Brancati- The Art Of Pimping And Other Articles y134s

The Art of Pimping IT'S HARD work becoming a revered attending physician in a university hospital. The task daunts the newly appointed junior attending as he strides down the corridor of his first ward with his first team. Oh, he's made some changes in anticipation of his new position. He's wearing a long coat now, an all-cotton coat with razor-sharp creases and knit buttons. The stained, shrunken polyester white pants and tennis shoes have given way to gray, light wool slacks with a cuff and polished loafers. Framed certificates bear testimony to his intelligence and determination. He should be ready to take the helm of his ward team, but he's not. Something's missing, something important, something closer to art than to science. When physicians talk about the "art of medicine" they usually mean healing, or coping with uncertainty, or calculating their federal income taxes. But there's one art this new attending needs to learn before all others: the art of pimping. Pimping occurs whenever an attending poses a series of very difficult questions to an intern or student. The earliest reference to pimping is attributed to Harvey in London in 1628. He laments his students' lack of enthusiasm for learning the circulation of the blood: "They know nothing of Natural Philosophy, these pin-heads. Drunkards, sloths, their bellies filled with Mead and Ale. O that I might see them pimped!" In 1889, Koch recorded a series of "Pümpfrage" or "pimp questions" he would later use on his rounds in Heidelberg. Unpublished notes made by Abraham Flexner on his visit to Johns Hopkins in 1916 yield the first American reference: "Rounded with Osier today. Riddles house officers with ques¬ tions. Like a Gatlinggun. Welch says students call it 'pimping.'

Delightful." On the surface, the aim of pimping appears to be Socratic instruction. The deeper motivation, however, is political. Proper pimping inculcates the intern with a profound and abiding respect for his attending physician while ridding the intern of needless self-esteem. Furthermore, after being pimped, he is drained of the desire to ask new questions— questions that his attending may be unable to answer. In the heat of the pimp, the young intern is hammered and wrought into the framework of the ward team. Pimping welds the hierarchy of academics in place, so the edifice ofmedicine may be erected securely, generation upon generation. Of course, being hammered, wrought, and welded may, at times, be somewhat unpleasant for the intern. Still, he enjoys the atten¬ tion and comes to equate his initial anguish with the aches and pains an athlete suffers during a period of intense conditioning. Despite its long history and crucial importance in training, From the

Department of Medicine, University of Pittsburgh (Pa). Reprint requests to 10404 Presbyterian-University Hospital, DeSoto streets, Pittsburgh, PA 15213 (Dr Brancati).

at O'Hara

pimping as a medical art has received little attention from the

educational establishment. A recent survey reveals that fewer than 1 in 20 attending physicians have had any formal training in pimping. In most American medical schools, pimping is covered haphazardly during the third-year medical clerkship or is relegated to a fourth-year elective. In a 1985 poll, over 95% of program directors itted that the pimping skills of their trainees were "seriously inadequate." It comes as no surprise, then, that the newly appointed attending must teach himself how to pimp. It is to this most junior of attendings, therefore, that I offer the following brief guide to the art of

pimping. Pimp questions should come in rapid succession and should be essentially unanswerable. They may be grouped into five categories: 1. Arcane points of history. These facts are not taught in medical school and are irrelevant to patient care—perfect for pimping. For example, who performed the first lumbar punc¬ ture? Or, how was syphilis named? 2. Teleology and metaphysics. These questions lie outside the realm of conventional scientific inquiry and have tradition¬ ally been addressed only by medieval philosophers and the editors of the National Enquirer. For instance, why are some organs paired? 3. Exceedingly broad questions. For example, what role do prostaglandins play in homeostasis? Or, what is the differen¬ tial diagnosis of a fever of unknown origin? Even if the intern begins making good points, after 4 or 5 minutes he can be cut off and criticized for missing points he was about to mention. These questions are ideally posed in the final minutes of rounds while the team is charging down a noisy stairwell. 4. Eponyms. These questions are favored by many oldtimers who have assiduously avoided learning any new devel¬ opments in medicine since the germ theory. For instance, where does one find the semilunar space of Traube? Or, whose name is given to the dancing uvula of aortic régurgitation? 5. Technical points of laboratory research. Even when gen¬ eral medical practice has become a dim and distant memory, the attending physician-investigator still knows the details of

his research inside and out. For instance, how active are leukocyte-activated killer cells with or without interleukin 2 against sarcoma in the mouse model? Or, what base sequence does the restriction endonuclease Z?coRI recognize? Such pimping should do for the third-year student what the Senate hearings did for Robert Bork. The intern, in contrast, is a seasoned veteran and not so easily rattled. Years of relentless pimping have taught him two defenses: the dodge and the bluff. Dodging avoids the question, wasting time as well as a valuable pimp question. The two most common forms of dodg-

ing are (1) to answer the question with a question and (2) to answer a different question. For example, the intern is asked to explain the pathophysiology ofthrombosis secondary to the lupus anticoagulant. He first recites the clotting cascade, then recalls the details of a lupus case he itted last month, and closes by asking whether pulse-dose steroids are indicated for lupus nephritis. The experienced attending immediately diag¬ noses this outpouring as a dodge, grabs the intern by the scruff ofthe neck, and rubs his nose back in the original pimp. A bluff, unfortunately, is much more damaging than a dodge. Allowed to stand, a bluff promulgates a lie while undermining the academic hierarchy by suggesting that the intern has nothing more to learn from his attending. Bluffs weaken the very fabric ofAmerican medicine, threatening our

livelihood and our way oflife. Like outlaws in a Clint Eastwood movie, bluffs must be shot on sight—no due process, no Miranda Act, no starry-eyed liberal notions of openness or dialogue—just righteous retribution. Bluffs fall into three readily discernible categories: 1. Hand waving. These bluffs are stock phrases that refer to hot topics in biomedicine without supplying detail or expla¬ nation. For example, "It's a membrane transport phenome¬ non" or "The effect is mediated by prostaglandins." In many institutions, they may evolve directly from the replies of Grand Rounds speakers to questions from the audience. 2. Feigned erudition. The intern's answer, though without substance, suggests an intimate understanding of the litera¬ to ture and a cautiousness born of experience. "Hmmm examined in a has been that not question my knowledge, prospective controlled fashion" is a common form. Frequent¬ ly, the bluff is accompanied by three automatisms: clearing of the throat, rapid fluttering of the eyelids and tongue, and chewing on the temples of the eyeglasses. This triad, when full-blown, will make the intern bear a sudden resemblance to William Buckley and is virtually pathognomonic. 3. Higherauthority. The intern attributes his answer to the teaching of a particular superior. When the answer is refuted, the blame of ignorance comes to rest on the higher authority, not on the obedient, accepting intern. The strength ofthe bluff depends on just whom is quoted. An intern quoting a junior resident about pathophysiology is every bit as cogent as Colo¬ nel Qaddafi quoting Ayatollah Khomeini about international law. An intern from an Ivy League medical school quoting the "training" he received on his medical clerkship goes over like Dan Quayle explaining the Bill of Rights at an ACLU conven¬ tion. The shrewd intern, however, will quote his Chairman of Medicine or at least a division chief, pushing the nontenured attending to the brink of political calamity. Did the chairman actually say thatl The attending is powerless to refute the statement until he is certain. Indeed, a good bluff is hard to handle. Sometimes the intern's bluff sounds better to the ward team than the attending's correct answer. Sometimes it sounds better to the at...

