Duke University School of Medicine - Aesculapian Yearbook (Durham, NC)

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L C 2' 3 3 'FI DJ CD 1-P P+ fu 3 F AUTHORITY AND COMPASSION The experiences of medical school have helped you prepare to change roles - from being a well-educated young adult to becoming a physician. As a physician you will have unique authority- to physically intervene on behalf of a patient to help restore health. While others may have a deep concern for the causes of illness or for the delivery of health care, or may prescribe and perform certain forms of therapy, only you the physician will have legal authority to direct and participate in all aspects of comprehensive patient care. Your medical education prepares you to assume this new authority, but it must also prepare you to assume new responsi- bilities - those of providing informed and compassionate care to people. Rather than being on a pedestal, where one with your newly acquired authority might be found, becoming a physician means becoming immersed in all aspects of human experience while using your authority to benefit people. You will come to know thousands of individuals as they become your patients, and you may know them as no one else does. They may care very little about the science, i.e., the cause, prevention and therapy of their illness, but they will seek to reacquire health by benefit- ing from your authority and talents as a medical scientist. However, they will need much more than the science you have learned, since very few of your patients will be cured of all their ills by your intervention. In order to properly care for you patients, you must maintain a commitment to them, to science, and to yourself. The process of first detecting illness is currently a job primarily for the patient, but defining the illness, understanding its development, knowing how and when to intervene, and knowing when to modify care using new techniques are your responsibilities as a physician. This commitment to science, at least to that body of medical facts and practice which is currently accepted, is empha- sized in medical school and is apparent in the performance of medical students. Sometimes less apparent is an understanding of when to add new or different methods of care to the currently accepted therapeutic programs, when to experiment on hu- mans, or by what criteria new information becomes better in- formation. Concepts involved in logical decision making have been presented to you in both abstract and tangible forms. 26 PHILOSOPHERS u These concepts must be reviewed and consistently practiced in order to help you know when to reject a particular idea, or with what level of certainty a concept may be accepted. Caring for patients requires providing compassionate care, which includes having an understanding of what it is that the patient gives up by being ill. Caring also includes having a sense of how to help the patient reduce the sacrifice caused by illness. For many patients, this may simply mean your bending from a rigid schedule to consider their needs and responsibilities when you plan for their continued care. For the patient with progres- sive disease, this may mean your advising how to make today more important while not giving up hope for tomorrow - to focus on the near term, to help forget the bad moments and to learn to cherish the good. But to care and to continue caring, you must also care for yourself To risk emotional commitment to patients whose fate is unclear makes you vulnerable to loss. To frequently risk this loss is too intense for you to cope with alone. The tension must be shared with colleagues who can support you and occasionally relieve you of responsibilities. You must recognize not only your need to care for others but also your need to save some energy for yourself. Your life will change when you receive the physician's authority, but you will remain the same person you always were. People other than your patients will need you for matters often less intense than those you will cope with in medicine. You must learn occasionally to put aside the more dramatic matters so that you may tend to private matters and maintain interests outside of medicine. Giving by becoming immersed in human experiences can lead to one having nothing to give. Remember to save some for the giver. john M. Falletta l'l'l 4 93 L CD 'Pi cr CD 1 3 p PHILOSOPHY My own experience as a physician living and working in two countries, South Africa and the United States, spans a period of thirty years. During these years three communities have had the greatest impact on my professional and personal development. The first community was in Durban, South Africa. From 1946 to 1954 my husband and I Worked in an Institute of Family and

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and dying, a five-minute negative contact of that physician with a terminal cancer patient can leave an horrendous emotional problem in the lap of the nursing staff on that ward. The physi- cian can leave expeditiously, but the nurse assigned to the patient has to cope with the problem for hours on end. A fatigue syndrome of nursing personnel on cancer wards has evolved. Many of the complaint letters I receive are due exam- ples of poor physician-patient communications and indicate the need for humanism in medicine in the form of more empathy and understanding for patients by future medical students and residents. William G. Anlyan l'Directory of Residency Training Programs for 1979-80. Pub- lished by The American Medical Association. Feb. 1980. H190 .19 'VXI 9U! ,- :ft CD -1 .swf r-P 3 F7 Young adults in medical school are a heterogeneous group of talented, highly motivated, unique individuals who have already accomplished a great deal during their undergraduate years. There can be no doubt that the diverse backgrounds of the students contribute a great deal to the interactions of the stu- dents with each other and with the faculty. One of