Athenian Children by Jane Lampton, University
of Mississippi School of Medicine
Grahic Jump Location
Open and frank communication between doctors and their patients has
always been the cornerstone of effective health care delivery. Patients willingly
relinquish detailed information about their physical conditions plus personal
and family histories to which few people, if any, are ever privy. Physicians
are entrusted to use this private knowledge, not for personal gain, but to
provide curative and palliative therapies that will unconditionally improve
the patient's well-being. These straightforward aims are threatened by the
practical difficulties that arise when the competing objectives of other parties
(nonphysician and nonpatient) enter the situation.
As described by Joel Schofer1 and
Martin Furmanski, societal exigencies can impinge on the relative sanctity
of the patient-physician relationship, as during wartimes when government
directives have contravened the privacy of the patient-physician relationship.
Fortunately, such situations rarely occur. A more urgent factor changing the
nature of the patient-physician relationship is the increasing prominence
of cost containment in medical practice and the resulting pressure on physicians
to see more patients in the same amount of time. As in any other human relationship,
trust between the physician and patient requires time to become established.
The patient may be initially skeptical of the physician's abilities or intentions
and withhold information necessary for a medical diagnosis. The physician
may require time to attune to the behavior and speech nuances of a particular
patient and appreciate the complete story. How long does it take for effective
communication to happen? As Dan Reirden recounts in this issue, years can
go by, and the physician may still not be completely aware of the circumstances
surrounding a patient's illness. In this age of 15-minute office visits, one
can only wonder how much information that could have been useful in treating
a patient's condition is left unsaid. Other factors modify the way patients
and physicians interact with one another. The growing number of non–English-speaking
patients has necessitated introducing multilingual intermediaries between
the physician and patient. As Lorna Breen discusses in this issue, information
can be readily lost or distorted as the message is translated from one language
The articles in this and future issues of MSJAMA
touch on only a few of the challenges faced by physicians in providing personalized
and competent health care. As the new academic year begins, medical students
would be well advised to keep abreast of the medical implications of changes
in the patient population and, perhaps most importantly, the growing dominance
of financial incentives in shaping the manner in which physicians interact
with their patients.
According to the 1990 US Census Bureau, 31.8 million residents, or 14%
of the population 5 years old and older, reported speaking a language other
than English at home.1 The most common non-English
language spoken at home was Spanish (17.3 million) followed by French (1.9
million), German (1.5 million), Chinese (1.3 million), and Italian (1.3 million).
Seven states—New Mexico, California, Texas, Hawaii, New York, Arizona,
and New Jersey—reported that 20% or more of their residents did not
speak English at home.1
Clear communication between the physician and patient is an obvious
requisite for effective health care delivery, but how is this best accomplished
when English is not the common language? While it may seem that the most logical
solution would be to use interpreters whenever possible, many hospitals do
not employ professional interpreters.2
Also, existing interpreters may be underused
if physicians and nurses overestimate their own language skills or those of
the patient. Some physicians may simply be uncomfortable with the potential
for information distortion that can occur through an interpreter.
Another common approach to communicating with patients who do not speak
English is to use ad hoc interpreters such as family members, friends, or
hospital employees. While this may be convenient, the interpretations may
not always be accurate. One study3 showed
that between 23% to 52% of words and phrases were incorrectly translated by
ad hoc interpreters. A drawback to letting family members interpret is that
one sacrifices patient confidentiality. Cultural mores may lead non–English-speaking
patients to withhold more information than one might otherwise expect. Friends
and family often are not prepared to deal with the complexity required by
an interpretation of medical information.
Perhaps the ideal solution to establishing clear channels of communication
between physicians and patients would be to recruit multilingual medical personnel
in hospitals serving large non–English-speaking populations. The multilingual
physician can immediately evaluate a non–English-speaking patient without
having to seek out and wait for an appropriate interpreter to arrive, and
the fear of mistranslation or shades of meaning being misinterpreted would
be removed. Studies have shown that language concordance also leads to increased
Is it possible for busy medical students to become completely fluent
in other languages? Many medical schools now offer foreign language electives.
