! Fourteen Stories: Doctors, Patients, and Other Strangers has been published by the Kent State University Press. Through his short fiction pieces, Dr. Baruch gives a voice to a variety of people who, faced with difficult moral choices, find themselves making disturbing self-discoveries. Dr. Baruch is a Clinical Assistant Professor and the Director of Education in the Department of Emergency Medicine at Brown Medical School. He is on faculty with the school’s Center for Biomedical Ethics.

ACEP is now soliciting nominations for Section Awards. Members can nominate their section for Service to the College, Service to the Section, or Outstanding Web Page by accessing the award criteria and nomination forms.
Nominations are due to Susan Morris by August 13, 2007. The Section Affairs Committee will review the nominations and announce the winners in early September. If you have any questions, please contact Lance Brown, MD, MPH, FACEP, Section Affairs Committee chair, at 909-558-7698 (Pacific Time Zone) or Susan Morris c/o section@acep.org.

 


 

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Photo: Royal Terns on Siesta Key, FL

0607royalterns

Royal Terns on Siesta Key, FL. Used with permission of Dave Baehren, MD, FACEP

 


 

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Spring in Virginia

By Peter Paganussi, MD, FACEP  

dandelions defiantly
dot the
green grass yellow.
with wind
rustling through
lush leaves
still frail and
folded in
infancy.
foxes frolic
and roll
red fur
a blur
against a
vernal vista.

 


 

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New Medical Humanities Publication Gets a Facelift

By Robert A. Schwab, MD, FACEP

In 2004, the Office of Medical Humanities at UMKC School of Medicine embarked on a project to create a new literary magazine, Touch, that would explore the human encounter with illness and suffering. We placed calls for submissions in national literary journals and pitched our project at the American Society for Bioethics and Humanities annual meeting. The response was gratifying; we received more than 250 submissions of poetry, essays, stories, photographs, and paintings from international as well as national artists and caregivers. The submissions told rich, powerful stories of the illness experience. After a laborious and often painful editorial process, we selected approximately forty pieces for inclusion in our inaugural issue. Little did we know that our work had just begun.

Preproduction and printing was an incredibly difficult process, full of myriad details that make an enormous difference in the appearance and quality of the final product. Paper selection, font type and size, binding, column width and number – decisions to be made on schedule, lest we fall behind. In parallel with preproduction, we were planning our fundraiser for the humanities program, which would provide a venue for introducing our magazine, and hopefully garner strong sustaining financial support. Once the event date was set, we had our deadline, adding unneeded urgency (and stress) to our work.

We were fortunate to work with a very talented graphic designer who guided us through many of the tasks, and kept the work loose, light, and fun. And miraculously, it got done on time. Then the trouble began.

As the date for the unveiling loomed closer, we presented our product to our dean and to our editorial board for final review. The dean and some of the board members objected strongly to four pieces that dealt with controversial issues, including abortion, inappropriate touching by caregivers, and surgery performed without consent. We knew these pieces might shock and perhaps offend some of our audience, but we were not prepared for the response from our own institution. Ultimately, the decision was made that the content was not appropriate for a publicly funded institution, and distribution was limited to contributors and staff. Over 6000 copies of the magazine were destroyed. Our fundraiser raised a lot of money for the humanities program, but there was no magazine to unveil.

In retrospect, our biggest mistake was failing to fully engage our editorial board and to ensure that they understood our editorial mission: to portray the entire breadth of the illness experience, bad as well as good, in order to help health care heal itself by addressing stories that often remain untold. We tried to convene the board on many occasions, and with a deadline looming, chose to move forward despite the canceled meetings. We obviously misjudged the degree to which the generally conservative philosophy of our university permeated its faculty and administrative leadership.

Our story has a happy ending, though. We have identified a new sponsor who shares our vision, and have both accepted positions as editors of the successor to our original magazine. A new effort deserves a new name, and so we introduce Voices: Of Illness, Suffering, and Healing, and invite you to join us in our new effort. We are accepting submissions now, with an eye toward publishing our first issue in early 2008. Please address submissions and inquiries to:

David Wendell Moller, Ph.D
Director of Office of Human Values
St. Luke’s Hospital of Kansas City
4401 Wornall Road
Kansas City, Missouri 64111

Our spirit and belief in what we are doing is unbowed. We look forward to hearing from you.

Dr. Schwab is a Professor of Emergency Medicine and Medical Humanities at the University of Missouri- Kansas City School of Medicine.

 


 

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Novel Excerpt

By Brian McBeth, MD
UCSF- San Francisco General Hospital
   
On my first call day, we are rounding in the unit and my pager goes off for the fourth time in ten minutes. Brady, the cardiology fellow, leans over and whispers in my ear.

"How goes the K hotline?"

"What?"

"The K hotline – that’s what the cards intern pager is. Nurses calling every five minutes to ask if they can give potassium to some patient who doesn’t need it. Get used to it, chief." He gives me a wink.

I return the call, and although it’s not a potassium request, it’s a question from the floor as to whether a patient can be started on vitamin supplements. I reply quickly and probably curtly to get back to rounds.

The other pager we carry as the cardiology intern is the adult code pager. When a patient "arrests" in the hospital, this pager goes off and we come running. It’s me or another intern, Roger or one of the other senior residents, and a CCU nurse. Occasionally one of the fellows will show up. Usually not, though. And then others without any clear role generally start to wander in, and add bodies and heat to an already overcrowded room. Radiology techs and phlebotomists, med students and social workers, custodial staff and food service workers. Most gawking, transfixed and attracted like unthinking moths to the spotlight of another fruitless resuscitation attempt.

