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Governor's Newsletter, Winter 2001

Joseph G. Weigel, MD, FACP
Governor, Kentucky Chapter

Governor's Column

As I sit here writing this newsletter, it is a cold, blustery, snowy Sunday afternoon just before Christmas. We have just completed, in September, an excellent scientific session, planned by the University of Louisville's Department of Medicine, and held in conjunction with and in cooperation with the Kentucky Medical Association Annual meeting. We had approximately one hundred persons attend the meeting, and had another 70 persons attend the dinner and award meeting at the Pendennis Club that evening. For all of you who came, thank you. For all of you who did not attend, we need you! Our effectiveness as a chapter largely depends upon knowing what you want and need - and we can only answer those needs if we hear from you.

We also recently held, in Somerset, our fall/winter council meeting. It was perhaps the best meeting the chapter has had in the last several years, and our ties with both universities seem stronger than ever. We hope to have the University of Kentucky sponsor the scientific content for our fall meeting in Louisville 2001, and plans are already underway for our annual Associates meeting in Shakertown in late March. We are also planning to become more "high-tech" about our fall meeting, and attempt to put the entire content of the meeting on CD and online, so that those who can not or do not attend will still be able to access meeting content.

I would again encourage all of you to try to become involved in the structure of Internal Medicine. The College, on a national level, is still discussing with the American Board of Internal Medicine the recertification process for maintaining board certification in internal medicine. The current process, which all internists boarded in 1990, or after, will have to undertake, is much different than I thought would be undertaken for busy practicing internists. It seems to me almost impossibly time consuming and cumbersome.

Recent thoughts on this process are in the letter which follows, written by one of my esteemed and very bright colleagues on the Board of Governors, elucidates some of the problems with the process. Dr. Faith Fitzgerald, in a current issue of Internal Medicine News wrote as follows in an editorial titled "The Measure of a Physician":

"Medical Schools and certifying boards increasingly want to make certain that the physicians whom they graduate or certify are, in deed, competent in the fundamental skills at the core of our craft for millennia. History taking, physical diagnosis, and communication are critical sources of information to the physician and of therapeusis to the patient.

I am concerned that the mode being used to test or evaluate these skills is taking a rather strange turn. In many schools of medicine, as well as in the system recently proposed by the American Board of Internal Medicine, we appear to be evaluating virtual skills rather than actual skills"
("Recert Exam Adds Communication,"' INTERNAL MEDICINE NEWS, Oct. 1, 2000,p.1).

Dr. Faith Fitzgerald is Professor of Internal Medicine and Assistant Dean of Medical Education at the University of California, Davis.

Simulated patients, videotapes, CD-ROMs, and written examinations are used to represent patients in order to provide a reliable - that is, in the statistical sense, reproducible and fair - evaluation. That this is occurring at a time when real patients languish, wondering who and where their doctors are, is another issue. The real question is whether one can truly evaluate the human skills of a physician with a simulacrum.

All of us know physicians who can take a detailed history and do a meticulous physical but whose intuitive receptors are nonfunctioning and can not interpret their findings. Other will rather carelessly interview the patient and throw a stethoscope on their chest and know immediately what is going on.

What are the different talents of the diagnosticians? Are they the same as the external choreography and structure that is being evaluated in the virtual examples of these tests? Can a simulated patient who has a defined problem and a script for its articulation, who is known to the person examining the patient to be possessed of a "right answer," present anywhere neat the genuine conundrum of the confused, inarticulate, or anxious patient whom the real physician sees each day? Can any simulated patient transmit the nonverbal information that the skilled diagnostician receives by empathetic conduits?

Without a doubt, the gross external skills of competence can be quanitated: Were the right questions used in the opening? Did the physicians listen? Did he or she offer the proper respect? Were the physical diagnostic maneuvers appropriately performed?

Yet the skilled diagnostician may be in peril in these circumstances, particularly if the simulated patient is doing the grading.

A neurologist at my school who took the student CLEX (clinical examination) as a faculty member to "test" it told me that her professorial status was unknown to the simulated patient. She said she felt as if she was participating in an in vivo multiple choice exam. When she began to seek information beyond the script, the simulated patient was unaware that this marked a greater sophistication rather than an error.

The doctor was, in fact, criticized by the simulated patient for doing unusual reflex studies, which are part of the armamentarium of the truly knowledge diagnostician in neurology but unknown to the simulated patient.

Having worked with the simulated patients, I found it very difficult to show the same genuine curiosity, emotional attachment, and sympathy that I do with those truly afraid, sick, or suffering. Thus, I may appear more callous than I would otherwise, or I may have to act sympathetic, setting up the scenario of the simulated physician interacting with the simulated patient.

