lee medical student mistreatment jama 1984

PulseTHE MEDICAL STUDENT SECTION OFJAMA

Medical Student Mistreatment

Breaking Bad News to Patients

at University of California - San Francisco on October 19, 2010 www.jama.comDownloaded from

http://jama.ama-assn.org

PulseCo-EditorsAmy D. Crawford-FaucherMedical College of PennsylvaniaFrancis S. LeeUniversity of Michigan Medical School

Senior EditorsMark D. Fox, MAVanderbilt University School of Medicine

Preeti N. Malani, MSJWayne State UniversitySchool of Medicine

Associate EditorsArlrian G. Battoli, MSUCLA School of Medicine

Beverly M. Calkins, DrPHLoma Linda University School of Medicir

Gregory R. SchwartzYale University School of Medicine

Stephen G. SchwartzNew York University School of Medicine

Art EditorJames D. VanHooseUniversity of KentuckyCollege of Medicine

¡AMA StaffCharlene BreedloveManaging Editor

Kate WhetzleProduction

AMA-MSS Governing CouncilElaine Holstine, ChairpersonHeidi Dunniway, Vice ChairpersonStephen Bayles, DelegateAnneke Schroen, Alternate DelegateAmber Chatwin, At-Large OfficerThomas Dalagiannis, SpeakerCharles Rainey, Vice SpeakerJane L. Uva, MD,Immediate Past ChairpersonPulse is prepared by the Pulse editors and JAMAstaff and is published monthly from Septemberthrough May. It provides a forum for the ideas,opinions, and news that affect medical studentsand showcases student writing, research, andartwork. The articles and viewpoints in Pulse arenot necessarily the policy of the AMA or ¡AMA. Allsubmissions must be the original unpublishedwork of the author. Work submitted to Pulse issubject to review and editing.

Address submissions and inquiries to PulseEditor Amy D. Crawford-Faucher, 3572 NewQueen St, Philadelphia, PA 19129; phone andfax, (215)843-3563.

Membership Has Its CostsFrancis S. Lee, University of Michigan Medical School

No one will dispute that medicaltraining is a demanding, arduousprocess with inherent stresses. As theleast experienced members in themedical hierarchy, medical studentsare particularly vulnerable to feelingthe rigors of clinical training. Addingto the tensions of training, a growingliterature suggests that medicalstudents are subjected to disturbinglevels of verbal and physical mistreat¬ment as well as sexual harassment.1 "3

Most studies of medical studentabuse use self-reported surveys andanecdotal accounts, which have inher¬ent limitations. Still, the consistentfinding that a majority of medicalstudents perceive themselves under¬going some form of mistreatment or

abuse must be taken as a serious andstartling indication of the nature ofmedical training. In one longitudinalstudy, self-reported incidents of abusecorrelated positively with the development of psychopathology such as

depression and escape drinking.4In this issue of Pulse we add to the

growing body of research on medicalstudent mistreatment a study byUhari and colleagues5 of Finnishmedical students given the same ques¬tionnaire used in many US studies ofmedical student abuse. Similar to thatobserved in US studies, the majorityof Finnish medical students reportedepisodes of mistreatment, includinga high rate of sexual harassmentof female medical students.

Previous studies in British andAustralian medical schools reported alower incidence of mistreatment. How¬ever, these studies used a narrowerdefinition of mistreatment and did notinclude specific examples in the ques¬tionnaire.67 The study by Uhari andcolleagues highlights the importanceof using uniform definitions of abuseas well as established instruments tomeasure self-reports of abuse.

One way to evaluate documented

self-reports of mistreatment is toconsider them in the context ofthe broader medical environment.By stepping back to consider theentire social and educational milieuthat medical students are placed in,one may gain fresh insights into thehigh rate of perceived mistreatmentor abuse.

A metaphor commonly used todescribe the institution of medicine isthat of an exclusive, private club or

guild. To gain entrance and accep¬tance within the guild one has to gothrough a series of hidden, punitiverituals that would ostensibly confirmthe ability of new members to with¬stand the demands of a guild career.

To reveal or resist these rituals wouldlead to rejection from the guild.