However, data suggest that these courses may not adequately prepare students
for interactions with non–English-speaking patients. A study of 8 first-year
resident physicians who had completed a 45-hour medical Spanish program at
the Stanford University/Kaiser Emergency Medicine residency program concluded
that although medical language courses may be a useful adjunct to interpreters,
significant errors occur when course participants assume their language proficiency
Keep in mind that traditional modes of communication, which may be the
most readily available, are not the only option. Patient education audiotapes
exist in various languages. Also, AT&T has a toll-free Language Line Service,
that will connect you with an interpreter in the language of your choice (with
up to 140 different languages) 24 hours a day, 7 days a week. Lastly, there
has been some movement toward the use of "remote-simultaneous interpretation,"
which uses cellular phone technology to link trained interpreters to the people
who need them most (Table 1).
Encounters with non–English-speaking patients are common, especially
in metropolitan areas with large immigrant populations. With increased recognition
of the difficulties posed by multilingualism as well as the growing number
of solutions, we can hope that the treatment of non–English-speaking
patients will become less problematic as we enter the 21st century.
It seems funny to me now that I was so surprised by his death. Four
months later, I seem to be able to regard the events of that week with a little
more objectivity, or perhaps a little less denial. I had known William for
slightly more than 2 years. In my Student Continuity Practice he came to represent
all of the joys and sorrows one can expect to encounter in primary care.
We met on a bright autumn day during my first year in medical school.
My preceptor, Dr P, had given me only brief introductory remarks about my
patient before William entered the room. I knew that he was infected with
the human immunodeficiency virus (HIV), and I knew that he had been through
some periods of ill health, but I don't recall having learned much more of
his story. In person he was slight of build. Despite a sense of fragility,
his spirit was vigorous. William embodied the seemingly contradictory qualities
of optimism and realism that are necessary to live with HIV. Still enrolled
as a graduate student, he had learned to work on his thesis when his body
allowed it and to rest when his body demanded it.
Over that first year, he graciously tolerated my fumbling attempts to
take a history and to perform parts of the physical examination. He willingly
opened his mouth to show me his thrush. Later, he volunteered to serve as
my subject during an assignment to interview a patient with a chronic disease.
So that I might better understand what happens after a physician writes a
prescription, William typed up a list of the 64 pills he took on a daily basis
along with the elaborate dosing schedule.
In addition to taking an enormous number of medications, William came
into the university infirmary every day to receive intravenous (IV) antiviral
medications through a central catheter. Although constrained by this regimen,
he never complained or refused to speak with me when I dropped by, almost
weekly, to learn more about his experiences. I remember the day when he described
his frustrating attempts to navigate several social service bureaucracies
so that he could get some dental work done. As he told me about spending hours
of each day on the phone, getting transferred from person to person, he was
forced to interrupt our 45-minute conversation at least 5 times to rush to
the restroom, dragging his IV pole behind him, on account of the diarrhea
that he lived with regularly. Each time he returned with little more than
a sigh or a roll of the eyes by way of complaint, continuing his story where
he had left off.
Over the 2 years I knew William, he began to divide his time between
two residences: his apartment in town and the infirmary at the university.
Eventually, his parents, who were both retired, moved into town to take up
residence in an apartment in the same building where he lived—close
enough to be helpful and still allow him to retain a semblance of independence.
This living situation was just one of the many contradictions and conflicts
that accompanied his disease. On one hand, he resented being nearly 40 years
old and still reliant on his parents for help; on the other hand, their presence
provided a degree of security. It was not uncommon for me to stop by his room
at the infirmary to find him dozing in bed, while his parents sat arm-in-arm
on the couch watching television. Suddenly, the hospital room became a living
room. I wondered on those nights how many homes would be so fortunate as to
know that kind of love. On more than one occasion, I found myself faced with
the contradictory thought, "How lucky he is." Not lucky to be ill, but lucky
to be surrounded by a sense of unconditional love.
Last autumn, the third since we first met, he was at the infirmary more
frequently than he was at home. In September, everyone at the infirmary seemed
to breathe a sigh of relief when he was able to go home for the weekend of
his 40th birthday party. Friends and family from all over the country arrived
to celebrate the occasion. I heard that William was in his glory that weekend.
Unfortunately, the glory was short-lived. Within days after the birthday party,
he was forced to leave his apartment again. This time he had begun to cough
up large amounts of blood. The infirmary wasn't going to be adequate this
time: he would be moved to the university hospital.