This is the scene on day three of the month, and I’m pumping up and down on a patient’s chest in a small room on the eighth floor. Roger is running the show behind me, barking out orders and attempting to battle the increasing entropy of the scene.

"Hold compressions. Slausberg, check again for a pulse. You and you," he points to a lab tech and student squeezed against the wall. "Out now. We’ll call you from the hall if we need more hands in here. Wait." He grabs the student on the way by. "Try to find the patient’s family for me. And bring me her chart, too. Thanks. Whatcha got, Aaron?"

"Still nothing." I reply. On the monitor a slow regular electrical pattern marches across the screen. The patient is in "PEA" – pulseless electrical activity. It has several other names, but it means that although there is some electrical discharge of a heart’s intrinsic pacemaker, it’s not making any kind of cardiac muscle contraction.

"Resume contractions. Jeri – another round of epi."

I don’t know much about this patient – she looks young, but still probably "older than her stated age," as they say. Bald with thin pale skin and a gaunt face – a wig of thick black hair lay forgotten next to her pillow on the ground. I noticed on her ID band that she was born in 1975 – younger than me. Damn. And I know we are on the oncology floor, so my bet is that she has some sort of bad cancer. They had called us about ten minutes ago when they found her unresponsive and pulseless. Anesthesia had quickly intubated her and now we were center stage: pounding her heart with fists and drugs, trying to get things started again. My arms are aching – doesn’t take long for CPR to fatigue me. No family had showed up yet, but I am vaguely aware that the hospital operator has been paging, "the Stillman family - return to 8B as soon as possible." Those entreaties always send chills down my spine whenever I hear them in the hospital – it never is a good thing if a family is being called to come ‘as soon as possible.’

The oncology senior resident shows up and I hear him talking to Roger about metastatic breast cancer and failed chemotherapy. My arms feel like lead now, and I fight to keep my elbows straight and my fists locked, trying to use my weight and not my muscles to keep up the rhythm. I hear the oncology senior say something about young children and I notice for the first time the plethora of crude crayon drawings adorning the walls in this room, mostly signed by "D.J." or "Kara." Up and down, up and down. One-and-two-and, one-and-two-and. The patient has a large diamond ring on her left ring finger that’s sliding up and down with each of my thrusts. It looks like it was sized at a time when she had much thicker fingers – they are now spider thin like the rest of her body. I suddenly become very concerned that the ring will slip right off, and tumble to be lost in the rising accumulation of medical waste at the side of the bed.

"Hold compressions. Still no pulse?"

"Nada."

"OK – you, take over compressions," he motions to one of the med students. "Marge, another one milligram of atropine."

I stand aside and the student takes over. "I’m not tired, Roger. I can keep going." My aching arms and chest scream otherwise.

He ignores the comment. "How many pericardiocenteses have you done?"

"Um, none."

"Well, me neither. First time for everything huh? You’re the ER cowboy – get some gloves on."

He calls out for the necessary supplies and again shoos three or four unnecessary people from the room. PEA has a number of different causes – big heart attack, large blood clot in the lungs, fluid accumulated around the heart. According to the oncology senior, this patient had had a small pericardial effusion – fluid around the heart, and they are concerned that this could have worsened. We are going to try to drain this fluid and see if this helps. There is a very large crowd just outside the door to the room now.

I spray her chest with yellow-brown Betadine underneath the student’s pumping hands. Quickly donning the sterile gown and gloves, I review the procedure in my mind. Thirty degree angle, start about an inch below the end of the breastbone. Aim for the left shoulder. The nurse drops a syringe into my hand that resembles a whale harpoon. I look up at Roger and hesitate.

"Hold compressions. Do it, Aaron – now."

I nod and advance the needle slowly through her chest wall. Everyone’s eyes are directly on me and the noisy chaos has now been replaced by an equally deafening suspension of sound. There is a collective apnea in the room as everyone waits expectantly for results. Nothing. I push it in farther, but the syringe remains empty. It is then that a piercing scream shatters the silence.

"What are you doing to my wife?"

I almost drop the syringe from my hand – in fact, it is only the fact that it is buried deep in the woman’s chest that prevents it from falling. With a start, I glance briefly to the side to a young mustached man with a toddler in his arms being whispered to by the oncology resident. He is staring past me, past all of us, but the baby girl in his arms has me transfixed with her uncrying blue-eyed gaze. There is accusation in her stare despite her tender age, but I pull my eyes away and refocus on the task at hand. Vaguely, I hear them being ushered from the room.

The syringe goes deeper, and finally the plunger gives way in my hand. The plastic tube fills quickly with amber fluid.

"Bingo," someone whispers behind me.

After about 50 cc’s, it stops and despite my pulling, I can’t convince it to give more. I remove the syringe and Roger has the student resume compressions. Nothing else changes. We continue for another ten minutes, but there is still no pulse or sign of life. Roger calls it, and I step away from the bed. The sense of hopeless failure is stronger than usual after an unsuccessful code. Normally I am excited about doing a new procedure, but there is none of that today. Just a sense of a life gone, wasted and a family broken. We slink off to fill out the paperwork as the husband returns to be with his wife. The children are not here now, and I imagine that another family member is watching them at the moment. But I can’t get her daughter’s knowing stare out of my mind. She knew we were failing her – she knew that the best that modern medicine had to offer was not enough to save her young mother’s life.

This excerpt is from an unpublished novel by Dr. McBeth loosely based on his residency life at the University of Michigan. This original work appears here with the permission of the author.

 

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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.

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