Medical students and residentshave published accounts suggestingthat such an atmosphere of hostilityand exploitation is acceptable inthe training process.8"10 The use ofhumiliation, rejection, and alienationin these punitive hazing rituals isreadily observable by insiders duringundergraduate and graduate medicaltraining. In this context, it is under¬standable why medical studentsreport such high levels of mistreat¬ment in anonymous questionnaires,yet few report mistreatment to theirmedical schools.2-3

The broader question remainswhy such an environment of accept¬able hostility exists at all. Ironically,most people enter the medical pro¬fession to help patients and to treatthem compassionately, but the educa¬tional process is imbued with a dehu¬manizing component. One has towonder about the implicit lessons ourteachers are imparting to medicalstudents.

In the 1950s the medical educa¬tion process was studied from a

descriptive sociological and anthro¬pological perspective.1112 As any

(Continued imp 1049.)The cover photograph, Mennonite Girl, is by Pulse Art Editor lames D. VanHoose, Universityof Kentucky College of Medicine.



Medicai Student Abuse: An International PhenomenonMatti Uhari, MD, Jorma Kokkonen, MD, Matti Nuutinen, MD, Leena Vainionpaa, MD, Heikki Rantala, MD,

Pentti Lautala, MD, Marja Väyrynen, RN, Department of Pediatrics, University of Oulu, Finland

Objective.—To evaluate the prevalence of physical andpsychological mistreatment of medical students at twomedical schools in Finland.

Study Design and Setting.—To enable comparisonbetween Finnish and American students, we used theAmerican Medical Association's Office of EducationResearch questionnaire.

Results.—Three of every four students surveyed reportedexperiencing some kind of mistreatment during their medi¬cal education. Students most commonly reported sexualmistreatment, usually as slurs and sexual discrimination,from classmates, preclinical teachers, clinical teachers,clinicians, nurses, and patients. Other forms of verbalabuse, psychological mistreatment, and physical threatswere also reported.

Conclusions.—All forms of mistreatment were reportedoccurring less frequently than in the United States; still, thelevel of such behavior was high. The results suggest theneed for more international awareness and debate regardingthe habits and behavior of teaching staff in medical schools.

Medical training is frequently a stressful experience thatmay lead to alcohol and drug abuse among students,1"3 andthe amount of stress is inversely correlated with academicperformance.4 Among the external factors contributing tostudent stress are a lack of administrative responsiveness tostudents' needs and an unsupportive learning atmosphereengendered by attending physicians and a lack of facultyrole models.1

Recendy, disturbing levels ofverbal and physical mis¬treatment of medical students have been reported.25"8 Sincemost reports of student abuse come from the United States,

and because there are marked social and educationaldifferences between European and US students, we usedthe same survey questionnaire that had been used in theUnited States to discover how students in two Finnish medi¬cal schools would report their experiences.6-7METHODS

Since we wished to elicit as fully comparable data as

possible, we used the survey designed by Baldwin and col¬leagues6 in 1988 and later used by several US researchers.In translating the questionnaire, we kept the format asclose to the original as possible, omitting only questionsirrelevant to the Finnish medical education curriculum.

We surveyed students in their third and fifth academicyears (the first and third years of clinical work) at two medi¬cal schools in Finland. After briefly introducing the surveyand its purpose, we distributed the questionnaires followinga clinical lecture. In Oulu, 108 (65.1%) of the 166 studentsin these years attended the lecture, and only one did not fillin the questionnaire. At Tampere Medical School, 148(80.4%) of the 184 students were present and all of themcompleted the questionnaire. This gave a total number of255 student participants.

Students' ages varied from 21 to 41 years, with a mean

age of 24.9 years. The majority were female (63.9%); 55.5%were unmarried, 23.8% were married, and 19.5% were

living with a partner. Three were divorced. Many of thestudents planned to work as general practitioners (16.8%);other specialty choices included surgery (11.7%), pediatrics(7.8%), internal medicine (7.8%), gynecology and obstet¬rics (7.4%), neurology (5.9%), and anesthesiology (3.9%).Almost half said their academic performance ranked in thesecond best quarter of their class.

The data from the questionnaires were analyzed using(Continued onp 1050.)

