The Power of Prayer as Medical Therapy

An interesting study regarding how powerful prayer may be was recently published in which some of the patients undergoing percutaneous coronary artery treatment were prayed for by “established congregations of various religions” off-site so that neither the physician nor the patient knew that they were the objects of the prayer. Any subsequent adverse reactions and death were determined and compared to other patients who had only standard care or those who had direct (unhidden) music, imagery and touch therapy alone or along with the hidden prayer.

Here is a summary of a study as written in the Lancet July 16, 2005 (pages 211-217) by Mitchell W Krucoff et al titled
“Music, imagery, touch, and prayer as adjuncts to interventional cardiac care: the Monitoring and Actualisation of Noetic Trainings (MANTRA) II randomised study”


Summary
Background
Data from a pilot study suggested that noetic therapies—healing practices that are not mediated by tangible elements—can reduce preprocedural distress and might affect outcomes in patients undergoing percutaneous coronary intervention. We undertook a multicentre, prospective trial of two such practices: intercessory prayer and music, imagery, and touch (MIT) therapy.

Methods
748 patients undergoing percutaneous coronary intervention or elective catheterisation in nine USA centres were assigned in a 2×2 factorial randomisation either off-site prayer by established congregations of various religions or no off-site prayer (double-blinded) and MIT therapy or none (unmasked). The primary endpoint was combined in-hospital major adverse cardiovascular events and 6-month readmission or death. Prespecified secondary endpoints were 6-month major adverse cardiovascular events, 6 month death or readmission, and 6-month mortality.

Findings
371 patients were assigned prayer and 377 no prayer; 374 were assigned MIT therapy and 374 no MIT therapy. The factorial distribution was: standard care only, 192; prayer only, 182; MIT therapy only, 185; and both prayer and MIT therapy, 189. No significant difference was found for the primary composite endpoint in any treatment comparison. Mortality at 6 months was lower with MIT therapy than with no MIT therapy (hazard ratio 0·35 (95% CI 0·15–0·82, p=0·016).

Interpretation
Neither masked prayer nor MIT therapy significantly improved clinical outcome after elective catheterisation or percutaneous coronary intervention.

How much faith one can put into this single study would be a matter of debate amongst research statisticians. However, while no benefit to the patient was found in the defined primary endpoints, the benefit of praying for an ill patient without the patient’s knowledge may have some personal value for the one doing the praying. This was not evaluated in this study. ..Maurice.

More Delay on OTC Procurement of Plan B

From the New York Times:
WASHINGTON, Aug. 26 - Federal drug regulators on Friday once again delayed making a decision on allowing over-the-counter sales of the morning-after pill, saying they needed more time to gather public reaction to the plan and to figure out how they could enforce it.

The FDA has been delaying and delaying a decision on Plan B despite clearance from its scientific advisory panel. And now it says it will delay for another 2 months for the reasons noted above. Plan B is a contraceptive and not an abortifacient and should prevent unwanted pregnancies to abortion. The pharmacology should be morally satisfactory to all except those who feel that any interruption of the sperm getting to the egg or preventing of fertilization is immoral. As for how to enforce a restriction to purchase by those under the age of 16.,no FDA officer needs to be sitting in each pharmacy. As with those businesses who sell tobacco or alcohol products to the public, screening for those underage for Plan B purchase can be done by the pharmacy personnel.

This whole business sounds like the FDA is further succumbing to politics regarding OTC distribution of Plan B rather than basing the decision on science. Although every governmental decision may have some political significance and fallout, the ethical issue is whether we should be content with decisions made under pressure for the benefit of the politicians versus the betterment of the public. I have a feeling that politics is trumping public good. That is my guess. What is yours? ..Maurice.

Telling the Truth the “Wrong Way”

The issue is whether a physician loses the right of free speech because he is a physician. Can the speech presenting realistic clinical information to a patient be found to be of the same harm as crying out “fire” as a prank in a filled theater? Or is there a limitation to speech because it may be contrary to professional standards?

The case, as published in the New Hampshire Union Leader is regarding the action of the New Hampshire Board of Medicine versus Dr. Terry Bennett and raises these questions. A year ago, a patient whom Dr. Bennett had been following for her obesity and who had developed complications of her weight disorder took offense at his “obesity lecture” and filed a complaint with the Board of Medicine.

