On a Personal Note

UNINVITED GUEST


Oh, Culex, you uninvited guest
Who kissed me, spreading your exotic gift
And leaving me weak, feverish, seeing double
And becoming suddenly a modern statistic.

Oh, Culex, where are you now?
What life are you going to challenge next?
Stay away. I'll be back.
And, you know, Culex, I have never been to Uganda.

Satisfactory and Effective Communication in Medical Care and Treatment

The medical humor in the last post virtually all point to the importance of and necessity for satisfactory and effective communication in medical care and treatment. As a member of a hospital ethics committee, I can attest to the fact that often what comes to the committee for resolution as an ethical conflict is not so much an ethical issue but a problem in communication between a physician and a patient or family or between physicians themselves or with their hospital nursing staffs.

In an outpatient setting, the study by Keating, Nancy L. MD, MPH; Green, Diane C. PhD, MPH; Kao, Audiey C. MD, PhD; Gazmararian, Julie A. PhD, MPH; Wu, Vivian Y. OTR, MS; Cleary, Paul D. PhD "How Are Patients' Specific Ambulatory Care Experiences Related to Trust, Satisfaction, and Considering Changing Physicians?" in the Journal of General Internal Medicine V.17, Nr. 1 pages 29-39, Jan 2002 statistically confirms the need for better doctor-patient communication.

The objective of the study was "To assess the relationships between outpatient problem experiences and patients' trust in their physicians, ratings of their physicians, and consideration of changing physicians. We classified as problem experiences patients' reports that their physician does not always 1) give them enough time to explain the reason for the visit, 2) give answers to questions that are understandable, 3) take enough time to answer questions, 4) ask about how their family or living situation affects their health, 5) give as much medical information as they want, or 6) involve them in decisions as much as they want." 2052 patients were contacted in a 1999 telephone survey. "Most patients (78%) reported at least 1 problem experience. Each problem experience was independently associated with lower trust and 5 of 6 with lower overall ratings. Three problem experiences were independently related to considering changing physicians: physicians not always giving answers to questions that are understandable,not always taking enough time to answer questions, and not always giving enough medical information."

In conclusion the authors state "Although most patients' experiences with their physicians are good, those that are not may have important consequences, including lower trust, lower ratings of physicians, and greater likelihood of changing physicians. More physician training in communication skills, particularly focused on answering questions in ways that patients can understand, taking enough time to answer questions, providing adequate amounts of information, and discussing differences in opinion about whether tests, procedures, or referrals are needed, may strengthen patient-physician relationships. This type of training is effective and should be a priority of residency training programs, medical schools, medical groups, and health care organizations."

Interestingly, though the importance of good communication is stressed in the business world and efforts are taken to improve communication skills with specific courses and consultations and there is some effort in medical school education to teach proper communication skills, virtually none is taught when the physician is in practice. There is a need for the medical community to show as much interest in improving medical communication as it does for improving diagnosis, medical drugs and treatments. ..Maurice.

Doctor Jokes: Reflections of Issues of Professionalism

For a change of pace, I am posting today examples of medical humor: "doctor jokes" from The Doctors Lounge where more humorous presentations are available. Notice how some of these examples of patient/doctor interaction seem to arise from professional issues which I have posted in the past month. If you know of some jokes that fit this point, click on comment and post them. ..Maurice.

· A man goes to his doctor and says, "I don't think my wife's hearing isn't as good as it used to be. What should I do?" The doctor replies, "Try this test to find out for sure.
When your wife is in the kitchen doing dishes, stand fifteen feet behind her and ask her a question, if she doesn't respond keep moving closer asking the question until she hears you."
The man goes home and sees his wife preparing dinner. He stands fifteen feet behind her and says, "What's for dinner, honey?" He gets no response, so he moves to ten feet behind her and asks again. Still no response, so he moves to five feet. still no answer. Finally he stands directly behind her and says, "Honey, what's for dinner?" She replies, "For the fourth time, I SAID CHICKEN!"