Membership Costs (Continued from p 1048.)insider on the wards is aware, many private rituals takeplace in the training process that cannot be fully examinedwith neat, scientifically controlled studies. Descriptive re¬

search on mistreatment of medical students may begin toflesh out what the various self-reported numbers and anec¬dotal accounts have been suggesting over the past decadeand shed light on the level and nature of mistreatment.Let us hope a thoughtful dialogue will emerge that distin¬guishes those aspects of the ritual-laden "curriculum" thatgenuinely enhance medical training from those that are

demeaning and undermine the profession.References

1. Silver HK. Medical students and medical school. JAMA. 1982;247:309-310.2. Silver HK, Glicken AD. Medical student abuse: incidence, severity, and signifi-

cance. JAMA. 1990;263:527-532.

3. Sheehan KH, Sheehan DV, White K, Leibowitz A, Baldwin DC Jr. A pilot study ofmedical student 'abuse': student perceptions of mistreatment and misconduct inmedical school. JAMA. 1990;263:533-537.

4. Richman JA, Flaherty JA, Rospenda KM, Christensen ML. Mental health conse-quences and correlates of reported medical student abuse. JAMA. 1992;267:692\x=req-\694.

5. Uhari M, Kokkonen J, Nuutinen M, et al. Medical student abuse: an internationalphenomenon. JAMA. 1994;271:1049-1051. Pulse.

6. Firth J. Levels and sources of stress in medical students. BMJ. 1986;292:1177-1180.7. Harth SC, Bavanandan S, Thomas KE, Lai MY, Thong YH. The quality of student

tutor interactions in the clinical learning environment. Med Educ. 1992;26:321\x=req-\326.

8. Klass P. A Not Entirely Benign Procedure: Four Years as a Medical Student. NewYork, NY: Signet; 1987.

9. Reilly P. To Do No Harm: A journey Through Medical School. Dover, Mass:Auburn House; 1987.

10. Litwin MS. A resident's reflections on medical education. JAMA. 1991;266:926.11. Becker HS, Geer B, Hughes EC, et al. Boys in White: Student Culture in Medical

School. Chicago, Ill: University of Chicago Press; 1961.12. Merton RK, Reader G, Kendall PL, eds. The Student-Physician: Introductory Studies

in the Sociology ofMedical Education. Cambridge, Mass: Harvard UniversityPress; 1961.



Medical Student Abuse (Continued from 1049.)Windows software (SPSS version 5.0). The differences be¬tween the frequencies were tested with the chi-square test.

RESULTSThree of four medical students (74.2%) reported having

experienced some kind of mistreatment during their medi¬cal education. There were no significant differences in thefrequency of reported mistreatment between the two medi¬cal schools evaluated.

Sexual mistreatment was reported by 95 students (37%).Sexual mistreatment by nurses was reported by malestudents (5%) and by female students (15%). The mostcommon forms of sexual mistreatment were slurs andsexual discrimination (Table 1). Male students reportedharassment from classmates (P<.01), preclinical teachers(P<.05), clinical teachers, (P<.01) clinicians (P<.01),and patients (P<.01) more often than femalestudents (Table 2).

Teachers and clinicians had shouted at about 10% ofthe students. One of every four medical students reportedbeing yelled at or shouted at by nurses; 39% had experi¬enced nurses being inappropriately nasty, rude, or hostile.These figures are about twice as large as those reflectingclinicians' behavior and represent the most common

source of verbal abuse (Table 3).Patients had yelled or shouted at 24 (9%) of the

students and had been nasty, rude, or hostile to 37 (15%).Threats of physical violence were rarely made by teachersor by clinical staff, but patients had threatened 16 of thestudents (6%) and had physically attacked 7 students (3%).Although patients had physically threatened only a fewstudents, 18% regarded the possibility as a serious problemin medical practice.

About 15% of the students reported derogatory or of¬fensive remarks about medicine or the choice of a medicalcareer, and a fourth of them considered this bothersome.Derogatory remarks were most commonly heard fromfellow students (25%) and nurses (22%), but also fromfamily members (17%) and teachers (17%). Only 11% ofstudents reported hearing clinicians make derogatoryremarks about medicine or a medical career.