“The State Law state law authorizes the board to take disciplinary action against physicians who engage in providing false information, practicing medicine while impaired, behavior that is incompatible with basic knowledge and competence, dishonest or unprofessional conduct, negligence, allowing an unlicensed person to practice in the physician's office, failing to provide aseptic safeguards, dishonest advertising or statements, willfully violating the Medical Practice Act or if convicted of a felony.” My understanding is that this authorization represents the usual standard criteria for disciplinary action. The complaint was not dismissed and is being investigated by the Attorney General’s office with a public hearing to be scheduled.

How and to what degree a physician expresses valid information to a patient with the intent to benefit the patient is an open question and depends on the personality, knowledge and motivation of both the physician and patient. It is my opinion that the penalty to the doctor for the consequences of telling the truth the “wrong way” should be the loss of a patient since the patient has the right to leave the physician’s care and go to another doctor. Prosecution of the physician for the results of this type of speech is wrong. ..Maurice.

Naked

There is an issue that most patients will experience and every family doctor or internist or surgeon will have contemplated as he or she has engaged in medical practice. Society has given the physician the right and duty to inspect and examine the human body by vision, hearing and touch. The issue will arise as to how the necessary examination can be performed skillfully and thoroughly and yet provide physical and emotional comfort for the patient. This procedure is what we try to teach medical students as they learn to perform physical examinations. Whereas, as mentors we can teach the techniques of inspection, palpation, percussion and auscultation and we can help the students understand general principles of professionalism and ethical behavior, more difficult for the student to learn is how to ensure a thorough and accurate exam while preserving the patient’s emotional comfort during the exam. In fact, there is also the issue of the student or physician’s emotional comfort during the exam. It all boils down to the matter of modesty by the patient and avoidance of any suggestion of voyeurism or prurient interest by the physician. Or even worse, sexual misconduct.

The problem in the American medical practice culture is that there are no strict and uniform rules regarding how to expose the patient’s body, whether or not to have a chaperone present with regard to genitalia, rectal or female breast examinations or other areas of the body and if present, who the chaperone should be.

This topic is discussed in the Perspective section of the current New England Journal of Medicine August 18, 2005 issue with the article “Naked” by Atui Gawande. M.D. Dr. Gawande is two years out of his surgical residency and has had the opportunity to talk with physicians who have practiced in other cultures around the world describing how the concern of modesty is handled in their country. He also discusses his own initial reaction about how he should examine a patient with strict attention to patient modesty such as avoiding the patient using a gown and simply or not so simply moving around the clothing. This action clearly became awkward and he resorted to gowned patients. Finally after noting the real professional problems of physician sexual misconduct but also false patient accusations due to misinterpretation, he concludes that explicit standards of what is a “normal” physical examination be set up or tightened so that both doctors and patients know and better doctor-patient relationships can be established.

I would be interested regarding what experiences you have had either as a patient or as a physician/nurse in the area of patient modesty and how the situation was managed. No names please. ..Maurice.

ADDENDUM (December 14, 2007): For more commentary on the same general topic, there are two addition thread sites, "Patient Modesty: A More Significant Issue?" and "Patient Modesty: Volume 2".

ADDITIONAL ADDENDUM: The photograph was taken by me on 8-21-2006 at J.P.Getty Villa Museum, Malibu, CA. is a Getty Bronze "Statue of a Victorious Youth" (Greek 325-300 B.C.)

ADDITIONAL ADDENDUM (May 10,2007): A link to the free pdf file of the NEJM article "Naked" was made available by one of the commentators. Use it to go directly to the article.

ADDITIONAL ADDENDUM (May 22 2008) WARNING:

THIS THREAD SEEMS TO BE OVERFILLED WITH COMMENTS AND YOUR FURTHER COMMENTS WILL NOT BE PUBLISHED. PLEASE GO TO "PATIENT MODESTY VOLUME 2" TO READ AND "PATIENT MODESTY VOLUME 3" TO BOTH READ AND WRITE NOW AND TO CONTINUE COMMENTS ON ISSUES WHICH HAVE APPEARED ON THIS THREAD. DO NOT TRY TO COMMENT ON THIS THREAD--IT WILL NOT BE PUBLISHED!!! HOWEVER, FOR THOSE WHO WANT TO READ ALL THE COMMENTS WHICH ARE MISSING ON THE FIRST PAGE, GO AHEAD AND CLICK "COMMENTS" ON THIS PAGE AND THEN CLICK ON "POST A COMMENT" ON THE NEXT PAGE AND FINALLY ON THE COMMENT WINDOW CLICK ON "NEWER" OR "NEWEST" OR "OLDER" AND SCROLL UP OR DOWN TO READ BUT DON'T WRITE!! ..Maurice.