· "Doctors at a hospital in Brooklyn, New York have gone on strike. Hospital officials say they will find out what the Doctors' demands are as soon as they can get a pharmacist over there to read the picket signs!"

· The difference between a neurotic and a psychotic is that, while a psychotic thinks that 2 + 2 = 5, a neurotic knows the answer is 4, but it worries him.

· Doctor: I have some bad news and some very bad news.
Patient: Well, might as well give me the bad news first.
Doctor: The lab called with your test results. They said you have 24 hours to live.
Patient: 24 HOURS! That's terrible!! WHAT could be WORSE? What's the very bad news?
Doctor: I've been trying to reach you since yesterday.

· A man speaks frantically into the phone, "My wife is pregnant, and her contractions are only two minutes apart!"
"Is this her first child?" the doctor queries.
"No, you idiot!" the man shouts. "This is her husband!"

· A List of Things You Don't Want to Hear During Surgery:

Oops!
Has anyone seen my watch?
Come back with that! Bad Dog!
Wait a minute, if this is his spleen, then what's that?
Hand me that...uh...that uh.....thingy
What do you mean he wasn't in for a sex change!
Damn, there go the lights again...
Everybody stand back! I lost my contact lens!
Well folks, this will be an experiment for all of us.
What do you mean, he's not insured?
Let's hurry, I don't want to miss "Bay Watch"
What do you mean "You want a divorce"!
FIRE! FIRE! Everyone get out!

· A man goes to his doctor for a complete checkup. He hasn't been feeling well and wants to find out if he's ill. After the checkup the doctor comes out with the results of the examination.

"I'm afraid I have some bad news. You're dying and you don't have much time," the doctor says.

"Oh no, that's terrible. How long have I got?" the man asks.

"10..." says the doctor.

"10? 10 what? Months? Weeks? What?!" he asks desperately.

"10...9...8...7..."

· The seven-year old girl told her mom, "A boy in my class asked me to play doctor."
"Oh, dear," the mother nervously sighed. "What happened, honey?"
"Nothing, he made me wait 45 minutes and then double-billed the insurance company."

Medical Student Abuse

As I noted in a previous posting, there currently is a problem in the education of medical students about professional behavior including humanism. They may be given explicit information during their first two years of medical school but by the 3rd year and beyond this information may be degraded by their tacit learning attending to patients under supervision of their superiors. They may “learn” wrongs from their superior’s misbehavior and yet many students may find it impossible to avoid this in view of the pressures, self-interest and abuse they will encounter. Yes, I wrote abuse. You have heard of child abuse, elder abuse, spousal abuse and abuse on the job.. well, there is also medical student abuse which has been going on for years and years. Many older physicians have never looked at this behavior as abuse but only part of the initiation ritual which they themselves had to survive during their formative years.

From the American Medical Association News in 2000:
Mistreatment of medical students appears to have declined during the past six years, according to surveys of fourth-year students by the Assn. of American Medical Colleges.
But medical education experts believe statistics are misleading and that students continue to be subject to unacceptable levels of public belittlement, humiliation, and physical and sexual abuse, and have been denied opportunities for advancement because of gender or ethnicity.
"If you think abuse is gone, it is not," said Harry Jonas, MD, co-secretary of the Liaison Committee on Medical Education. LCME accredits the nation's 125 medical schools.
In a survey of 12,734 seniors conducted last year, the AAMC found that 26.7% had been occasionally belittled or humiliated compared with 28.1% in 1998. Slightly more than half, 51.1%, said they had never been subject to such abuse during their four years compared with 48.1% in 1998 and 61.7% in 1996.
As in past surveys, women and minority students recorded more incidents of sexual, physical and mental abuse than white men, the AAMC survey found.

As you can see from the above statistics, whether the situation is improving or not, the percentages are still large and may be incomplete. Ritual or not, either is destructive toward instilling the professional behavior we all would like to see in our physicians. ..Maurice.

Should Medical Students be called "Student Doctor"?