Sleep deprivation while studying for courses was

reported by 36% of the students, whereas 67% experiencedsleep deprivation while preparing for examinations. Twothirds of the students regarded loss of sleep as an unneces¬

sary aspect of medical training, 54% thought it had no

value for learning, and 45% felt that doing without sleephad sometimes impaired their ability to care for patients.COMMENT

Reports of abuse during medical education were surpris¬ingly common among the medical students surveyed, sincealmost 75% had experienced at least one episode of mis¬treatment. In the study by Baldwin and colleagues8 thefigures for various forms of mistreatment were generallythree to five times higher than ours, and US studentsreported worse experiences with clinical teachers and clini¬cians than with preclinical teachers. In a study by Silverand Glicken,5 which surveyed all students at a US medicalschool in 1985, respondents reported most abusive experi-

Table 1.—Frequencies of Different Forms of Sexual MistreatmentReported by Female Students (n=163)

Form of Sexual Female StudentsMistreatment %Denied opportunities 19 12Sexual reward 1 1

Advances 12 7Slurs 52 32Malicious rumors 2 1

Other sexual discrimination 38 23

enees during their junior year, ie, during the first clinicalcontact. More than two thirds could recall one episodefrom that year. Of those who had been abused or mis¬treated, 70% had experienced at least one episode theyconsidered "of major importance and very upsetting."In three British medical schools 34% of the fourth-yearstudents described relations with consultants as most stress¬ful because they felt humiliated in front of their peers.3Relations with academic staff (13%) and clinical staff(11%) were less often reported to be particularly stressful.'

The fact that students recalled most negative experi¬ences from their first clinical year is understandable—it wasthe first time they were taking responsibility for patients. Asmost students had anxiously awaited that opportunity foryears, and many had no prior patient contact whatsoever,some disappointment was unavoidable. Since their clinicalself-esteem is not firmly established, students may easilyblame their teachers or clinical staff for their first problemswith patients or even for what they feel to be their psycho¬logical failures.

Sheehan and colleagues7 reported verbal abuse directedtoward students to be equally dispensed from nurses, clini¬cians, clinical teachers, and patients; whereas in our studythe nurses were clearly the most common source ofverbalabuse. Conceivably, medical students found it easier to

report derogatory comments made by nurses than thosemade by physicians; more likely, the results reported herereflect problems in professional relations between nurses

and physicians and nurses' felt need to exercise controlover "young doctors." We found no differences betweenmale and female students in their experiences with nurses,contrary to Spiegel and colleagues,9 who reported more

conflicts involving women than men.

Sexual harassment and mistreatment were considerablyless frequent in Finland than in the United States.6·7 Thetradition ofwomen working outside the home in Nordiccountries, and a recent increase in the proportion ofwomen in medical schools may have led to their greateracceptance as medical students. Even so, 37% of studentsreporting some kind of sexual mistreatment is high, show¬ing that sexual mistreatment is a problem in medical educa¬tion in Finland, too. Women's consistently higher stressscores may also be due to the more frequent sexual mis¬treatment of female students.9

Although sleep deprivation is a major Stressor duringresidency training,10 Finnish students reported it less than



Table 2.—Frequency and Source of Episodes of Sexual Harassment or Mistreatment Reported by Female (n=163) and Male (n=92) Students

Source of Abuse

_RarelyI IFemale Male (%) (%)

Sometimes

Female Male (%) (%)

Often

Female Male (%) (%)

Classmates 20(12) 2(2) 7(4) 2(1)

Preclinical teachers 19(12) 4(4) 6(4) 1 (1)

Clinical teachers 31 (19) 1 (1) 13(8) 1(1) 3(2)

Clinicians 28(17) 0 11 (7) 4(3)

Nurses 13(8) 2(2) 8(5) 3 (3) 4(3)

Patients 26(16) 4(4) 6(3) 2 (2) 2(1)

Table 3.— umber and Percentages of Students (n=255) Reporting at Least one Episode of Mistreatment, by Type and Source

Type of Abuse

Teachers

Preclinlcal (%)

Clinical (%)

Clinical Staff

Clinicians (%)

Nurses (%)

Verbal abuseYelled or shouted

Nasty, rude, or hostile33(13)51 (20)