I viewed a videotape of a question on the test for recertification proposed by the ABIM. A recording of a murmur was given. As a teacher, in my experience it is not identifying the nature of a known murmur, but the ability to know, by other historical and physical cues, when specifically to listen for and interpret the implication of the murmur that is in question in most missed diagnoses by students and house staff.

Once the murmur is presented, it is immediately known to the student to be of some significance. The information given is the sort that we hope the skilled diagnostician can, in fact, elicit-not simply be "given."

The argument has been made that using real patients is difficult and tedious, and that they are not suitable for comparative evaluation. This has validity but it raises the question: If something is difficult to study, should we study something else? What if it were the case that a scientist, doing a bench evaluation of one virus, found it difficult to work with and substituted another and published those results? Would this not be seen as fraudulent?

The argument has been made that airplane pilots fly simulators, and that virtual patients have an analogous role for physicians. I think not. First, airplanes are machines and have no emotional responses to turbulence. Also, pilots put in hundreds of training hours flying with more experienced pilots and observing their reactions. It is the analogy to this part of flying that, in the hurly-burly days of managed care, we in medicine appear to have successively eliminated: the ability of experienced clinicians to work closely and carefully with the students and junior colleagues, with enough time to constructively criticize their basic skills.

I think this attempt to set up virtual patients is yet another of the fundamental errors of medical education in our age: It is adapting to a bad system, rather than insisting on a good one. What we may wind up teaching our students is compromise, acceptance of the loss of the centrality of the actual patient in clinical medicine and in teaching medicine and acceptance of the concept that there is "an answer" rather than a continual, multiply nuanced, hidden, complex, and perpetually uncertain interplay between physician and real, suffering people.

If teachers of medicine give students, house staff, and graduate physicians the idea that these examinations are a true test of clinical skills, we also concurrently send the message that an actual patient is expendable. In this age of technology, I believe this message may be sent too often to ourselves and to our students. Is this really what we want to do? I would like to hear what other people think.

Over the last several years, as I have had the privilege to participate in the College as your Governor on a national level, the depth and breadth of the services the College offer, and the professionalism of the staff remains stunning to me. The following is a comprehensive list of the services available to members of the College:

EDUCATION

Annual Session
Chapter/regional meetings
Clinical skills teaching modules
In-training examination
Post-graduate review courses
Recertification courses
Programs for community-based teachers

ADVOCACY AND PROFESSIONALISM

Online membership directory
Grassroots hotline
Career opportunities
Decision 2000 campaign
Doctors for Adults public awareness campaign
Ethics case studies
ACP Ethics Manual
Legislative Action Center
Access to legislative and regulatory information, national and state
"Membership Enhancement" programs
Position and policy papers
Volunteerism project

PUBLICATIONS

Annals of Internal Medicine
ACP Journal Club
Effective Clinical Practice
ACP-ASIM Observer
Books and expert guides

SELF-STUDY

Internal medicine board review course (audio and video versions)
Internal medicine recertification preparation course (audio and video versions)
MKSAP 12 update
Annual session audiocassettes
Best Evidence (CD-ROM)
Bioterrorism resource center online
Clinical practice guidelines
Clinical problem-solving cases
Clinical skills videotapes
Firearm injury prevention resource center
MKSAP for students
MKSAP Prep for Boards
Subspecialty MKSAPs
Telemedicine resource center
Virtual Annual Session

FOR ASSOCIATES AND MEDICAL STUDENT MEMBERS

Residency information
Career counseling information and Web links
Career counseling brochures
Community-based teaching program support
Impact newsletter
Mentoring database
MKSAP for students
Representation through Council of Associates and Council of Student Members
Video and slides about internal medicine careers
Support for internal medicine clubs
Annual Session workshops

PRACTICE ASSISTANCE

Professional liability insurance
Center for a Competitive Advantage
Medical informatics program (Annual Session)
Medical Laboratory Evaluation Proficiency Testing
Program
Qnet
Quality 101

INTERNATIONAL PROGRAMS

Clinical skills teaching modules
Internal medicine overseas
Action in internal medicine
International speakers program
Eurasian Medical Education Projects
Annual Session workshops
Representation in the International Society of Internal Medicine

RECOGNITION PROGRAM

Fellowship credentialing process
Associate and Medical Student competitions
Convocation
Chapter awards program
Laureate awards
Mastership awards
Community-based teaching awards

PERSONAL BENEFITS

College accessories and gifts
Doctors for Adults accessories and gifts
Affinity credit card
Car rental discounts
Financial planning service
Group insurance plans
Loan programs

To medical students and associate members of the Chapter: We have not forgotten you. Our Shakertown program for 2nd year residents at both schools will follow again in March, and freshman students at both the University of Kentucky and University of Louisville continue our preceptorship program each summer. Let us know how this Chapter can serve you better. I hope to again have medical student and associate members on our council in the upcoming year.