As I have noted on previous postings on this blog, there has been a change in recent years in how patients relate to the medical profession and vice versa. Along with the rise of consumerism, society has shown that it wants to deminish paternalistic behavior by physicians and assure informed consent on the part of the patients. Therefore the current ethical consensus is that there should be a clear understanding between patient and physician regarding all that is transpiring in medical care. This also means that any words or behavior on the part of the caregiver which may lead to deception is not right and may defeat attempts at informed consent.

Medical students have long been identified by the words "student doctor" or "student physician". Medical students, of course, have neither obtained as yet their M.D. degree nor have the legal responsibility of a physician. In keeping with the societal consensus described above, there is some concern whether using these words by medical students in identifying themselves either orally or on their name tag or by others identifying these students may itself be deceptive. The issue here is whether patients or families would misinterpret the qualifications and responsibilities of the student by these descriptions. Would you agree that these words may be deceptive and that medical students should only be identified by the words "medical student"?

My own opinion is that that "student doctor" or "student physician", as examples of student titles, are deceptive and only "medical student" should be used. I have posed this question to visitors to my "Bioethics Discussion Pages" website and I have received a number of responses. If you would like to read them, click here. ..Maurice.

Hippocratic Oath: Is it Necessary? Are the Words Right?

The Hippocratic Oath either in the classical form or in one of the modern forms has been a fixture in the graduation exercise of medical students in most medical schools. By repeating the Oath, medical students receiving their diplomas can then enter the profession of medicine and become physicians. However, particularly in recent years, there has been controversy as to whether the words are up to date in the Oath or whether the Oath itself is really necessary. This debate has been presented in the PBS Nova website including comments by physicians and non-physicians. Go to the site by clicking here but return and write your comments. (PBS is no longer accepting comments to be posted on their site.) For those of my visitors who just want to read the classical Oath and an example of the modern one, I have pasted them below. ..Maurice.

Hippocratic Oath -- Classical Version

I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfil according to my ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.

If I fulfil this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

Hippocratic Oath -- Modern Version

I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.

I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.


Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.

Why Can't a Patient Be More Like a Doc?

Continuing with the consideration of the ideal physician and ideal patient…
Here is a satirical takeoff by Steven Miles, MD,Professor of Medicine and Geriatrics,Center for Bioethics,University of Minnesota on a familiar My Fair Lady lyric.

Thanks Steve.

A HYMN TO HIM


Why can't a patient be more like a doc?
Docs are so honest, so thoroughly square;
Eternally noble, historic'ly fair;
Who, when you win, will always give your back a pat.
Well, why can't a patient be like that?
Why does ev'ryone do what the others do?
Can't a patient learn to use her head?
Why do they do ev'rything other patients do?
Why don't they grow up- well, like their doctor instead?

Why can't a patient take after a doc?
Docs are so pleasant, so easy to please;
Whenever you are with them, you're always at ease.

One doc in a million may shout a bit.
Now and then there's one with slight defects;
One, perhaps, whose truthfulness you doubt a bit.
But by and large we are a marvelous lot!

Why can't a patient take after a doc?
Cause docs are so friendly, good natured and kind.
A better companion you never will find.

Why can't a patient be more like a doc?
Docs are so decent, such regular chaps.
Ready to help you through any mishaps.
Ready to buck you up whenever you are glum.
Why can't a patient be a chum?

Why is thinking something patients never do?
Why is logic never even tried?
Questioning me is all that they do.
Why don't they straighten up the mess that's inside?

Why can't a patient behave like a doc?
If I was a patient who'd been offered a cure,
Hailed as a miracle by one and by all;
Would I start weeping like a bathtub overflowing?
And carry on as if my home were in a tree?
Would I run off and never tell where I'm going?
Why can't a patient be like me?