tending himself. Ultimately, the cunning intern is best dis¬ couraged from bluffing by aversive training. Specifically, each time he bluffs successfully, the attending should counter by inducing Sudden Intern Disgrace (SID). SID is induced in two ways: 1. Question the intern's ability to take a history. This tech¬

nique depends on the phenomenon ofhistorical drift. That is, a patient's story will reliably undergo a significant change in the 8- or 16-hour interval between ission and attending rounds. The attending need only go to the bedside and ask the same questions the intern did the night before. Now the entire case is seen in a light different than that cast by the intern's assessment. Yesterday's right upper quadrant cramping be¬ comes right-sided pleuritic chest pain. Yesterday's ill-defined midepigastric "burning" becomes crushing substernal heavi¬ ness radiating to the arm and jaw. Suddenly, the intern is disgraced. He will never bluff again. 2. Question the intern's compulsiveness. In less rigorous programs, this is easy. Did the intern examine the peripheral

blood smear and the urine sediment himself ? If the intern does routinely examine body fluids, a more methodical ap¬ proach is required. In this case, results of the following tests, procedures, and examinations may be requested in rapid succession: Hemoccult slide test, urine electrolytes, bedside cold agglutinins and serum viscosity, slit-lamp examination, Schi0tz' tonometry, Gram's stain of the buffy coat, transtracheal aspiration, anoscopy, rigid sigmoidoscopy, and indirect laryngoscopy. Once the attending discovers a test or examina¬ tion left unperformed, he asks the intern why this obviously crucial point was neglected. (The tension may be heightened at this point by frequent use of the word "cavalier.") The intern's response will generally revolve around time con¬ straints and priorities in diagnostic evaluation. The attending's reder: did the intern eat, sleep, or void last night? The scrupulous intern at once infers that he has placed his own needs before the needs of his patient. Suddenly, he is dis¬ graced. He will never bluff again. Clearly, pimping—good pimping—is an art. There are styles, approaches, and a few loose rules to guide the novice, but pimping is learned in practice, not theory. Despite its long and glorious history, pimping is in danger of becoming a lost art. Increased specialization, the rise of the HMO, and DRGbased financing are probably to blame, as they are for most problems. The burgeoning budget deficit, the changing demo¬ graphic profile of the United States, the Carter istra¬ tion, inefficiency at the Pentagon, and intense competition from Japan have each played a role, though less directly. Against this mighty array of historical forces stands the belea¬ guered junior attending armed only with training, wit, and the determination to pimp. It won't be easy to turn back the clock and restore the art of pimping to its former grandeur. I only hope my guide will help. Frederick L. Brancati, MD

populations suggest humor may be of therapeutic benefit to hospitalized patients.1 These studies are generally not controlled and suffer from possible subject-selection bias as well as other methodological problems. The present report suggests the helpful effects of humor in hospitalized patients may be less than previously indicated. Studies. \p=m-\Afterapproval by the appropriate research committees, two groups of volunteers were recruited for these projects. All were competent, male veterans willing to sign the approved consent form. One group (8 patients) received transurethral prostate surgery under local anesthesia2 and the second group (16 patients) received pe-

ripheral (leg) arteriography.3 Subjects were randomly assigned to

either a humor or ocean sound (control) audiotape condition. The humor tape consisted of a recording of an old Jack Benny radio show. About 85% of the humor-tape subjects described the tape as humorous in posttreatment assessment. After the tapes were adjusted to the patient's hearing, both groups in both procedures listened to the 1-hour tapes through stereo headphones dur¬ ing the procedure. In the transurethral prostate surgery group, six patients were assigned to the humor condition and two to the control condition. In the arteriography group, seven patients were assigned to the humor condition and nine to the control condition. No

significant (P<.05) differences between groups receiving either procedure were

found in age, ission heart rate, overall hospitalization distress ratings, initial anxiety scores, personality style scores,4 or ratings ofthe patients' ability to hear and understand the tapes. Dependent variables assessed during the transurethral prostate surgery con¬ dition were heart rates at time of resectoscope insertion, 10 minutes later, and after its first use for cutting; immediate postoperative State Trait Anxiety In¬ ventory scores; postoperative and re¬ covery room heart rates; total recovery room scores; subjective estimates of procedure pain and anxiety; and 1-hour postsurgical heart rate, State Trait Anxiety Inventory score, and recovery room pain levels. Dependent variables assessed during the arteriography pro¬ cedure were heart rates at time of nee¬ dle insertion, at time of dye insertion, and 3 minutes after dye insertion; imme¬ diate postprocedure State Trait Anxi¬ ety Inventory and heart rate scores; and subjective estimates of procedure pain and anxiety. No statistically significant group dif¬ ferences were found. Small patient numbers may limit study generaliza-

tion. However, there were also no con¬ sistent trends between groups when considering both physiological (heart rate) and psychological (subjective anxiety ratings) variables. For exam¬ ple, transurethral prostate surgery pa¬ tients in the control group reported more procedure anxiety but less proce¬ dure pain than the humor-tape group. Comment.— Caution is urged in ad¬ resources for "hu¬ vocating extensive " mor therapy. While the therapy proba¬ bly does not hurt, this as well as other controlled studies6 cast doubt on the ef¬ ficacy of humor- or music-tape ap¬ proaches. Further controlled research is needed to find out if humor therapy works and, if it does, with what patients and under what conditions. Joseph K. Neumann, PhD Veterans istration Medical Center

Quillen-Dishner College

of Medicine Johnson City, Tenn

Appreciation is expressed to Jo Ann Blankenship, RN; Dexter Brummitt; Carolyn Cross, RN; Ellen Ford, RN; Leo Harvill, PhD; Helen Hunt, RN; Jennifer Ivey, RN; Piysuh N. Jnshi, MD; Senter Jackson, CRN A; Sankar Lakshman, MD; Anthony Paulantonio, MD; Hilton W. Pittman, MD; Steve Simerly; and Janice Sutter, RN. Further informa¬ tion may be obtained by writing to the author at Psychology Service (116B), Veterans istra¬ tion Medical Center, Mountain Home, TN 37684. 1. Ljungdahl L. Laugh if this is a joke. JAMA. 1989;261: 558. 2. Orandi A. Urological endoscopic surgery under local an-

esthesia: a cost-reducing idea. J Urol. 1984;132:1146-1147. 3. Srikantawsamy S, Segal LI, Chandramouli S. Percutaneous Angiography. Springfield, Ill: Charles C Thomas

Publisher; 1977. 4. Miller SM, Mangah CE. Interacting effects of information and coping style in adapting to gynecologic stress: should the doctor tell all? J Pers Soc Psychol. 1983;38:223\x=req-\ 236. 5. Reynolds SB.

Bio, relaxation training, and mucoping with stress. Biol Self-Reg.

sic: homeostasis for

1984;9:169-179.