28 (11)74 (29)

23 (9)54 (21)

61 (24)100 (39)

Psychological mistreatmentAssigned tasks as punishmentTook credit for your work

Unjustifiable bad grades

18 (7)10 (4)15 (6)

15 (6)5 (2)5 (2)

15 (6)8 (3)

15 (6)23 (9)

Physical threats or abusesThreatened with physical violence

Subjected to physical violence13 (5)0

10 (4)3 (1)

5 (2)3 (1)

3 (1)18 (7)

Derogatory remarks about medicine 44 (17) 44 (17) 28 (11) 54 (21)

did their US counterparts, all of whom had experiencedsleep deprivation on clinical rotations.7 Students do nothave night duties during clinical rotations in Finland anddid not feel that a lack of sleep impaired their ability tocare for patients as often as did US students.

The fact that only about one tenth of the medical stu¬dents had experienced verbal abuse from patients reflectsthe social respect patients in Finland generally have for themedical profession. Patients understand that they are beingexamined by medical students and accept that they are

object lessons for teaching.The number of medical students reporting abuse in

Finland, the United States,3-5 and Britain8 " indicates thatalthough the prevalence and forms of student abuse vary,the phenomenon is common. Even if all the experiencesreported here and elsewhere were merely single, isolatedepisodes, the cynical attitudes of the clinical staff towardstudents and toward medicine in general are alarming andrequire a response.2,78 We need to press for more interna¬tional awareness of the climate endorsed in medical educa¬tion and more debate on the subject.

References

1. Lloyd C, Gartrell NK. A further assessment of medical school stress. Med Educ.1983;58:964-967.

2. Richman JA, Flaherty JA, Rospenda KM, Christensen ML. Mental healthconsequences and correlates of reported medical student abuse. JAMA.1992;267:692-694.

3. Firth J. Levels and sources of stress in medical students. BMJ. 1986;292:1177\x=req-\1180.

4. Spiegel DA, Smolen RC, Hopfensperger KA. Medical student stress and clerkshipperformance. Med Educ. 1986;61:929-931.

5. Silver HK, Glicken AD. Medical student abuse: incidence, severity, andsignificance. JAMA. 1990;263:527-532.

6. Baldwin DC Jr, Daugherty SR, Eckenfels EJ, Leksas L. The experience ofmistreatment and abuse among medical students. In: Research in MedicalEducation. Proceedings of the 27th Conference. Washington, DC: Association ofAmerican Medical Colleges; 1988:80-84.

7. Sheehan KH, Sheehan DV, White K, Leibowitz A, Baldwin DC Jr. A pilot studyof medical student 'abuse': student perceptions of mistreatment and misconductin medical school. JAMA. 1990;263:533-537.

8. Baldwin DC Jr, Daugherty SR, Eckenfels EJ. Student perceptions of mistreatmentand harassment during medical school: a survey often United States schools.West J Med. 1991;155:140-145.

9. Spiegel DA, Smolen RC, Jonas CK. Interpersonal conflicts involving students inclinical medical education. Med Educ. 1985;60:819-829.

10. McCue JD. The distress of internship: causes and prevention. N Engl J Med.1985;312:449-452.

11. Wolf TM, Randell HM, Alen von K, Tynes LL. Perceived mistreatment andattitude change by graduating medical students: a retrospective study. Med Educ.1991;25:182-190.



Breaking Bad News to Patients

Margaret L. Campbell, RN, Detroit Receiving Hospital

Delivering bad news is a difficult and unavoidable responsi¬bility for medical practitioners. Students may have limitedexposure to this sensitive and demanding task, and fewhealth care professionals have had formal training in thisarea.1 The following strategies for health care providersmay prove helpful.Prepare in Advance

What do the patient and his or her family already knowabout the patient's diagnosis and prognosis? Is this new

information, or is it building on previous conversations?How have the patient and family coped with the hospitaliza-tion, diagnostic workup, and earlier meetings? Are theresupport people in the patient's social network, or willhospital personnel fulfill that role?