the rewarding aspects of being a teacher in the Duke Medical School environ- ment is observing the mutual respect which students have for one another. During the third year of medical school when more time is available for thinking and integrating information, it is delightful to see the student interactions as they share informa- tion with one another and learn by discussions with their peers. The Duke Medical School curriculum is unique. The first year provides a vocabulary and exposure to an insurmountable quantity of information. The second year clinical clerkships then expose the student to disease processes and people. The variability of diseases, the sometimes overwhelming sadness of illness, and the frustrations and pleasures of caring for people become a strong motivating force for integrating basic science information and returning to obtain additional facts from the basic sciences when necessary. The relative freedom of the third and fourth years at Duke provide the opportunity for further enhancement of the basic science background of our students, as well as for continued acquisition of clinical skills. This time allows the student to develop a critical approach to acquiring information, to assimilate further facts, and to develop the ability to solve problems relevant to the practice of medicine. The development of these skills is far more important then the individual facts which are acquired during medical school. The education of students can be successful only if they develop this ability and acquire confidence in solving each problem as it presents itself. The factual foundation provided by medical school must be built upon during the productive lifetime of the student. This obligates the medical school to provide the factual background but even more importantly, to help students understand the need for continuing acquisition of knowledge. Not only do students need to continue learning from the literature, but also from their own experiences in medicine. The guiding principle must be the ultimate concern for providing optimal health care to the individual patient. There are mutiple pathways which can be pursued within the broad framework of medicine. For example, a student may elect sub-speciality training or may elect to become involved in health care administration, either choice narrows his or her focus in medicine. Such decisions are the province of the student, but based on experiences occuring during their four years in medic- al school. Most of us have chosen medicine as a personally satisfying occupation. It is constantly stimulating, sometimes terrifying, and always interesting. This commitment to medicine as a pro- fessional career requires great understanding on the part of other persons sharing our lives. Medicine is not an eight hour a day job. Under no circumstances can responsibilities be dis- carded at the end of a Working day. There are ways in which responsibilities can be shared, but the time commitment and anxieties of caring for other persons will consume the majority of the waking hours of most persons in medicine. This is a difficult responsibility to integrate with family life and personal obligations. In particular, for women who elect to have a family and be in medicine, time commitments are sometimes extreme- ly difficult to manage. The biological role of women in bearing children may require compromise with other commitments and certainly requires emotional support. The physiological needs of infants are relatively simple when compared to the emotional needs and demands as they grow and develop daily. This is often not appreciated until such development is observed within the individual home. The joys are more than enough compensation for the difficult times, but unanticipated compromises may occur in the amount of time or the direction of training of individual physicians. Assistance within the household often becomes a necessity for homes with two working persons, parti- cularly two physicians. The quality of love and care within the home are far more important than the number of hours spent within a home. Thus, with planning, compromise, and hard work, it's possible to reap the enjoyment ofa happy personal life as well as the fulfillment of a satisfying career. Finally, a personal note of gratitude to the students who provide the motivation to continue teaching. Perceptive ques- tions, refreshing novel approaches to problems and enthusiastic interest in learning are constant stimuli to me to continue learn- ing in order to teach. Catherine Wilfert PHILOSOPHBRS 2 5

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Community Health as salaried employees of the government health services. The Institute trained doctors, nurses and health assistants to set up community health centers. CAt that time these centers were envisaged as the basic units of a proposed national health service which unfortunately never ca.rne to passj. Each center gave truly comprehensive ambulatory services - curative, promotive and preventive - to a geographically de- fined population. The work was clone by teams of doctors, family nurses and health assistants. Except for the doctors, team members were of the same ethnic background as the patients they served. Besides our recognition of the importance of in- digenous staff, we accepted the cultural milieu of the African population whom we served including the leadership of the tribal chiefs, the patriarchal system, the extended family, the supportive community networks and the role of indigenous healers. As family doctors with a holistic approach, we found the work professionally very satisfying. At the same time we were acutely aware of the limited role of medical care in dealing with gross poverty and malnutrition and the overwhelming influence that political, social and economic factors had on health status. We left South Africa in 1956, and started a new life in the United States. After a nine year stint in epidemiologic