What Do They Want to Know?

A few of the visitors that come to my blog are the hardy souls who have my blog bookmarked and seem to be willing to see my latest exposition without trepidation. There are also a few more who come here, perhaps more curious than anything else, via a link from another blog. Finally, as I am sure is typical for many blogs, the majority come via a question to an internet search engine. The topics they request seem to vary considerably though many visitors seem directed to a specific previous posting. However, some seem unique and represent issues I have not as yet covered. As you may have noted, I have reacted to these topics by writing a new posting and acknowledging the source of the topic as coming from the visitor.

As an example of the search topics whose writers were sent to my blog, here is a list of this morning's requests courtesy of BlogPatrol:

bulimia + blog
case studies euthanasia by omission
lying to insurance company
physician gifts from pharma
misfits html codes
break patient confidentiality ama
Surgeons Prayer before surgery
"what are miracles"
1975 ny subway gas experiments
million dollar baby blog
blog jokes
Human Experiments: A chronology of Human Research
what a nurse should do on patients having ovarian cyst
international bioethics survey 2005 in philippines
poem i am not dead don't stand at my grave
Million dollar baby explanation
Mary Frye don't stand at my grave and weep (
motto of nurses for caring a psychiatric patient
Why become a physician?
bed side manner

What do they want to know? Often, the very same things I also did. ..Maurice.

Telling Patients They are Terminal (2): Doctor’s Fear of Failure

My posting of August 12, 2005 received this comment from a medical student today:

Dr. B.
As a current medical student and future physician reading your posting, “Telling patients they are terminal” I felt a surprising emotion: fear. My feeling of fear came from your comment that physicians often cause much of the confusion that surrounds end of life care. Specifically you stated that certain physicians will order more aggressive therapies and more diagnostic test when they know in their hearts that there is nothing more to do but ease the pain. In this situation, as you stated, the families will often get an unclear message as to the condition of the patient and how much time is left with their loved one. This confusing message that doctors often give patients can translate into disastrous effects. In this example the family might not understand that the last few days are near and the opportunity to say goodbye may pass them by.

It is easy to say that such physicians that give unclear messages are "bad doctors." However, although I promise to be the best physician possible I fear that I could someday make the same mistake. As a student among so-called "overachievers" in medical school the idea of failure is so frightening that we all work as hard as we can. In fact this fear of failure is what was selected for when we were accepted to medical school among thousands of applicants. Certainly this culture of fear will increase competition and cause us to study harder and ultimately work harder. So, as a medical student it is easy to see how a physician, who is deathly afraid of failure, would try to guard himself/herself as a human by squeezing any feeling of personal success out of every sick patient. However, as evident here, the patient's best interests may not always be aligned with those of the physician.

It is clear then that a truly great physician is one that is not afraid of being exposed to the feelings of failure (and this rationale should be taught in school) and is able to identify the patient's needs as much more important than any feeling of personal success. I guess a good way to look at this situation is that a physician can gain a small victory of personal success by giving a clear message to the patient and his/her family so that the concluding days are filled with love and goodbyes. By acknowledging small victories like this a physician can maintain his/her sense of purpose and provide the best care for patients all the while.

Dear Medical Student, doctors are human. Doctors have feelings and can make mistakes. Sometimes the mistake is not a technical error but one related to feelings. Think about perhaps knowing and caring for a patient for years and then having to provide care when the patient becomes terminally ill. Perhaps the physician also has known the family for a long time. The physician may find it difficult emotionally to discard understandably subjective concern for the patient and proceed in a purely objective manner. So sympathy is the culprit that enters into the physician’s decisions. Then, there is the doctor’s concern of what others expect of him or her. Unfortunately, the public sees modern medicine and physicians as possible miracle makers. Can the physician have enough self-confidence to be able to tell the patient and family that there are no miracles that he or she can provide but there is always hope that the body and the illness will change course? Everybody eventually dies, even those under the best medical care, so failure to cure is not necessarily a stigma of a “bad physician”. Failure to acknowledge this truism and instead provide unrealistic hope to the patient and family is the doctor’s real problem.

