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

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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

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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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CD r-l- CD 'CT Z' CD 2 GJ C CD CD 1h CD Z' '4 MY PHILOSOPHY ON MEDICAL EDUCATION To be a good physician an individual must have a sound current fund of knowledge which is utilized in a scientific man- ner and implemented with personal honesty, compassion, empathy, and interest in the well-being of a patient as an indi- vidual. The responsibility ofa medical faculty is to choose those who will enter a School of Medicine, and in doing so they should look for persons of diversified backgrounds, who are intellectually capable, and who embody a strong interest in the total well being of their fellow man so that they are highly motivated to enter the healing arts. An applicant should have demonstrated a past record of personal integrity, honesty, and past activities which indeed reflect his motivation. The faculty, however, should be fully aware that there are many gifted and dedicated individuals in our society who wish to be physicians but have been deprived of prior opportunities in education and in other areas. To these individuals, the medical school must extend admissions and then provide such individuals with full faculty and medical school support in order to overcome possible academic shortcomings. Such support must be intensive, pro- vided by the most talented and dedicated of teachers in the respective areas, and given in an atmosphere of genuine caring. A medical school is built brick by brick by each of its faculty members. It is built by dedication, excellence, interest in stu- dents, and by the ability of each faculty member to serve as a model which can be emulated by the individual student. The worst faculty can put together the best curriculum to provide the worst experience. The relationship between faculty and stu- dents should be built on mutual respect. Those faculty members assigned the responsibility for and given the honor of teaching should be interested in teaching, should present material in a carefully prepared, considerate manner, and where possible, should provide insights into clinical applicability. The teacher must temper his enthusiasm in his individual discipline by taking the time to give the novice student a perspective in a new area and an introduction to its vocabulary. Faculty members should be readily available for informal meetings and conferences with students and should not be sequestered either in location or in mental preoccupation. To foster good teaching, a medical school must put as high a 28 PHILOSOPHERS priority on teaching as it does on research and patient care. These are not mutually exclusive, and indeed, the best teaching may be done at the bedside or in the laboratory. However, the pressure applied for faculty publications and grant support should be realistic so as not to infringe on the time necessary for the effective preparation, teaching and student-faculty interac- tion. Oftentimes, because of excessive medical school pressure for faculty members to attain such grant support, individual faculty may assign low priority to their teaching efforts and to their student contacts. The administration must recognize their teachers as being the mortar that holds the medical school together and must support them financially, philosophically and morally. This attitude is based on the philosophy that teaching, spending time with a student, giving a conference, making rounds, listening to a studentls future plans, sitting on a curricu- lum committee, and writing letters of recommendation are worthwhile and necessary activities. There is less and less public support and funding available for the teaching effort of medical schools, and as such, a tremendous dependence is placed on the grant support available for research efforts and on the funds generated by patient care. Teaching, however, requires time. Time requires support. Such support translates into the abandonment of clinical academic appointments which serves to rank those who are strictly clini- cians below those who do research. It calls for greater medical school support in salaries and for makingsuch salaries competi- tive with those of private practitioners so as to attract valuable members who would otherwise be lost. For the medical school to do this, the provision of funds must be based on careful and conservative spending in the area of buildings and capital im- provements. It calls for the creation of funds which have been generated by clinical efforts to be shared mutually and equitably by teachers, basic scientists, and clinicians alike, whether or not such individuals directly contributed to the fund. It calls for the application of political and governmental pressure to recognize the need for public support and subsidy of teaching efforts. It calls for third party payments which subsidize bedside teaching. It calls for increased tuition as the cost of living increases. It calls for enhancement of private and foundation endowments ear- marked for teaching purposes. The curriculum should be well founded to provide a careful background in the basic and clinical sciences. The basic science courses should permit clinical correlations from the earliest time so as to relate the clinical and basic science areas. A curricu- lum should wed the basic and medical sciences into one. The interpretationof a patient's problems must be in a pathophy- siologic terms with full understanding of anatomic, biochemical, genetic, and environmental factors. The curriculum must allow insights into the moral, ethical, and philosophical issues as they relate to a physician. It is vital to understand the moral and philosophical issues which daily confront a physician in applying a growing technology. It is important that a physician under- stands the Hippocratic Oath and his responsibility to practice each day of his professional life in the spirit of that Oath. The most important responsibility of a medical student is the realization that the period of time spent as a student is finite, but that the need, responsibility, and self-motivation for continuing education each and every day of one's professional life is inhe- rent and mandatory. Medical school is but the introductory chapter to a book which is written by our dedication to con- tinuing education and to the fluent application at the bedside of sound scientific technology. The greatest lesson that the medi- cal student must learn is that which we can not teach. It is to respect life. To treat people as we would like to be treated. It is to communicate, to be gentle, to be understanding, to be com- passionate, and most of all, to be human. In the words of J.