The Ideal Patient

In my posting on July 30th mention was made of an "ideal patient". What do you think is the physician-view of such an ideal patient? Well, as physicians, though we would like to think of caring for an ideal patient, we have to face the reality that this would rarely happen. You see, the ideal patient would be one who, first of all, bears many of the views and goals of the physician. As physicians, we really can't believe that we will be so lucky. Then, physicians generally yearn for illnesses which they can easily diagnose and readily treat to an outcome which is optimal for the patient. That usually means that the patient has real physical symptoms, one acute disease-- not confusing multiple new diseases at the same time and, finally, clear cut physical findings and lab tests. The illness, hopefully, would have standard treatment which is virtually universally satisfactory and the risks of treatment being minimal, if at all. The patient should be alert, in good spirits (not too sick), have confidence in the physician, readily competent to make decisions, thoroughly interested in learning about the illness and its treatment and willing to take time to listen carefully to the explanation by the physician and the options of further diagnostic tests and treatment. And when it comes to treatment, the ideal patient will make the effort to follow the physican's prescription directions and remain fully complient. The patient will also carefully monitor their reaction to the medication and promptly report to the physician any side-effects or complications. The ideal patient will also have the ideal family. Such a family will support the patient but also show confidence in the physician and support the physician.

As I mentioned at the outset of this posting, this all may be just wishful thinking on the part of the physician. It is unlikely that all these features would appear in the one patient. However, if the doctor had repeatedly such ideal patients, caring for them might be a boring experience. The wonderful "goose-bump" experience of a physician suddenly finding that he/she has made an emotional/spiritual connection with a patient would no longer occur. The wonderful challenge of the difficult diagnosis and the emotional uplifting for the physician who has made the diagnosis that was missed by others, even specialists, would be missing. The splendid realization of a cure, finally occuring after a course of many ups and downs, would be a rarity if all cures occurred easily and on schedule. Finally, if the physician had all ideal patients, the challenge of the difficult patient, the difficult family and the challenge of managing the patient and family if the cure doesn't come will be absent.

It is the job of a physician to make the diagnosis when the illness is not easily identified, to make the patient's treatment satisfactory when that isn't easy or simple and finally to meet the criteria and be that ideal doctor to every patient who turns out not to be the ideal patient imagined by the physician. ..Maurice.

More on Teaching Medical Professionalism

"Although disagreement persists among experts
as to which aspects of medical practice are
captured by the term “medical professionalism,”
in recent years there has nevertheless
been widespread agreement within academic
medicine that it is essential to teach about medical
professionalism to medical students and
residents."
From "Training Doctors for Professionalism: Some Lessons from Teaching Medical Ethics" by Mark Siegler, M.D. [note: this is a PDF/Adobe Acrobat file]

Another view regarding the teaching of professionalism to medical students and residents is found in the American Journal of Bioethics, V. 4 Nr.2 2004 pages 1-10
"The Professionalism Movement: Can We Pause?" by Delese Wear and Mark G. Kuczewski. Here is the abstract of the article which is also available on the Univ. of Pennsylvania bioethics website

"The topic of developing professionalism dominated the content of many academic medicine publications and conference agendas during the past decade. Calls to address the development of professionalism among medical students and residents have come from professional societies, accrediting agencies, and a host of educators in the biomedical sciences. The language of the professionalism movement is now a given among those in academic medicine. We raise serious concerns about the professionalism discourse and how the specialized language of academic medicine disciplines has defined, organized, contained, and made seemingly immutable a group of attitudes, values, and behaviors subsumed under the label of "professionalism." In particular, we argue that the professionalism discourse needs to pay more attention to the academic environment in which students are educated, that it should articulate specific positive behaviors, that the theory of professionalism must be constructed from a dialogue with those we are educating, and that this theoretical and practical discourse must aim at a deeper understanding of social justice and the role of medicine within a just society."

Finally, the following is a list of pertinent articles regarding the teaching of medical professionalism from: Virtual Mentor,
Ethics Journal of the American Medical Association,
December 2003, Volume 5, Number 12
©2003 American Medical Association
Publication notice from AMA:This publication may be downloaded and reproduced for educational purposes. Sale or distribution for non-educational purposes is prohibited.