If any of you have thoughts about how to improve the Chapter or wish for the information about the Chapter or how to advance to Fellowship, please contact me at:

350 Hospital Way Somerset, KY 42503-2869 Phone: (606) 451-2628 Fax: (606) 451-2630 E-mail: joeweigel@hotmail.com

Finally, I always try to leave you with a piece of writing that I have found which had affected me profoundly, and made me think again about the essence of internal medicine. This recent piece in JAMA truly brought tears to my eyes and made me understand once again, what this profession is about.

With best wishes for the holiday season,

Your Governor,

Joe Weigel

I Held Him in My Arms and Wept

Michael K. Elmore-Meegan, BPhEccl, MSc, TCD, PhD

Ngong Hills, Kenya

A year before his death 17-year-old Atria weighs 7 stone. He has left his village, He is afraid and he is ashamed. He is embarrassed to be here. He is sweating, he fights. His hands tremble. His pulse is rapid. He tries to smile.

His problems aren't on the rashes and the intestinal worms. These are easily cleared up. But you can't "clear up" anger and fear, or sleepless nights and panic attacks or how long a few minutes can seem... or the sense of powerlessness watching your own body fall away, the humiliation of disintegration.

Some infections are harder to deal with: a mouth filled with ulcers, and inflamed penis. As the disease progresses so do the nausea, the back pain, the headaches. Muscle cramps always hurt, especially when one has very little muscle. Atria has severe diarrhea and the dull aches in his stomach become sharp pains. Despite our best efforts he becomes anemic. His sight fades, as well as his concentration. Atria has stinging burning pain from urinary tract infections, as his urinary tract is blood red and raw.

Moving his bowels has become a feared ordeal, as his anus has lost its muscular contractility and often gets infected. He has no buttocks, not really, just skin stretched over bone, sore to lie on. His joints are hypersensitive. Above all Atria finds it difficult to breathe. His dreadful wheezing-gurgling prevents sleep and he moans a lot because the painkillers are useless.

Over the coming months Atria finds some support and friendship, some dignity and encouragement. He was a beautiful young man with stunning eyes. A proud, energetic guy, very popular and ambitious with a deadly since of fun. Now most of all he hates that he leaks and drips, smells bad, and often cannot control his bowel movements or urination.

He gets angry at himself. He is weak and dizzy and has constant headaches. He cannot eat easily and his ability to digest is deteriorating, as his enzymes are breaking down. The slightest knock causes a painful bruise. Atria is now 6 stone.

After another few weeks, the boy is drained; his mouth full of thrush, a thick, white fungus over his tongue and gums-and ulcers- he has difficulty swallowing. Breathing is increasingly labored. By now, pneumonia is taking over.

All movement is acutely painful and distressing. Intestinal worms are back again. Atria's limbs are stiffening and his back is covered with ulcers that leak and bleed but do not heal, impossible to manage in a small hut.

His issues are controlling pain, managing extreme distress, reducing humiliation, creating dignity, reducing multiple infections, reducing cross-infection to others. But the worst thing is the loneliness. To die of AIDS in Africa is an intensely humiliating ordeal, slow..... obscene.

Atria is now in his last days of life. His tear ducts have dried up, his hair has fallen out, his bones are brittle. He has no muscle or fat and his heart is 70% weaker than pre-HIV. He has been eaten alive and he has no resistance. All of Atria's senses are shutting down.

His fingernails and toenails have fallen out. His skin is blistered and scaly, and scabs cannot form. The bedsores and ulcers have spread, sources of multiple deep infections. Breathing is almost impossible and the slightest movement is slow and full of dreadful anxiety. I give him water drop by drop through a straw.

I hold his frail, stiffened hand. He is cold, he has no tears. I look into his eyes. I whisper to him, and kiss him. He slowly inhales, half closes his eyes. He breathes out, very slowly.

Atria's face relaxes, his tormented body sags. He is gone.

I held him in my arms and wept.

I cannot describe the fear and emptiness watching such disintegration. As I write this, the images that flash across my mind are not the data, the plan, the project, but the faces, the faces of those who have had no one else to love them...... nowhere else to go--dumped, neglected, unwanted.

I feel so inadequate, so useless and unworthy, flawed and pathetic, so utterly overwhelmed. I want to be somewhere else. I am not able for all of this.

The horror of the holocaust revolts me. I have sights so unspeakable in my mind. What has humanity done?

Why do we allow people to die this way? What manner of beast are we?

In my aloneness, in my fear, in my pathetic inadequacy, in my own humanity, despite myself, I fall before the feet of God and cry:

Why?

Yet in the end, I find the only thing that matters is to do the best I can. I leap into the darkness and find myself in a sweltering, disease-ridden place, full of flies and gross smells-- and a child is crying. I reach out to gently grasp his small, withered hand, too weak to tremble.

I am here. All shall be well.

I am here.