Reading the chart, especially the detailed nursing notes,may answer these questions and provide clues to thepatient's concerns and questions. Review earlier conversa¬

tions with the patient or family before sharing new informa¬tion. The presence of a support person—from either thepatient's social network or the hospital—should be soughtin advance. The patient's nurses, hospital social workers,chaplains, and medical students who know the patient wellcan provide this support.

Practical aspects also need to be considered. Arrange a

mutually convenient time for the meeting, considering thepatient's care schedule, level of fatigue, and availability ofsupports. Schedule the meeting for a time of day with fewinterruptions, or hand off your beeper to a colleague forthe duration. These meetings may require up to an hour,depending on the complexity of the news being conveyed,and on the preparedness of the patient and the family.Establish a Therapeutic Environment

Sensitive information will be shared more readily andeffectively if the discussion occurs in a private, quiet setting.Consider asking an ambulatory patient roommate to leavefor a time, or moving the patient and family to anotherarea for the meeting—preferably a space with a closed doorand sufficient seating for all concerned. If the patient andfamily are seated, the person delivering the news shouldalso be seated to minimize the physical and psychologicaldistance. Avoid artificial barriers such as desks and tablesbetween the provider, patient, and family. Also, sit closeenough to the patient so that you can easily be seen andheard and so that you can extend a comforting touch tothe patient's shoulder or hand if appropriate.

No matter how difficult a challenge for the provider, theinformation delivered must be honest, reliable, and com¬

prehensible. The health care provider must avoid euphe¬misms, jargon, and acronyms, as most patients are notfamiliar with medical terminology.

Euphemisms for dying are often employed to make thenews more comfortable for the speaker. These ambiguitiesblock effective understanding and impair subsequent

discussions and decisions, as this dialogue illustrates:Physiaan: 'Your mother's condition is deteriorating and

we don't expect her to do very well."Family: 'Thank you, Doctor, we know you are all doing

your best."Family to each other. 'Thank goodness, he didn't say

she's dying."A direct approach that prepares the patient and family

without misleading them is best. Prefacing your remarkswith "I'm afraid I have bad news" is a simple yet effectiveway to introduce the subject.Dealing With Patient and Family Reactions

Patients and families react differently to bad news,depending on their preparedness, culture, and copingskills. Initially they may remove themselves, either physicallyor emotionally, from the discussion to avoid hearing anymore. The patient or family may become openly hostileand aggressive at the news; it is important not to personal¬ize their response or to react defensively. Supportive repliesfrom the health care provider may calm them; "I know thisnews can make you angry, but I want to help."

They may display anticipatory grief, characterized bysomatic distress, guilt, preoccupation with the patient,emotional displays, and dysfunctional conduct.2 These are

normal grief reactions and should not be suppressed.The patient and family may challenge or question theinformation, which should be viewed as a need for more

information and not as a challenge to the integrity of themessenger or the validity of the news. Denial may indicatethe patient or family's inability to accept the news and is a

common coping strategy. Again, avoid defensive responses.Repeat the information, ask the patient and family to

explain their understanding of the situation, and thenclarify any points of confusion.

The patient or family may calmly accept the news. Theymay have been anticipating the news and feel prepared forit. On the other hand, they may not have understood thenews and may be unable to articulate their lack of under¬standing, or they may be shocked into passivity. Acknowl¬edging their reaction, "I notice that you are taking thisnews very calmly; many people react differently," may elicitan explanation.

Additional meetings with the patient and family areoften required. Patients may need information repeatedsince the initial shock of the bad news can interfere withtheir attentiveness and comprehension. These simple yetimportant points may make a difficult and necessary taska little easier.

References

1. Quill TE, Townsend P. Bad news: delivery, dialogue, and dilemmas. Arch InternMed. 1991;151:463-468.

2. Lindemann E. Symptomatology and management of acute grief. Am J Psychiatry.1944;101:141-148.



EpilogueAdam J. Ratner, Columbia University College of Physicians and Surgeons

Anton was right, I suppose. He said it would get all ofus, that it was going to empty out the city. So I went to StLuke's, not Sinai, because Anton and Rachel both gottheirs at Sinai, and I was born at St Luke's. Anyway, thatdidn't stop them from giving me the yellow paper, themiddle copy of my triplicate death sentence. It didn't even

bother me, almost like I expected it. Then they wanted me

to hang around, go through their counseling and find outthat I can't get into any of the drug trials until I'm so sickthat it doesn't matter. I walked out, though. Walked out thefront door, with my yellow paper in my pocket.