Smiley's People To the Editor.\p=m-\Hospitalsare stressful places, not only for patients and families, but for staff

as

well. There

are

many methods of stress reduction available to the health care professional, but few are readily accessible. We suggest

the use of a simple but poorly studied method of decreasing stress, the smile. Smiling is an unsophisticated yet effective means of social . Selye1 noted that a lack of socialization plays a role in perpetuating the "stress response." Increased smiling between health care professionals could, therefore, play a role in decreasing stress. The following study was undertaken to determine the effectiveness of a smile in eliciting a smiling response. A multicenter trial using a prospective, randomized design was undertaken to test the following hypothesis: medical personnel who are smiled at will

smile more than those who are not smiled at, or, in medical , a smile is contagious. Three hundred medical personnel were randomly assigned (coin flip) to either an experimental or control group. Subjects in the experimental group received eye plus a smile as they ed the investigator in the hall, while those in the control group received only eye . The results of this study ed our

hypothesis. Eighty-seven percent

ofthe staff who were smiled at smiled at the investigator, while only 8% of the control group did the same {\2,P<. 001). Interestingly, 60% ofthe subjects in the experimental group offered a "Hi" or other salutation in addition to smiling. This research s the theory that a smile begets a smile. Implementation of this technique has the potential to in¬ crease socialization and decrease stress in large, impersonal medical centers. It is highly recommended that this study be replicated at other institutions, not only with staff, but with patients and families as well. Keep smiling. Beth Henneman, RN, MSN Janice Hanc, RN UCLA Medical Center Los Angeles, Calif Philip L. Henneman, MD Harbor-UCLA Medical Center Torrance, Calif 1.

Selye H. The Stress ofLife. New York, NY: McGraw-Hill

International Book Co; 1974.

Pimper Pimped To the Editor.\p=m-\While I was training from 1971 to 1976,I experienced "pimping" on several occasions. After reading

Dr Brancati's1 commentary in a recent issue of JAMA, I must say that pimping accomplished only four things for me: (1) establishment of a pecking order among the medical staff; (2) suppression of any honest and spontaneous intellectual question or pursuit; (3) creation of an atmosphere of hostility and anger; and (4) perpetuation of the dehumanization for which medical education has been criticized. This last point is probably the most serious complication of pimping. Dr Brancati fears that pimping is "in danger of becoming a lost art." Let us hope that it becomes exactly that. Pimping has no place in the medicine that I

practice today.

Christopher Stanton, MD Feather River Physicians Portola, Calif

1. Brancati FL. The art of pimping. JAMA. 1989;262:89-90.

To the Editor.\p=m-\I hope that Dr Brancati's commentary1 will not render attending rounds dull by discouraging all "pimping." He gives advice on how not to pimp. Medicine, like good pimping, should stick to the truth. What a bluff:

ed from jama.ama-assn.org at Duke University on July 7, 2011

In 1916 Osler was in Oxford and since it World War I he was not once in the United States that year. Koch could not have asked a single P\l=u"\mpfrage(much less a series) since there is no such word in German. And Harvey could not have expected his students to know much about circulation in 1628 in London, since De motu cordis was published only that very year (abroad, in Frankfurt am was

Main).

Claus A. Pierach, MD Abbott Northwestern Hospital Minneapolis, Minn 1. Brancati FL. The art of pimping. JAMA.

1989;262:89-90.

To the Editor.\p=m-\Theother of my division and I savored Dr Brancati's commentary.1 We have become familiar with the expression "pimping" from its use by our division chief. Curiosity prompted my consultation with several unabridged American English dictionaries as well as the first edition of the Oxford English Dictionary. These sources fail to provide a definition consistent with the activity satirized in the article and understood by my colleagues and me. In addition to describing a disreputable activity, the Oxford English Dictionary gives examples of its use in a more figurative sense for arranging deals ofdubious propriety. The only other use of the word I could find was a somewhat archaic reference to the activity of getting oneself up in foppish finery, perhaps a variant of primping. In any event, I am now curious about the origins of pimping as used by physicians, especially academicians, to refer to needling questions by attending physicians during rounds. Jack G. Kleinman, MD Medical College ofWisconsin Milwaukee

1. Brancati FL. The art of pimping. JAMA. 1989;262:89-90.

To the Editor.\p=m-\I was most impressed by Dr Brancati's article on the art of "pimping" in the July 7 issue of The Journal.1 His grasp of the subject is superb. He has provided us with a co-

gent summary ofmaterial critical to success in the academic world. He a void left when the most

has filled creative among us began to devote our time to obfuscating insurance companies instead of each other. I am grateful for his timely article. However, I find a major omission in Dr Brancati's otherwise excellent article. Regrettably, he has failed to mention one of the more effective techniques of SID (Sudden Intern Disgrace), employed by advanced practitioners of the art in leading medical centers (although perhaps not widely known in Pittsburgh) and termed "the Feint." When a particularly intense intern (or

other antagonist) completes an extensive and thorough evaluation of a clinical problem, the attending's status is momentarily threatened. Immediate action is required. At such times, the Feint is especially useful. Begin by praising the presenter's grasp of the subject, erudition, and clear explanations. Wax effusive. Un¬ used to praise, your adversary will be disarmed, sheepish, and vulnerable. At this moment, pounce on him with a vi¬ cious "However. ..." Sink your fangs in with the deprecatory adjective "oth¬ erwise." Make a pointed reference to the presenter's previous failures. Final¬ ly, make a veiled condemnation of the individual's prior training or city of

origin.

As the intern's limp but still warm body quivers before you, thrust the final dagger—more compliments. Victory is yours.

To understand the Feint, imagine a cobra, swaying back and forth, then suddenly striking. The Feint succeeds by lulling your opponent to sleep with praise and then attacking at an unex¬ pected moment. Having said all that, I thank Dr Brancati for a clear and organized review. In all my years in medicine, I have not seen its equal. Terry A. Rustin, MD University of Texas

Medical School at Houston

1. Brancati FL. The art of pimping. JAMA.

1989;262:89-90.

In Reply.\p=m-\Mentors and colleagues warned me that I'd be playing with fire when I went on record about pimping. They were right. On the one hand, Dr Stanton worries that I have fanned the flames. The thought of unleashing an angry horde of chief residents and attendings bent on dehumanizing defenseless interns does make me feel a bit like J. Robert Oppenheimer watching that first mushroom cloud rise above the New Mexico desert. On the other hand, Dr Pierach fears that I've doused the last embers of a once proud tradition with the icy water of deceit. Furthermore, the prospect of contributing to the growing problem of attending-round dullness chills me. I am, however, heartened by Dr Pierach's lusty attack on my slick historical bluffs. Let me come clean about pimping. I love it\p=m-\when it's done right. Pimping can entertain and teach at the same time. It can promote a feisty esprit de corps among the pimped, as when interns begin to quiz each other ("crosspimping") and even the attending (the dreaded "reverse pimp"). Sometimes pimping can be the only way to keep the ward team awake, let alone in-

volved.