Dr P had already made a difficult decision by the time I was able to
see William in the hospital. In his opinion, this new development was far
worse than anything previous. As he looked at William's pale and wasted body,
Dr P didn't believe William's observation that "It just doesn't feel like
I'm ready to go." Dr P advised William's parents to call the rest of the family
lest they miss their opportunity to say goodbye. The family all rushed to
his bedside, but William was right; it wasn't yet time. In several weeks he
was strong enough to return to the infirmary, the cause of his bleeding still
unexplained. Somehow, he had managed to rally. Intellectually, I understood
that this most recent hospitalization changed everything that had gone before.
But hadn't he managed to surprise us time and time again?
It was a Tuesday, my clinic day, when he arrived back at the infirmary
from the hospital. I decided that I would go upstairs and spend some time
with him before I headed home for the day. Sitting up in bed, he looked tired
but not as bad as I had feared. William's mother was visiting while he was
attempting to eat some dinner, so I sat for a while to chat. No more than
a few minutes had passed when William uttered a startled sound and I looked
over to see him, looking terrified, with a bloodied cup in his hand. I grabbed
a pair of gloves and a warm washcloth. This time it looked like the blood
was coming from a sore on his tongue, and with a little pressure I was able
to stop the bleeding. I breathed a sigh of relief, grateful that things weren't
as bad as they had first appeared. I said good night and told William that
I would see him next week. I really believed that I would.
But, if I really believed that I would, why couldn't I shake the sickening
feeling in the pit of my stomach? If I really believed that I would, why was
I so obsessed with getting back to the infirmary to see him again? It seems
so clear now, yet I was truly unprepared for the news of his death when Dr
P paged me on Friday morning.
Dr P explained that he had received a phone call from the nurses' station
in the infirmary at noon on Thursday. William was requesting that he come
up as soon as possible. When Dr P arrived in the room, William calmly stated
that he felt like the time had arrived for him to go. He wanted to know if
that would be okay. William then looked at his mother and asked her permission
to die. I suspect that granting this permission was the hardest thing this
mother had ever done. Soon after, a morphine drip was begun and, as Dr P told
me, a most amazing change took place in William. William had always denied
that he was in pain; in fact, he rarely complained of anything. Yet when the
morphine drip began, a brightness overtook William's face. Dr P said that
it was like watching years of accumulated pain melt away. William spent several
hours sharing the company of his family and a few close friends, with whom
I felt privileged to be included. People held hands, hugged, prayed, laughed,
and cried. Eventually, William felt the need for sleep, so he curled into
a fetal position and slept. The friends stayed in his room sharing stories
about his life while a brilliant sun set over the gothic buildings outside
the infirmary's windows. As the light of the beautiful autumn day faded, William's
breathing slowed. At 10 that evening, it ceased.
I attended a memorial service held in William's memory about a month
after his death. William had planned this memorial himself as a celebration
of his life: he alone had chosen the readings and the music. The service was
held in an old Unitarian church on the university campus. In-between the music
and the readings, friends had been invited to speak about their relationships
with William. A woman with whom he had been friends since second grade had
flown in to tell about her lifelong friendship with William. His college roommate
shared stories of William the budding actor and intellectual. William, an
actor? Another man shared a story about William's struggle as a pastor to
a congregation. William, a pastor? William had found himself at the center
of a bitter debate about whether homosexuals should be allowed to function
as ordained ministers. As William struggled to find the meaning of his role
in this debate, he had continued to minister to his congregation until the
time that his illness forced him to leave. Many from that congregation sang
in the choir at his memorial service.
I discovered that day that there was a lot I didn't know about William.
As each friend shared his or her story, I found myself smiling through my
tears. I had always thought William to be remarkable, but what I didn't realize
was that I had judged him knowing only the smallest sliver of his life. How
arrogant it was for me to think that because I had shared intimate knowledge
of his illness, I knew the whole man. As a physician one is privileged to
gain a certain intimacy with a patient. What I learned that afternoon is that
our patients always are so much more than just the person we find sitting
across from us in our examination rooms. They are each the sum of a life's
worth of loves and struggles. In caring for each patient, our task demands
that we respect the limits our patients place on revealing their lives to
us, while never forgetting that often we get only the briefest glimpse of
those lives. It is by recognizing that we tend to the person who exists both
inside and outside of our encounters with them that we provide our best care.