Suggested Reading and Resources
Professionalism in Medical Education

Accreditation Council for Graduate Medical Education (ACGME). Common program requirements. Available at: http://www.acgme.org/DutyHours/dutyHoursCommonPR.asp. Accessed September 2, 2003.

Ambady N, Laplante D, Nguyen T, Rosenthal R, Chaumeton N, Levinson W. Surgeons' tone of voice: a clue to malpractice history. Surgery. 2002;132(1):5-9.

American Medical Association. H-275.956: Demonstration of Clinical Competence. (CME Rep. E, A-90; Reaffirmed: CME Rep. 5, A-99; Modified: Sub. Res. 821, I-02).

American Medical Association. Principle IV. Principles of Medical Ethics. In: Code of Medical Ethics Current Opinions, 2002-2003 edition. Chicago: AMA Press; 2002:xii.

American Medical Association. Principles of medical ethics. Code of Medical Ethics, 2002-2003. Available at: http://www.ama-assn.org/ama/pub/ category/2512.html. Accessed September 15, 2003.

American Medical Student Association Web site. AMSA Advocacy Guide: Understanding and Preserving Your Student Rights. Available at: http://www.amsa.org/adv/advguide.cfm. Accessed October 10, 2003.

Association of American Medical Colleges Web site. Medical School Graduation Questionnaire, All Schools Report, 2003. Available at: http://www.aamc.org/data/gq/allschoolsreports/start.htm. Accessed October 10, 2003.

Boulet J, McKinley D, Whelan GP, Van Zanten M, Hambleton RK. Clinical skills deficiencies among first year residents: utility of the ECFMG clinical skills assessment. Acad Med. 2002;77:S33-35.

Boulet JR, van Zanten M, McKinley DW, Gary NE. Evaluating the spoken English proficiency of graduates of foreign medical schools. Med Educ. 2001;35:767-773.

Epstein R, Hundert E. Defining and assessing professional competence. JAMA. 2002;287:226-35.

Fincher RM, Lewis LA. Learning, experience, and self-assessment of competence of third-year medical students in performing bedside procedures. Acad Med.1994;69:291-295

Ginsburg S, Regher G, Hatala R, et al. Context, conflict, and resolution: a new conceptual framework for evaluating professionalism. Acad Med. 2000;75:S6-11.

Hatem C. Teaching approaches that reflect professionalism. Acad Med. 2003;78:709-713.

Health Care Quality Improvement Act (HCQIA). 42 USC § 11101 et seq.

Hemmer P, Hawkins R, Jackson J, Pangaro L. Assessing how well three evaluation methods detect deficiencies in medical students’ professionalism in two settings of an internal medicine clerkship. Acad Med. 2000;75:167-173.

Hopkins MA, Kalet A, Janicek R, et al. Integrating communication skills teaching into the surgery clerkship. Focus. 2003;4:33-35.

Howe A. Professional development in undergraduate medical curricula—the key to the door of a new culture. Med Educ. 2002;36:353-359.

Jackson, P. Life in Classrooms. New York: Holt, Rinehart, and Winston; 1968:353.

Kohn LT, Corrigan JM, Donaldson MS, eds. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC: National Academies Press. 2001.

Kohn LT, Corrigan JM, Donaldson MS, eds. Committee on Quality of Health Care in America, Institute of Medicine. To Err is Human: Building a Safer Health System. Washington DC: National Academies Press; 2000.

LaCombe MA. On professionalism. Am J Med. 1993;94:329.

Liaison Committee on Medical Education. Function & Structure of a Medical School, 1990 Accreditation Standards. Available at: http://www.lcme.org/standard.htm, current.

Lowenstein J. Can you teach compassion? In: Lowenstein J. The Midnight Meal and Other Essays about Doctors, Patients, and Medicine. New Haven, CT: Yale University Press; 1997:12-19.

Ludmerer KM. Instilling professionalism in medical education. JAMA. 1999;282:881.