Nevertheless, roundsmanship be allowed to force patient care and honest inquiry into the back¬ seat. My own approach is to pull each student and intern aside individually at the start of the rotation to explain the distinction I make between style and substance in patient care and medical education. I emphasize that I will evalu¬ must

never

ate students and interns based on hones¬

ty, thoroughness, and knowledge of

medicine relevant to the patients cur¬ rently under their care, not based on their ability to handle pimp questions. When this line is not clearly drawn, pimping may indeed become as repres¬

sive as Dr Stanton describes. Having been warned that pimping seemed an unsavory topic for an august journal, you can imagine my pleasure in reading Dr Kleinman's letter. I can as¬ sure him, however, that a variant of a word meaning "to get oneself up in fop¬ pish finery" just wouldn't play in Pitts¬ burgh. The Oxford English Dictionary does note the use of pimping as an adjec¬ tive meaning petty or insignificant. Did pimping questions echo down the musty corridors of Guy's, Bart's, and St Thomas'? I found Dr Rustin's vivid description ofthe Feint" delightfully and unexpect¬ edly venomous, even as the fangs broke my skin. We should applaud his courage in mixing metaphors. When I read his description of the sheepish intern's warm body quivering in the shadow of the attending's dagger, I thought, "My word, what can we do to attract more people like this into psychiatry?" Frederick L. Brancati, MD The Johns Hopkins University School of Medicine Baltimore, Md

Lines Missing An error occurred in the Original Contribution entitled "Functional Status and Well-being of Patients With Chronic Conditions," published in the August 18 issue of THE JOURNAL (1989;262:907-913). On page 910, the third sentence in the first paragraph in column 1 Should have read as follows: "(When we adjusted the mean scores for the general-population sample to reflect sociodemographic characteristics of the patient sample, differences [not 'differencesthout chronic conditions (P<.01) for physical functioning, role functioning, and health perceptions.'] in predicted scores were so minor that we decided that no adjustments were necessary.) As hy-

pothesized, using

test of differences,

independent

an mean

health

groups t

scores were

better for the general population than for patients without chronic conditions (P<.01) for physical functioning, role functioning, and health perceptions."

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tens of millions of our citizens who have no health insurance, and many need

This approach can help. And, yes, in contrast to some, this editor recognizes an ancient ethic that care now.

espouses that we all are indeed "our brother's keeper." George D. Lundberg, MD 1. Lundberg GD, Bodine L. JAMA. 1987;258:3157. 2.

Lundberg GD,

Bodine L.

JAMA. 1988;260:3178.

Lundberg GD, Bodine JAMA. 1989;262:3045. 3.

L.

Fifty

hours for the poor.

Fifty

hours for the poor.

Fifty

hours for the poor.

4. Bodine L. It pays to stick your neck out: fifty hours for the poor. JAMA. 1988;260:3127. 5. Davis JE. Let's work together! A call to America's physicians and the public we serve. JAMA. 1988;260:834-836. 6. Gunby P. First public service award goes to Kentucky. JAMA. 1988;260:3106.

In Reply. \p=m-\DrEvans will be interested to know that 100 000 lawyers participate each year in some 500 organized pro bono programs for the poor in this country. This does not include private, nonreported pro bono work for the local church, art center, or service club. Since August 1988 \p=m-7\months after the editorial was first published in the ABA Journal and JAMA \p=m-\it has been the official policy of the American Bar Association that lawyers should devote at least 50 hours oftheir time to the poor each year. Dr Haynes misses the point. I believe that the moral price for holding a license to practice a profession of specialized knowledge is devotion of some of one's skills at no charge to the needy. The country cannot afford otherwise. Dr Tauber is wrong. The duty to devote time to the poor arises not from the wealth of attorneys and physicians, but from their privilege to practice their skilled arts for pay. Government cannot do it all, as Medicare and the Legal Ser¬ vice Corporation demonstrate. The country also needs the pro bono efforts of its professionals. Laurence Bodine, Esq Lawyer's Alert Wheaton, Ill

History and Examination Should Precede Tests To the Editor. \p=m-\Dr Kolder,1 in his discussion of a patient who suffered loss of vision following cataract surgery, correctly indicates the unlikelihood of the proffered diagnosis of multiple evanescent white dot syndrome. He also briefly lists a potpourri of entities that may have resulted in visual loss following a surgical procedure. If Dr Kolder had been less kind, he might have pointed out that a markedly restricted peripheral vision in,an eye with permanent loss of central vision is not compatible with the physical findings as given, specifically, a normal optic disc and a "dissipated" swollen retina. He also might

have pointed out that a brain scan, elec-

troretinogram, and fluorescein angio-

gram would have little likelihood of showing an abnormality that was not suspected on the basis of a careful oph-

thalmologic examination.

It seems to me that this problem is another illustration of how readily physicians discard the use of a careful history, physical examination, and logic in favor of easy technological procedures and their reported results. Physical ex¬ amination takes the physician's time, tests do not. One of the initial allures of ophthal¬ mology for many physicians, and I am sure that this is true in other specialties as well, is the gratification that comes from being able to make a presumptive diagnosis on the basis of a careful histo¬ ry and physical examination. In my oph-

thalmologic experience, a presumptive diagnosis can be made on this basis 95% of the time and tests are only confirma¬ tory. If the patient in question had nor¬ mal visual function prior to cataract sur¬ gery, then it is not anatomically or physiologically possible for the patient to have a malfunctioning optic nerve or malfunctioning retina without there be¬ ing evidence of that disorder in the physical examination. Physical exami¬ nation tests such as pupillary response,

color vision, stress test, noncomputer¬ ized visual field, and biomicroscopic ex¬ amination of the retina invariably indi¬ cate the site and pathophysiology of any dysfunction, if not the exact clinical en¬ tity. A proper physical examination de¬ mands the recognition by the examiner of the incompatibility of normal ocular findings in the presence of significant visual pathology. If the questioner de¬ sires the explanation for the patient's poor visual acuity, she should be evalu¬ ated by someone who is experienced in the use of traditional medical methods. Michael Rosenberg, MD

Northwestern University Medical Center Chicago, Ill

1. Kolder H. Vision loss after cataract surgery. JAMA.

1989;262:3058.

Potassium Iodide Stockpile for Nuclear Accidents To the Editor. \p=m-\ The American Thyroid Association (ATA) has long had an interest in the thyroidal consequences of nuclear reactor accidents because of the large amounts of radioiodine that would be released into the atmosphere. The ATA also has endorsed the use of potassium iodide as an effective radioprotective agent. In light of the Chernobyl disaster, the ATA has reexamined the issue of potassium iodide stockpiling for use in the event of a core melt accident

and has adopted the following statement: The recent reactor accident at Chernobyl, in which large amounts of radioactive iodine were released into the atmosphere, again raised questions about proposed methods of protecting those at risk of exposure. In a previous statement,1 the ATA reviewed the scientific information available about the usefulness of potassium iodide as a blocking agent to prevent radioactive iodine from entering the thyroid gland of those exposed to fallout. It also reviewed available data about the possible effects on the thyroid of lowlevel radiation exposure from radioiodine as well as the potential toxic side effects of dis¬ tribution of potassium iodide to large, unsu-

pervised populations.