We used to listen to the doctors. When Anton was in thehospital the first time and finally got into the ddl trial, hehad to sign a consent form. He asked the doctor, some palekid with a shiny stethoscope, what the initials stood for. Thekid fumbled for a while, then admitted that he didn't know.So I was going to stay there and let them counsel me andtell me it's okay to be angry and it's okay that I can't gettreatment because they don't know what's going on?Thanks, I had better things to do.

So I went across the campus to get to Broadway. A pan¬ther smile on the face of a homeless man reminded me ofAnton. That bookstore where we met was only a block away,but I kept walking. The Saturday morning line at Zabar'sfish counter was huge, but I took a number and lookedaround, remembering when the pots and pans and orangejuicers used to hang from the ceiling and my hair could justtouch the bottom of some of them. The coffee grinderswhirred and sent off their morning smell, and peoplepushed by me, but I just stood there, taking it all in. Thisold woman was over by the checkout line screaming at herhusband that he forgot to buy coffee, only he was alreadyon the other side, by the door. So she started lobbing thebags of coffee beans over the line to him. He tried to catchthem, but he dropped his hat, then the beans spilled allover the place and he shrugged and picked up his hat andwalked out the door.

So I bought my lox and I stopped to buy bagels—sixsesame and six poppy, but by the time I got home the seedswould all be mixed. I thought about Rachel. She was reallythe one who took care of Anton. Since the day sheannounced she was moving in, she kept Anton and me sane,kept us from staying out too late and killing ourselves or eachother. She used to run in the park every day, but once he gotsick she would run straight to the hospital. I would see herthere later, sitting next to his bed, wearing her green tights.

Rachel used to say that she just hoped she got it last, so

she could take care of me. I told her that by the time we

got it there would be a cure, that it wouldn't matter.At Anton's funeral she told me she wanted to get testedagain—she needed to know. Then she put her head on

my shirt and it got wet, and I put my arms around her,and they buried Anton.

When Rachel got her yellow paper, she said she felt worse

for me because I was last. Then she went out for a jog andcame back in 3 days. Anyway, they buried her Monday andnow I have mine.

I walked the extra blocks to the record store and found a

Gershwin album because both of them loved Gershwin.There was this really huge line at the counter, but I felt thepaper in my pocket and pushed to the front of it.

In the apartment, I put on the album and carefully slicedone of the sesame-poppy bagels. I toasted it and put more

cream cheese and lox on it than I should have. I threw thepaper on the table and watched it slowly try to unfold itself.I made sure the lights in the rest of the house were off andthe windows shut, and I turned the TV on and the sound offThere were cartoons on, and I like cartoons. So now I'm justsitting on the old, ratty couch, eating my bagel with toomuch lox and cream cheese, and watching cartoons withGershwin sound and on the table are my keys and the yellowpaper and a picture of me and Anton and Rachel and in thecloset is our gun and I'm getting the feeling that it's going tobe a very short night.

-

Murmurs-

"Violence ¡ America: Costs and Responsibilities" is the theme oftheAMA-MSS Annual Meetingtobeheld June 9 through12 in Chicago, III. In addition to a panel discussion on the theme, meeting highlights include the MSS Chapter Poster Session,a Chapter Development Seminar, and election of the 1994-1995 MSS Governing Council, Speaker, and Vice Speaker.Resolutions and convention committee applications must be postmarked no later than April 14. Call the Department ofMedical Student Services (DMSS) at (800) AMA-3211 ext 4746 for registration information.

Apply now for the medical student seat on the AMA Women in Medicine Advisory Panel. The panel advises the AMA on

policies and programs that affect women physicians and medical students. Statements of interest and curricula vitae mustbe postmarked by April 14. Call the DMSS for further information.

Correction.—In the March 2 Pulse the institutional affiliation for book reviewer Pamela Wine was inadvertentlyomitted. Ms Wine is a medical student at the University of Pennsylvania School of Medicine.



lee medical student mistreatment jama 1984

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