research at the Harvard School of Public Health, I became absorbed in another community as Director of the Martha Eliot Family Health Center in Boston. This Center was sponsored by the Children's Medical Center, which had obtained a Children and Youth Grant, and the Boston Hospital for Women, which re- ceived Maternity and Infant Care funding from HEW's Chil- dren's Bureau. The Martha Eliot Center was located in a low- income city housing project and served both the project's population and that of the surrounding census tracts. This community at first was as foreign to me as the African community had been. The housing project's population was almost all black and very poor and was surrounded by a hostile lower middle class white Irish population and a rapidly growing Spanish speaking population. The two and a half years I spent working in this community were the toughest and at the same time the most rewarding years of my professional life. Since only the poor were eligible for low-rent housing, all the project families had severe problems. Ill health, unemployment or underemployment, inadequate police protection, criminal violence and drug abuse was prevalent - as were rats and roaches. The insensitivity of legislative bureaucracy was epito- mized by the fact that one section of the housing project had been set aside as housing for the elderly - extraordinarily unsuitable for defenseless citizens. The project was ugly, lit- tered and badly maintained. Elevators malfunctioned, mail- boxes were frequently pilfered and tenants mugged. What could a program of medical care, limited to serving pregnant women, infants and youth up to the age of twenty-one hope to achieve under such circumstances? As in South Africa there was joy in this work which included a large proportion of indigenous manpower, and again as in South Africa, health status depended far more on external environmental, economic, political, and social conditions than on medical care. The third community is in a rural setting in nothern Durham County, in the adjoining villages of Rougemont and Bahama, which I slowly grew to know when I became Director of the Division of Community Health Models in the Department of Community and Family Medicine. This time I neither gave nor planned the delivery of medical services to this community of about two thousand persons. Rather, I was involved with survey research and community health education, and recently I have become particularly concerned with the lives of elderly resi- dents who live alone in this area. The community is rural, small farm and stable, with lives revolving around the home, work and church. Again, there are environmental problems for many who have inadequate housing with no indoor running water or in- door toilets. There is no public transportation - a particularly difficult problem for the elderly who are faced also with rising costs of food, fuel and rent, which are increasingly difficult to meet on inadequate social security incomes. How much can medical care contribute to the health of this community? The lessons I have learned from these three communities are simple and fundamental to medical care and medical education. First, we must look for and work with people's strengths rather than concentrate on their weaknesses. In doing so we must try to separate people's role as citizens from their roles as patients. For if we think of them as citizens who happen to be ill, we will treat them as equals in control of their own lives, but if we think of them only as patients we are apt to be authoritarian and to initiate a dependent relationship. And if we separate our own roles as citizens and as professionals, we can treat biological ills as professionals while helping to fight social ills as citizens. Second, I believe that health professionals must plan their services and deliver care according to the basic health needs of the communities they serve. This tenet presupposes a knowl- edge of the communities' own perception of their needs and priorities. Third, I believe that all health professionals are second con- tact rather than first contact persons and that primary care is properly centered in the family or other close social support system within the natural Ccommunityj social structure. Since professional care is external to that natural structure, it is second- ary in function and should be supportive of the primary care givers. Fourth, I believe that the medical model is inadequate to deal with illness in its social context. The South African experience made this very clear, and Boston and Rougemont! Bahama reinforced this lesson. Fifth, I believe that we must recognize the importance of peoples' involvement in their own health care, encourage and support this involvement, and develop linkages between profes- sionals and the communities they serve. We can educate every person who comes to us so that they will share responsibility in their own health care. And we can go further than that by trying to identify the natural helpers in a community, and by offering them educational programs, to enhance their effectiveness and thereby raise the health consciousness level of the community. Lastly, I believe we should encourage and nurture those medical students who believe strongly in a more humanistic approach to medical care. In the last few years I have witnessed many instances of medical students expressing their idealism through community involvement. Examples range from work- ing in migrant worker programs to the community organization efforts of the North Carolina Student Rural Health Coalition, from workin Womenis Health Collectives to assisting teenagers in peer counseling on sexual behavior, and from community needs assessment to the establishment of a community con- trolled clinic. Clinical medicine has done and is doing much for individuals and their illnesses but community medicine is much broader in scope - it enhances the public's health. Eva Salber PHILOSOPHERS 27