It was concluded at that time that informa¬ tion necessary for the development of a suit¬ able public health strategy required risk/ benefit data (ratio of the risk of the hazards of radioiodine exposure to those of stable iodine istration) but that such information was not available then. The ATA is aware of no new information that alters the issues raised at that time. It was concluded in that report that al¬ though the general distribution of potassium iodide was not recommended except in spe¬ cial locations and under special circum¬ stances, advanced planning for possible dis¬ tribution was advisable, and it urged that a national task force of specialists be convened to review the issues in potassium iodide dis¬ tribution and to develop alternate national distribution strategies for consideration. As best as can be determined at this time, no substantial stockpile of potassium iodide is available for public use. Despite the improba¬ bility of an emergency that requires its use, the ATA believes that the option of potassi¬ um iodide distribution should be available for consideration to those responsible for public health measures. To this end, the ATA be¬ lieves that it would be prudent to have avail¬ able at central locations a suitable stockpile ofpotassium iodide for possible distribution should its use be contemplated.

It is hoped that this recommendation will generate renewed discussion of this

important question.

American Thyroid Association David S. Cooper, MD, The Johns Hopkins University School of Medicine, Baltimore, Md; David V. Becker, MD, New York (NY) Hospital-Cornell Medical Center; Bertrand Brill, MD, University of Massachusetts Medical Center, Worcester; John T. Dunn, MD, University of Virginia School of Medicine, Charlottes ville; Eduardo Gaitan, MD, Univer¬ sity of Mississippi School of Medicine, Jackson; Raymond Lindsay, PhD, University of Alabama School of Medicine, Birmingham; Marvin Mitchell, MD, Tufts University School of Medicine, Boston, Mass; and Lester Van Middlesworth,

MD, UniversityofTennessee SchoolofMedicine, Memphis. 1. Becker DV, Braverman LE, Dunn JT, et al. The use of iodine as a thyroidal blocking agent in the event of a reactor accident: report of the Environmental Hazards Committee of the American Thyroid Association. JAMA. 1984;252:659\x=req-\ 661.

Pimping To the Editor. \p=m-\In the November 10, 1989, Letters column, Dr Kleinman1 quite correctly calls attention to the fact that the word pimping does not exist in any dictionary.

ed from jama.ama-assn.org at Duke University on July 7, 2011

Lest this word, possibly used as a sensational catchword, become a neologism, I would like to call attention to an error that must have occurred and that I cannot understand escaped your reviewers. What is obviously meant is pumping. It is found in all dictionaries defined as "to question persistently." In its milder and more modern form it is referred to as "debriefing." The German word that Dr Brancati misused is the same without an umlaut. It has the pumpe \p=m-\ identical meaning to its English counterpart and was much used with respect to the interrogation of prisoners. I have no reason to believe that William Harvey would have used a word with as bad a connotation as "pimp" or as

curry favor or to act meanly" and of pimping as an adjective meaning "fee¬

ble or inconsiderable." The earliest ref¬ erence is attributed to Smollett in 1749: "They care only for pimping syco¬ phants." And unlike my apocryphal at¬ tribution to William Harvey, this quote is no bluff. Finally, allow me to apologize for the ersatz umlaut. As Dr Beck points out, the word "Pümpfrage" does not exist in German, and even if it did, it would not carry an umlaut. Please excuse my re¬ viewers at JAMA who let this misuse slip by. They knew I could use all the punctuation I could get when they heard me speaking with tongue in cheek. Frederick L. Brancati, MD The Johns Hopkins University School of Medicine Baltimore, Md

inconsequential as "pimping."

We look to JAMA as a guide and would hope that they would discover rather obvious misuse of language. William C. Beck, MD Donald Guthrie Foundation for Medical Research Sayre, Pa 1. Kleinman JG. Pimper pimped. JAMA. 1989;262:2542.

In Reply. \p=m-\I applaud Dr Beck for recognizing that, despite my best effort to feign erudition, my historical attributions were nothing more than clever bluffs. Calling the bluff and chastising the bluffer are crucial skills for the attending who practices the art of pimping and I thank Dr Beck for his timely

demonstration.

I must, however, disagree with his characterization of the word pimping as a neologism coined either by mistake or with the intent to sensationalize. I first learned the term 6 years ago as a medical student at Columbia. An informal survey of my colleagues reveals use of the word at Pitt, Maryland, Bowman Gray, Johns Hopkins, BU, and Harvard. I have received more than 30 letters from physicians throughout the country who understand the word as I do. (One

correspondent, an attending physician at the Mass General, went so far as to

reveal that he had earned the nickname "Pimp-monster" from his house officers.) In general, physicians unfamiliar with pimping either have trained abroad or are older than 40. Dr Beck's suggestion that pimp de¬ rives from pump deserves serious con¬ sideration. , however, that the pumper wants to get something from the pumped while the pimper wants to give something to the pimped. The derivation that comes closest to capturing the subtle flavors of the word in its current usage is offered by Dr Nelson H. Brown of Atlanta. He refers to Slang and Its Analogues,1 which notes use of pimp as a verb meaning "to

Hanley WE. Slang and Its Analogues. New York, NY: Arno Press; 1904:204. 1. Farmer JS,

Editorial Note. \p=m-\ Althoughover 40 and brought up in what Dr Brancati calls the "musty corridors of Guy's,"1 I was so astonished at Dr Beck's unfamiliarity with the word pimping that I decided to

print his letter, and I respond only because

he takes JAMA to task for miss-

ing a "rather obvious misuse of language." Pimping is used by persons in power to put their juniors in place by harassing them with esoteric questions that, if answered, gain neither credit nor relief.

The interrogating pumper is interested in answers, the pimper in selfesteem. I first heard the term pimping used in this way 9 years ago in Chicago, at about the time it became popular to use the bullying term to "jerk around":

something pimpers

are good at. I don't know what pimping, in its modern, medical sense, has to do with "feeble or inconsiderable," but I'd suggest that Smollett's sycophants were

good old-fashioned pimps. Eric Partridge,2 quoting from reré and Leland's A

Bar¬

Dictionary of

Slang, Jargon and Cant, published in 1890, says that the verb pimp meant, at University College (London), "to do lit¬ tle, mean, petty actions." Not too differ¬ ent from the practices of our modern medical pimpers. Drummond Rennie, MD 1. Stanton C, Pierach CA, Kleinman JG, Rustin TA, Brancati FL. Pimper pimped. JAMA. 1989;262:2541-2542. 2. Partridge E. Supplement to A Dictionary of Slang and Unconventional English. 8th ed. London, England: Routledge & Kegan Paul Ltd; 1974.

Ibuprofen and Aspirin

in Acute Rheumatic Fever To the Editor. \p=m-\Iwould like to clarify one point in the article "The Return of Acute Rheumatic Fever in Young

Adults."1The authors state that the one patient with rheumatic nodules re-

sponded to ibuprofen therapy. This patient presented to the hospital while taking ibuprofen and continued its use for a short period. His anti-inflammatory therapy was changed from ibuprofen to a delay-release, enteric-coated aspirin preparation. He required a daily dose of 5850 mg (80 mg/kg per day)

to clear the arthritis. I point this out to emphasize that aspirin has been and should still be the indi-

cated anti-inflammatory drug of choice for the arthritis of acute rheumatic fever so that no one may falsely be misled to believe this young man responded to the ibuprofen therapy alone. R. Larry Marshall, MD Fort Worth, Tex

1. Wallace MR, Garst PD, Papadimos TJ, Oldfield EC III. The return of acute rheumatic fever in young adults. JAMA.

1989;262:2557-2561.