I agree, medical school education should include a curriculum beyond what diagnosis to make and when and how to treat. The curriculum should also include the issue of “when to give up”. There are signs in the complexity of organ failure, the response of the patient to treatment, the available statistics of recovery and the patients known desires of a wanted quality of life if some degree of recovery occurs which are markers of the current illness. They all will lead to a fairly reliable conclusion of when energetic attempts at treatment of the illness becomes futile and when to concentrate on comfort care alone.

You are correct that it is the multiple “small victories” that enhance the physician’s love for his or her profession. Remembering also that the “big defeats” are often beyond the physician’s skills. ..Maurice.

Blog Pollution by SPAM: Unethical Behavior

Ethics is not something to take lightly. Ethics provides a guideline for every person to be doing something good and valuable, not only for the individual but for others. Without ethics there is chaos. Can unethical behavior be tolerated on a bioethics blog. No!

As is probably happening on other blogs, there has developed a behavior on the part of some assuming that it is perfectly ethical, legal and proper to place SPAM messages in the Comments section of the blog postings. The comments section has been made available to provide access to the blog for conversation about the topic presented in the original posting. It is not to provide a free and unfettered resource for the broadcasting of commercial material. Spammers can fill their own personal blog with whatever they please but they may not contaminate and pollute access to rational discourse.

We all have heard of companies discharging their waste into what previously were clean rivers. Is that ethical for the local residents and those down stream? The blog spammers are doing the same thing to our river of communication. Don’t do it anymore because soon our river will be clogged, communication will stop and the life in our river will end.


Specifically, today I have had to clean up a posting polluted by glok41lcac. And there have been others.Instead of “using” someone else for their self-interest purposes without permission, the spammers would be more ethical and could possibly contribute by participating with pertinent comments about the issue being discussed. Can’t we all get along? ..Maurice.

Telling Patients They are Terminal

A visitor to my blog wrote me this e-mail today:

“Dear Dr. Bernstein,

I'm writing a pro and con article in physicians' voices for [a] magazine on the topic of telling patients that they are terminal. On one side, a physician will argue that it is necessary to be brutally honest with a terminal patient so he/she can get affairs in order, fulfill a wish, say goodbye, etc. The other side is to withhold information--unless asked outright--to continue giving the patient hope.

I'm sure we can find a physician who will take the side of being brutally honest, but we're wondering whether physicians also hold the opposing view--that of not revealing that the patient is terminal. “

I wrote back:

The fact is that most patients who are terminally ill already know they are terminally ill and so, frankly, there is nothing to hide. The biggest problem of all is for the physicians themselves (and of course, the patient's families) to acknowledge the inevitable course of the illness. Yes, in their physician's brain they know the end is near for their patient but in their heart they will deny it. The grim prognosis is denied because doctors don't like to have their patient die. It represents failure and to them, perhaps, a personal failure on their part. So some physicians find some diagnostic test or procedure or medication to provide which under other circumstances might be helpful but in their terminal patient there is of no benefit for the patient and may actually prolong the patient's dying or add unnecessary discomfort. The result of this behavior on the physician's part actually provides the basis for confusion to the patient's families. That is because the families may get "mixed messages" since one physician may be providing them a realistic prognosis and refusing their requests for futile tests or treatments while another of the patient's physicians may be giving in to the requests and thus signaling to the family that there is still procedures or treatments beyond comfort care available to perform.

If a patient is truly unaware of the terminal prognosis, in the U.S.A. culture, a careful, empathetic explanation of the disease, previous course and outlook and measures to be taken for comfort care should be provided by the physician. The degree and velocity of information disclosure would depend on how the patient is responding to the disclosure and what questions the patient is asking. However, within the U.S.A. there are other cultures where full or even partial disclosure of bad news to the patient is prohibited, the families instead are to be fully informed. Therefore standard disclosure practices to the patient may need to be tempered when these particular cultures are involved. I hope you see that this issue of informing the patient is not a simple one. ..Maurice.

Addendum: For more on the same topic read the post of July 18, 2004. I provided some links there to further resources on the topic.