Mansky, PA, Physician Health Programs and the potentially Impaired physician with a substance use disorder. Psychiatr Serv. 1996;47:465-467.

Mansky, PA. Chapter 46, Impaired physicians. In: Galanter M and Kleber HD, eds. Textbook of Substance Abuse Treatment, 3rd ed. Washington, DC: American Psychiatric Press, Inc. In Press.

Medical Professionalism Project. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002:136; 243-246.

Medterms Web site. Prayer of Maimonides. Available at: http://www.medterms.com/script/main/ Art.asp?ArticleKey=7295. Accessed September 15, 2003.

Moore PJ, Adler NE, Robertson PA. Medical malpractice: the effect of doctor-patient relations on medical patient perceptions and malpractice intentions. West J Med. 2000;173:244-250.

National Board of Medical Examiners. Special Medical Student Liaison Meeting Minutes. Philadelphia. NBME Special Medical Student Liaison Meeting. 2001-2002.

Physicians for Human Rights Web site. Islamic Code of Medical Ethics. Available at: http://www.physiciansforhumanrights.org/research/methics/methicsoath.html.

Regier DA, Farmer ME, Rae DS, et al: Comorbidity of mental disorders with alcohol and other drug abuse. JAMA. 1990;268:1012-1014.

Reid WH. Recognizing and dealing with impaired clinicians, Part 1: Recognition and reporting. J Med Prac Manage. 2001;17:97-99.

Sieminska MJ, Szymanska M, Mausch K. Development of sensitivity to the needs and suffering of a sick person in students of medicine and dentistry. Med Health Care Philos. 2002;5:263-71.

Silver HK, Glicken AD. Medical student abuse. Incidence, severity, and significance. JAMA. 1990;263:527-532.

Stern D. Practicing what we preach? An analysis of the curriculum of values in medical education. Am J Med. 1998;104:569-75.


Stewart M, Brown JB, Boon H, et al. Evidence on patient-doctor communication. Cancer Prev Control. 1999;3:25-30.

Stillman PL, Regan MB, Swanson DB, et al. An assessment of the clinical skills of fourth-year students at four New England medical schools. Acad Med. 1990;65:320-326.

Talbott GD, Gallegos KV and Angres DH. Impairment and Recovery in Physicians and other Health Professionals. In: Graham AW and Schultz TK, eds. Principles of Addiction Medicine. 2nd ed. Chevy Chase, MD: American Society of Addiction Medicine, Inc; 1998:1263-1279.

Taraban R, Rynearson K, Stalcup KA. Time as a variable in learning on the World-Wide Web. Behav Res Methods Instrum Compute. 2001;33:217-225.

The sick physician. Impairment by psychiatric disorders, including alcoholism and drug dependence. JAMA. 1973;223:684-7.

United States Medical Licensing Examination Web site. Clinical Skills Exam: FAQs. Available at: http://www.usmle.org/news/cse/csefaqs2503.htm. Accessed October 21, 2003.

Vincent C, Young M, Phillips A. Why do people sue doctors ? A study of patients and relatives taking legal action [comment]. Lancet. 1994;343:1609-1613.

Virmani v Novant Health, Inc, 259 F3d 284 (4th Cir 2001).

Virtual Hospital Web site. Sir William Osler: Aphorisms from His Bedside Teachings and Writings, #47. Available at: http://www.vh.org/adult/provider/history/osler. Accessed September 25, 2003.

Virtual Hospital Web site. Sir William Osler: Aphorisms from His Bedside Teachings and Writings, #3. Available at: http://www.vh.org/adult/provider/history/osler/1.html. Accessed September 25, 2003.

Waldman JD, Spector RA. Malpractice claims analysis yields widely applicable principles. Pediatr Cardiol. 2003;24:109-117.

Yedidia M, Gillespie C, Kachur E, et al. Effect of communications training on medical student performance. JAMA. 2003;290:1157-1165.

Yedidia MJ, Gillespie CC, Kachur E, et al. Effect of communications training on medical student performance. JAMA. 2003;290:1157-1165.