In Reply. \p=m-\The single patient with rheumatic nodules described in our article and referred to by Dr Marshall had an interesting clinical course. Believed by many observers of our outbreak to have the most severe case of acute rheumatic fever, he presented with fever, severe polyarthritis, carditis, and rheumatic nodules. He had been receiving ibuprofen prior to ission to the hospital, but compliance was uncertain. On ission he began ibuprofen therapy, 800 mg every 8 hours. As noted in his hospital record, he had a "dramatic improvement" within 48 hours of ission, with defervescence and markedly decreased t pain, swelling, and stiffness. This rapid response was typical of the other nine patients, all of whom were treated with aspirin. Several days into his hospitalization the house staff, now convinced the diagnosis was acute rheumatic fever, considered a change to

aspirin. However, the rheumatology staff physician (Dr Marshall) recom-

mended the continuance of ibuprofen istration as it was "controlling" the patient's symptoms. Twelve days af¬ ter ission the patient was dis¬ charged; he was still taking ibuprofen and complaining only of morning stiff¬ ness. Subsequent to discharge, the pa¬

tient changed from ibuprofen therapy to istration of an aspirin prepara¬ tion, with total resolution of residual

t symptoms.

We agree with Dr Marshall that the

patient's later clinical course may be ad¬ ditional evidence that aspirin should re¬ main the anti-inflammatory drug of

choice for acute rheumatic fever. How¬ ever, we believe that the potential for ibuprofen, a widely used nonprescription drug, to dramatically alter the clini¬ cal course of acute rheumatic fever

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Morning

Distort

You're a proud new second-year resident. You've tackled internship and you've prevailed. You're a giant, a marine, a pillar of granite. Okay, so you overcame anxiety, anger, and depression. But you have not yet faced terror—not until this morning. Today you face the terror of morning report for the first time. In the eerie morning light you see the long, ponderous oak table like some sacrificial altar; the pantheon of former chief residents judging you from portraits on every wall; the icy stares of the attending and the chief resident, their hands folded as if in contemplation before an ancient ritual. You notice that your cardiac rhythm has jumped from a traditional march into progressive jazz. Coffee splashes out of your Styrofoam cup as an adrenergic surge rattles your forearm. Yet, as you look around the table, the senior residents are smiling, some with their feet up, others leaning back with hands clasped behind their heads. Why are they so relaxed? It so happens they've been there. They've lived it, they've learned the rules. Yes, they've learned the rules of morning distort. Rule #1. Make it pat, but not too pat. Morning report is not a forum for sorting out hundreds of unrelated facts. That's a job for naive third-year medical students and compulsive attendings. The resident who wallows in messy details and multiple diagnoses is soon bound to feel the cold edge of Occam's razor against his or her neck. After all, the chief resident wants to hear a story. Make the story short and pat, aiming for what Poe called the "unity of effect." Each word should point unerringly to one diagnosis and create a mood of solemn certitude. You may even wish to drop verbs from your presentation: For example, "Middle-aged man, tobacco, dyspnea, wheezing, sputum, barrel chest, COPD exacerbation." But too many pat stories will arouse suspicion. After presenting several pat cases, present an open-ended, confusing case, just to appear earnest. Rule #2. Be bold. Nobody likes a wimp. Nowadays medical schools offer so many courses on humanism and ethics that many

graduates quiver like gelatin in the face of real disease. Intern¬ ship should have already taught you to think less like Schweit¬ zer, more like Schwarzkopf. Your chief resident will want to hear that you've driven a needle deep into every lump, space, and swelling. Or better yet, a trochar. To highlight your cour¬ age, call in an interventional radiologist from home for an emergency procedure after 2 AM. Whatever you do, don't say 'We observed the patient carefully" or "We waited watchfully." Even if you've done nothing beyond taking the H&P, say something like "We monitored him aggressively and sat on him

hard." Rule #3. The best defense is a good offense. Some morn¬ ings even the best residents are unprepared. If you feel weak, go on the attack. For example, say the attending taking report is a crackerjack endocrinologist and you have a case of multiple endocrine neoplasia to present, but you're unprepared. Why not present a cardiomyopathy case first, stress the patient's unusu¬ al rhythm disturbance, and corner the attending into interpretEdited by Roxanne K.

ing a 10-foot-long rhythm strip? Or, if you believe that the chief resident might attack, launch a preemptive strike. Within ear¬ shot of the attending, turn to the chief resident and say, "Gee, you look tired. Must be all that moonlighting, huh?" Just don't try to hide at the far end of the table. The chief resident, bred to smell fear, will lunge at you like a Doberman. Rule #4. Image is everything. Your superiors are going to put you in a pigeonhole, so you might as well choose which hole is yours. One effective image is the hardworking, straightlaced grunt look. Garb is the same for men and women: white poly¬ ester coats and slacks accented by pressed scrubs. White tennis shoes and a synthetic pocket protector complete the look. When presenting, play it straight: no jokes, no colloquialisms, just facts read directly from note cards. It's functional, but tedious. Another image is the uptown intellectual, dolce-vita look. Wom¬ en wear dresses, light makeup, and heels. Manicures are option¬ al, but recommended. Men wear light wool slacks and Italian ties. The presentations are lyrical and witty, often presented from memory (note cards are so bourgeois, n'est-ce pas?). For¬ eign eponyms are properly accented. It's fun, but it takes work to look the part, and it doesn't play well in the Midwest. A third choice is the look of total desperation. The resident doesn't shave or bathe and rushes into every morning report 10 minutes late wearing oversized scrubs. The aim is to recreate the image of Jimmy Stewart on the verge of collapse at the climax of Mr Smith Goes to Washington. It's okay for sympathy, but doesn't garner much respect. Rule #5. Stay calm. They are going to rattle your cage and they are very good at it. Don't act like a trapped animal; collect yourself and stand straight. For example, they are going to ask whether you sent some fancy test last night: an alpha,-antitrypsin level maybe, or a urine for porphobilinogen. Of course, they figure that you didn't send it. It's your choice. You can nervously whimper, "Shoot, I didn't think of that. I'm awfully sorry. Please forgive me, I'm a worthless slug. I'll send it right away." Or you can confidently declare, "Sent." You see, "Sent" is really short for "I'll send it so fast, you can consider it sent" or "It's as good as sent," and it makes a much better appearance at report. They are also going to ask you to summarize cases that you don't . You can sweat and make excuses or you can calmly explain that "After a thorough assessment, we rounded up the usual suspects and took the traditional measures." Finally, they are going to ask you for laboratory results that you didn't write down. If you take a blank index card from your pocket, scruti¬ nize it, flip it over a few times, and say "Nothing remarkable here, you've learned your lesson. Whether you call it morning report, morning retort, or morn¬ ing distort, the rules remain the same around the country. The bottom line is style above substance. It worked in the 80s and it can still work for you in the 90s. Go ahead, then. Lean back, put your feet up, and smile. Be happy. Now you know what the seniors know. You know the rules of morning distort. "

Young, Associate Editor.

ed from jama.ama-assn.org at Duke University on July 7, 2011

Frederick L. Brancati, MD Baltimore, Md

The Generic H & P 8 AM\p=m-\the end ofanother long call night and time for attending rounds. Your team awaits you. "Gee, you look terrible. How many did you get last night?" "Seven. Actually, eight if you count that ICU transfer. Not

too bad." Not too bad for an intern like you, but a killer call night for a lesser house officer. You know it and they know it\p=m-\you're