Cancer and Peter Jennings: Controlling the Uncontrollable? (2)

I watched the Charlie Rose program on PBS, where a close friend of Peter Jennings and the family was interviewed. He had visited Peter during the last months of his illness. It appears that Peter and the family knew at the outset of the high probability of a losing outcome. However, Peter requested chemotherapy and radiation with the intent of living despite the toxicity and the odds. This decision was probably the last significant act to maintain control over his life. The friend said that it was the tremendous support of Peter’s wife and family, even including his ex-wife that made his final days acceptable.

I am trying to contrast Peter Jennings action with Bob Stern’s response to illness. Both men were said to demonstrate need for personal control in their lives. Peter chose, in the end, to do whatever was necessary to live. Bob chose suicide. Of course, Bob was 10 years or so older but had a less defined immediacy of death from illness than Peter. Why didn’t Bob choose to do the most to preserve and continue his life? I suspect that the difference compared with Peter was that depression was a factor in Bob’s decision. If so, as I previously suggested, Bob’s decision for suicide was probably not strictly “rational”.

Perhaps I am attempting too much analyzing of the final actions before death of these two men said to show their need for personal control in managing their jobs and possibly their whole lives. But I have an interest in wondering about why people do what they do. ..Maurice.

Cancer and Peter Jennings: Controlling the Uncontrollable?

With the eulogies expressed by many of his professional colleagues, there came a new sense of the persona of the American Broadcasting Company’s news anchor Peter Jennings who died in the past week of lung cancer. On the TV screen, Mr. Jennings presented himself with a concerned but yet a calm, intellectual and humanistic appearance. What most of us didn’t know until now was that in the newsroom he was controlling to those who worked with him and always attempted to be in great personal control in his work. What the degree of situational or personal control was expressed at home is not clear to us outside his family.

What would be of interest to me and as an extension of the discussion of the recent postings (July 25 and 31, 2005) here about the response of the “self-made man” Bob Stern to his illness, how Peter Jennings dealt with the discovery that he had inoperable lung cancer and its course. For if Mr. Jennings was able to live the last months of his life in peace despite a cancer which he could not personally control, there would be much to learn about how this was accomplished. What do you think? ..Maurice.

Sacrifice the Value of a Human Life to Convenience (2)

Yesterday, August 6th, is a day 60 years ago, we remember as the day when the United States exploded an atomic bomb over Hiroshima. This act and the act a few days later of the atomic bombing of Nagasaki, appears to me an example of sacrificing the value of human life, hundreds of thousands, for convenience. Perhaps you may find the term “convenience” is not appropriate but I think it is. The U.S. government gave the excuse that the atomic bombing was the quickest way to end World War II and prevent the deaths of U.S. soldiers in an invasion of Japan. In this regard, it was “convenient” that there was an atomic bomb that could be put into use. Convenient that using this weapon invasion might not be necessary. And after Nagasaki, Japan promptly surrendered.

Each of lives taken at the moment of the explosions and those who died later from the effects of the blasts and the radiation sickness and cancers that followed already had a history and established values that were sacrificed. Were these sacrificings for a cause the same as preventing implantation of a fertilized ovum or the death of a frozen embryonic cell cluster? I think not. The morality of a woman sacrificing potential human life, yet unborn for her purpose is quite different than society finding a rational purpose to kill those already born and living. ..Maurice.

“Sacrifice the Value of a Human Life to Convenience”: Any Examples?

An anonymous visitor wrote the following, in part, as a comment on a previous posting, about Plan B:

”More information is needed to confirm that BCPs and Plan B do not act as abortifacients. Until then, the society should treat them as abortifacients. This means, patients should be informed of the possibility of a chemically-induced abortions before they are prescribed hormonal contracpetives and/or Plan B. Pharmacists and doctors should be given a good opportunity to avoid using/dispensing these drugs if they have CO. The best way of doing it is taking these drugs off the formularies of usual hospitals, and off the inventories of pharmacies. Just like in case of abortions and mifepristone, patients would have to go to specialized clinics.
To some it may seem like a very radical measure. If it does, it may be just because it is a very inconvenient one. Should we sacrifice the value of a human life to convenience?”

It is the last sentence: “Should we sacrifice the value of a human life to convenience?” that I thought was a topic worth expanding into further discussion. Can my visitors think of examples, beyond the application of Plan B to prevent pregnancy, where society is routinely sacrificing the value of human life to the convenience of others but in those cases involving already born humans who already have a history and an established value, unlike a few hours old embryo? I want to read what other think before I write my own comments on the subject. ..Maurice.