Chief Resident material. You reach into your pocket for that stack of index cards, your notes from last night. Instead, you discover a Hemoccult card, some Kleenex, and a gum wrapper. No note cards. Your cheeks flush. Beads of sweat collect on your upper lip. You feel your esophagus twist like a rubber band in a model airplane. You spent most of last night learning the intricacies of your patients' lives and illnesses, but right now your mind's a blank. How can you honestly present seven cases without a shred of detail and still preserve your stellar reputation? How indeed. Only one approach can preserve your dignity without making a total mockery ofthe truth—the generic history and physical. In presenting the traditional, personalized H & P, the in¬ tern strives to focus his or her audience on what is special or different about each particular case. By necessity, the person¬ alized H & P is chock-full of detail. The chief complaint is analyzed exhaustively, minutiae of medical history are scruti¬ nized, dates and times are checked and rechecked. In con¬ trast, the generic history fosters broader outlook, emphasiz¬ ing what is common to all cases. Your voice crackles as you cautiously begin to present your first patient's reason for ittance. Mr Jones is a middle-aged man with a long history of multiple medical problems who was itted last night with an exacerbation. We don't have old records, the patient's a poor historian, and no family was available, so most of the history comes from the ER sheet and his nameplate. He was in his usual health until recently, when he noticed that "something wasn't right." He said he used to have spells like this once or twice a year, then he developed longer bouts, and now he's having very frequent episodes. He was seen by an outside physician who told him he had the "flu" and started him on a third-generation cephalosporin. When his symp¬ toms persisted he was itted to an outlying hospital. Records were not available. Reportedly, they ruled him out, performed an MRI, and sent him home on thyroid extract. He continued to do poorly at home and finally called the paramedics last night. Current medications include a tiny white pill, a larger pink pill, and a foul-tasting powder. Most of his family have been ill at one time or another, and several of them have died. There's a question of alcohol and tobacco use. He used to work and currently lives at home. His medical history includes several inconsequential surgical procedures when he was younger. About 10 years ago he was itted to another hospital with an acute illness. After a number of tests they told him he might get this again and to call his doctor immediately if he did. So far, so good. The generic physical examination is, how¬ ever, a little harder to finesse. Of course, salient findings are easily recalled and apt to be mentioned even without the aid of note cards. What really gives texture and depth to the presen¬ tation, though, are the subtle nuances that are virtually irreEdited

by Roxanne K. Young, Associate

Editor.

producible on successive examinations. Your confidence wax¬ ing, you resume. Mr Jones is found lying in bed. The vital signs are stable. There are several small, ill-defined, pigmented lesions of the skin that he says have always been there. A 5-mm, soft, movable, nontender lymph node is palpated in the submandibular area. Subtle anisocoriais appreciated. The thyroid is top-normal. Basilar rhonchi are heard to clear after coughing. There's a 1/6 systolic murmur at the base and a question of an intermittent S3. An ill-defined firm¬ ness is palpated by some examiners in the epigastrum. Genitalia are present, with prominent scrotal rugations. Last night there was trace ankle edema, which was absent this morning. The neurological examination is grossly nonfocal. The generic physical examination reminds your audience that each patient is a little different without bogging them down in a quagmire of nit-picking details. Moreover, it soothes your attending to the point of somnolence. Fully satisfied that a thorough examination was performed, the attending can settle back and doze off until you reach the assessment. (You can deepen the slumber by carefully enu¬ merating every negative finding and by frequently repeating the phrase "regular rate and rhythm.") Contrast this with the so-called normal examination. Every attending knows that nobody's exam is completely normal. If you imply that your exam is normal, even the most docile conference room couch potato is bound to become a rabid diagnostic pit bull who will drag you and your team all the way to the bedside just to prove you wrong. Fortunately, you know better. You can see in their faces that they're buying the whole presentation. Emboldened, you close with a concise assessment and plan. In summary, Mr Jones is a middle-aged man with an exacerbation of a chronic illness. His course is complicated by several underlying conditions, some ofwhich are poorly controlled. Our plan is as follows: 1. Tb perform some specialized blood work. 2. Tb obtain high-resolution images of the involved organs. 3. Tb consult

a

procedure.

subspecialty

4. To follow his clinical

service for

course

empirical therapy.

an

closely after

invasive a

trial of

5. To get services involved and start discharge planning. If there's been no progress after 1 or 2 weeks, we'll reassess and consider further therapy using modal¬ ities with a higher risk-benefit ratio. If there's still no improvement at that point, we'll pursue a code status and arrange transfer to the rehabilitation service.

There you have it—the generic history and physical. It's a tried-and-true approach to presenting under fire, recom¬ mended by experienced interns in all 50 states. So sit down, straighten your coat, take a deep breath, and relax. With no sleep, no notes, and no wealth of knowledge, you can still present like a star. Yes, indeed. You are Chief material. But do wipe that sweat from your lip.

Frederick L. Brancati, MD Baltimore, Md

We welcome contributions to A Piece of My Mind. Manuscripts should be sent to Roxanne K. Young, The Journal of the American Medical Association, 535 N Dearborn St, Chicago, IL 60610.

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Clinical Years

Readers of the Lost Chart: An Archaeologic Approach to the Medical Record Frederick L. Brancati, MD, The Johns The first 2 years of medical school are spent in class memorizing biochemical details such as the Krebs cycle, visualizing the anatomy of the pterygopalatine fossa and making up lewd mnemonics for the cranial nerves—facts that instructors insist will be crucial to becoming a success¬ ful clinician. Why, then, once finally arriving on the wards, do students feel as clueless and misinformed as Dan Quayle at a cabinet meeting? Think. While students perform excruciatingly complete histories and physical exams and continuously review pocket notes on inborn errors of metabolism, the resident is focused on the ever-expanding document of patient knowledge—the medical record. The medical record is regarded as an object of awe, much as historians revere the Dead Sea Scrolls or Harvard graduates worship their diplomas. Although it contains the distilled wisdom of past physicians and scholars and the resulting truths of prior tests and studies, these revelations are obscured by strange idioms and are buried in an ava¬ lanche of bureaucratic landfill. Like Indiana Jones, the astute physician must take an archaeologic approach to becoming a reader of the lost chart; plunge courageously into these dark tomes in search of the grail of knowledge. Adventitious Markings. Food stains related to note writ¬ ing in the hospital cafeteria are easily identified by color and aroma. A clear stain is pathognomonic for the drool of an exhausted intern who has fallen asleep while writing, sandwiching the chart between cheek and desktop. The finding of a long, straight pen line trailing off the side of the page confirms the impression of sudden somnolence. Such markings often precede a collection of medical mumbo-jumbo that reflects neuronal activity emitted solely from deep in the midbrain and should prompt skepticism of the chart's reliability. The Nursing Note. Exploration of nursing notes is risky. They have the potential to contain buried clinical trea¬ sures—perhaps the first mention of delirium or a critical summary of important psychosocial factors. On the other hand, they may contain no data at all. An "alteration in comfort" may signify anything from nasal congestion to a ruptured aortic aneurysm. An "alteration in bowel habits," although more specific, is hardly news in a hospitalized patient. Especially worrisome, however, is a flat-line flow sheet, in which the same values (most commonly respira¬ tion 20, pulse 80, blood pressure 120/80 mmHg, and tem¬ perature 37°C) are recorded for 3 consecutive days. The status of patients during the flat-line interval is uncertain; they may be gravely ill, dead, or vacationing in the Carib¬ bean. The Surgical Note. The beauty of the surgical note is its simplicity. For example: "Post-op day #2, afebrile, vital signs stable, exam unchanged, continue post-op care." It's re¬ freshingly clear, free of the detail, insight, and deliberation that so often mars the notes of internists. Do not, however, underestimate the significance of even small deviations in

Hopkins University School of Medicine the

content

of the

note

from

day to day. For example:

"Post-op day #3, temp 37.5, vital signs now stable, exam

improved, continue current management" means that the previous night, the patient developed septic shock, was pancultured and started on a third-generation cephalosporin, and will possibly require transfer to the surgical intensive care unit later in the morning.