Who is Being Kept Alive: Baby or Mother?

From Scotsman.com:
In a day of emotional highs and heartbreaking lows, Jason Torres yesterday gained a daughter but bid farewell to his brain- dead wife after she was kept alive on a life support machine for three months while their baby developed. …
…Last night, she was pronounced dead after her life support was finally switched off. …
…All the days from here on out are a gift," said Justin Torres just weeks ago. "We know that by some legal standards she's considered dead already, but we don't believe it. All you have to do is spend any time in the room with Susan, her doctors, her family or Jason. She's the strongest person in that room."

From CBC News:
A brain-dead American woman was disconnected from life support and died a day after giving birth to a girl in a hospital in Virginia.

From USA Today:
Susan Torres, the pregnant woman kept alive on a respirator for nearly three months after a stroke caused by cancer, died in a hospital here Wednesday, a day after delivering a premature but very active girl.
Torres, 26, died after she was disconnected from artificial breathing and feeding devices, her family said in a statement. She had been declared brain-dead May 7 after the stroke caused by an undiagnosed case of melanoma that spread to her brain.

Patients who meet the criteria for brain death are dead. In the United States this is the law and ethics. There is no further need for “life support” for the deceased patient. The stories are therefore misleading as they tell about “life-support” for the mother. The mother did not need “life-support” since she was already dead. It was her baby who was medically managed who needed life support to continue to live until delivery.It is sad that the news media have been consistent in this repetition of wrong information. Sad, because by presenting to the public unexamined and undocumented statements as facts, the U.S. public will be mislead but also will be lead to unfortunate consequences. Sad, because these words in the media may cause families with brain-dead members to request or demand continued treatment as if the member was actually alive and had a future. Sad, because a major source of needed organs for transplant, the brain-dead patient, will be diminished because of the family’s concern that the organs would be removed from a patient not as yet dead. As with the Terri Schiavo case, the media continues to contribute to the medical confusion of the public and it is a shame. Now that I got this off my chest, I feel better. ..Maurice.

"Bringing Out the Dead" in One Way or Another

I would like to bring to the attention of my visitors a new publication. It is ATRIUM- The Report of the Northwestern Medical Humanities and Bioethics Program of Northwestern University Feinberg School of Medicine. The title of this first issue is “Bringing Out the Dead”. Amongst other considerations, the ethics of the use and display of the dead is discussed. There are articles presenting the two views of whether specimens of the dead fetuses representing developmental anomalies should be displayed in a museum-type setting. There is an article dealing with the “Body Worlds Exhibit” which is a public display of human corpses which have been preserved in plastic “appearing in naturalistic, non-clinical settings and pose with their skin removed, revealing the inner dimensions of the body to the museum goer.”

An article, to which I was most interested dealt with the medical school teaching of human anatomy either by the longstanding practice of student dissection of the dead body versus the relatively new teaching of anatomy only by prosections: students looking and studying anatomical specimen which had been previously professionally dissected out by their anatomy teacher. With prosections, the medical student will not be faced with a whole human corpse and will not spend hours cutting through fat and muscle to find or follow an anatomical structure. It will all be there clearly defined in the prosected specimen. The student will save time, save frustration and save much of the odor of formaldehyde permeating the nasal passages. But will the student miss something? Would there be some value for the students to actually be introduced to their “first patient” on the anatomy table? To recognize that their “patient” was once a live human being with all the capacity for feelings and anticipation of the future which the students themselves hold. And that the students, as humans, are no different than their subject except they are still alive. Would it provide them with a special experience to emphasize, from the beginning of their careers, that all human beings deserve respect including the deceased and the disabled?

Apparently, there are both advantages and disadvantages for medical schools to teach by prosection. It would be important to know what differences in knowledge or skills have been observed in students who learn anatomy by prosection alone as compared with personal dissection. Of interest would be studies to establish whether the absence of this “first patient” in year one anatomy makes any difference in the clinical relationships with the later live patients.

Have any of my visitors had their own human anatomy education in medical school solely by prosection? I would like to know what it was like and if the lack of dissection experience makes them feel now like they are not a “real doctor”. ..Maurice.