The Consultant Note. To the untrained eye, this note appears to be divine scripture written with the authority born of specialization. Textual analysis, however, reveals that it is actually the work of several all-too-human authors writing at different times. The "M Source," or medical student, composes the bulk of the treatise, usually one and a half pages of transcribed text that avoids providing any opinion or recommendation. The "R Source," or resident, generally edits the work of the M Source and provides

"The medical record is regarded as an object of awe, much as historians revere the Dead Sea Scrolk or Harvard graduates worship their diplomas. " commentary. The written

tone

of the R Source is one of

righteous indignation, heaping judgments on medical student, patient, and referring physician alike. Squeezed on the bottom edge of the second page are the cryptic markings of the "A Source" or attending physi¬ cian. The A Source is best recognized by its constant repeti¬ tion of two phrases: "Agree with above plan" and "Will follow with you." Since neither the M nor the R Source ever really describes a plan of action, and since it is unusual for the A Source to inscribe even one follow-up note, experts believe that these phrases are to be understood in purely mystical . Special reverence is accorded the traditional rhyming incantation of the A Source found only in neurol¬

ogy notes: CT, LP, EEG, EMG, and NCV. The Medical Student Note. Warning: these notes are dangerous. Many physicians have been missing for hours or even days sifting through the seething miasma of verbiage spewed out by earnest medical students. Moreover, because of their prodigious length, these notes are hard to avoid. Scientists estimate that medical student notes for more than 60% of the chart's weight. Fortunately, several features make medical student notes easily recognizable: (1) compulsively neat penmanship, (2) unusual ink colors (including the popular lavender and green), (3) diagrams of family pedigree so extensive as to include deceased inlaws and close childhood friends, (4) stencils of neck and abdominal anatomy, and (5) liberal use of stick figures. These notes should be explored only by teams of experi¬ enced, well-rested professionals in brightly lit rooms using

ed from jama.ama-assn.org at Duke University on July 7, 2011

(Continued on p 1861.)

Abstract

jfâ&

Noninvasive Determination of Coronary Artery Reperfusion in Patients With Acute Myocardial Infarction Using Plasma Myoglobin Measurements Gerard A. Dillon, State University of New York at Buffalo School of Medicine The aim of this study was

determine whether the rate of myoglobin entry into the blood is an accurate indicator of myocardial reperfusion following therapy in patients with acute myocardial infarction. Myoglobin is one of several intracardiac proteins that rapidly enter the blood following coronary artery reperfusion. Detailed myoglobin concentration-time curves were reviewed in 20 patients undergoing attempted reperfusion for acute myocardial infarction. Using a biexponential flow-based, one-compartment model, rate constants for myoglobin appear¬ ance in blood (ka) were calculated for each patient by nonlinear least squares analysis and compared with the occurrence of vessel opening as detected by immediate posttreatment angiography. In patients unsuccessfully reperfused (control group), ka averaged 0.005 + 0.003 min1 (range, 0.002 to 0.009 min1). In 16 patients successfully reperfused, the rate con¬ stant (ka) was significantly higher (P<.05) and averaged 0.0122 to 0.182 min1 (range, 0.005 to 0.648 min'1). One patient was noted to have incomplete reperfusion and a high-grade residual stenosis, falling within the 95% confidence internal of the control group. The chance corrected correlation (kappa statistic) between a ka>.01 min"1 and vessel reopening is .86. The overall sensi¬ tivity of using myoglobin kinetics to detect reperfusion is 94%, the specificity 100%, and the positive and negative predictive values are 100% and 80%, respectively. We conclude that a flow-based physiologic model allows calculation of ka, thereby allowing attempted reperfusion to be predicted with a high degree of sensitivity and specificity. to

This abstract received the Roche Laboratories Award at the 1991 National Student Research Forum.

Readers of the Lost Chart (Continued from 1860.) modern excavating equipment. The Order Sheets. If the chart has been vandalized or debrided, the order sheets may be the only source of coher¬ ent data. Date of ission, attending physician, and medi¬ cations are points of obvious interest; however, pay special attention to certain seminal orders signaling minor prob¬ lems such as: "Four-point restraints to bedside, Stat social work consult, 1800 calorie ADA diet with no sharp utensils," and simultaneous consult requests to either oncology and nephrology or to orthopedics and psychiatry. In addition, minor entries in the order sheet may sometimes hint of past working relationships between physicians and nurses on the ward, such as, "5 AM: Change docusate 100 mg bid prn constipation to docusate 100 mg PO bid prn constipa¬ tion as per nurse's request." The Lost Chart. Every resident fears congestive chart failure, requiring a journey to the Temple of Doom—the medical records department. Guarded by file clerks, who in Greek mythology were described as having the body of a serpent and the head ofJohn Sununu, the eye perceives the gory silhouettes of unsorted charts strewn haphazardly across long tables in dim light. To find the grail, the only option is to examine the grisly remains of each chart oneby-one while suffocating in the heavy odor of bureaucracy. The medical chart, the mother lode of medical history, contains data beyond the wildest dreams of the most com¬ pulsive diagnostician. Although exploring and interpreting the chart is dangerous, the rewards are great. With insight, patience, and courage, even the lowliest third-year medical student can accomplish great feats of archaeologic discov¬ ery. So don your fedora, secure your whip, gather up your white coat underneath your leather jacket, and get ready for adventure in the place where Harrison Ford meets Harrison's textbook—the medical record.

A Funny Thing Happened (Continued from 1856.) how humor can be the physician's asset on many levels— from the clinically therapeutic effects of laughter to seeing the absurdity in searching through the cryptic treasure trove of a medical chart. Physicians joke about things that most people can't think about and do it in a way that most people would find unintelligible, inane, or offensive. Humor can be our great¬ est ally if we use it to bond with our patients, console our colleagues, and protect ourselves; but it can be our worst enemy if it alienates, abuses, or betrays them. Laughing at success and recovery helps us remain humble and pushes us to work harder; laughing at failure and death protects us from the fear and sorrow these events arouse in us. Laugh¬ ter reminds us of our humanity, and using it properly re¬ quires that we be able to laugh at ourselves. After all, everyone else does.

ed from jama.ama-assn.org at Duke University on July 7, 2011