I think of William often. I find myself missing him when I arrive at
my continuity site. It is then that I think about who will be on the schedule
that day, and I remember that his name will not be among those on the list.
I hesitate to invoke the cliché that our patients are our teachers,
but, I'm left with no more appropriate description of what William's relationship
was to me. And he, like all of my great teachers, has left me with knowledge
that I will carry with me for my entire life.
Joel Schofer presented well the ethical controversy surrounding use
of unapproved agents for chemical and biological warfare defense in Operation
Desert Storm.1 Such dilemmas are not new,
however, nor the risks purely ethical or medically theoretical. They occurred
several times during World War II, the most dramatic and sobering being the
yellow fever vaccine incident of 1942.
In January 1942, immediately after Pearl Harbor, the US military decided
to vaccinate all active duty personnel with yellow fever vaccine. This decision
was based largely on the fear that an enemy power would launch a strategic
biologic attack by releasing a virulent virus in areas that harbored the vector.
The area at risk included vital areas of the United States: much of the East,
Midwest, and South and southern California. It also included essentially all
overseas combat areas: China, the Pacific islands, Australia, India, Burma,
southern Britain, coastal France, the Mediterranean area, and the southern
Soviet Union. The army had since January 1941 already addressed possible accidental
transmission of the virus from endemic areas by selective vaccination, fumigation,
Concern regarding biological attack was well founded. From 1932 to 1945
the Imperial Japanese Army undertook a massive and ethically horrific program
to develop biological weapons. The United States became aware of this effort,
sought intelligence, and took the threat seriously. The FBI investigated repeated
overt and covert attempts by Japan to obtain virulent yellow fever virus in
In 1942, all military personnel received typhoid, smallpox, and tetanus
vaccines, and soldiers who refused vaccination were subject to court-martials—a
military legal principle originating in World War I and continuing to this
day.4 However, during World War II, a yellow
fever vaccine had not yet been licensed for civilian use in the United States
and an FDA-approved vaccine would not be available until 1953. The yellow
fever vaccine used in early 1942 contained human serum, and despite earlier
published reports of unexplained or "homologous serum" jaundice occurring
after its use, the perceived urgency of the biological weapon threat propelled
this vaccine into use. Unfortunately, many lots were contaminated by the hepatitis
B virus. An epidemic of unexplained hepatitis began in March 1942, and yellow
fever vaccination was halted on April 15, 1942. Approximately 51,000 military
personnel with symptomatic hepatitis were hospitalized, and subsequent serologic
investigation of veterans concluded that approximately 330,000 persons had
This is the largest point source outbreak of hepatitis B ever recorded.
Although chronic hepatitis following yellow fever vaccination was recognized,
the vaccinated soldiers have fared surprisingly well: on follow-up they have
an unexpectedly low carrier rate and no increase in death from chronic liver
disease. They have, however, a small excess in deaths from liver cancer.6
Of course, in 1942 the principles of the Nuremberg Code (1947) had not
yet been formulated, nor had the US military officially adopted them as policy
(1953).7- 8 Although modern
codes of medical ethics did not exist to restrain the use of unlicensed vaccines
by the military, the tens of thousands of iatrogenic casualties from the yellow
fever vaccine experience may well have had a chilling effect on further use
of other experimental vaccines.
In fact, in 1944 an erroneous report of Nazi weapons using botulinum
toxin was taken seriously by the US government, and in response a crash program
produced enough unlicensed botulinum toxoid to immunize the entire D-day assault
force. Despite strong recommendation by the US Army Surgeon General to immunize
all personnel before the Normandy invasion, the theatre surgeon, responsible
directly to Eisenhower, opted to hold the toxoid in stockpile.9
Ironically, during Desert Storm large-scale administration of this toxoid
had to await the formal informed consent process.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and
Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early
dhildhood mortality and growth failure data and their association with maternal
Thank you for submitting a comment on this article. It will be reviewed by JAMA editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more
Subscribe for full-text access to content from 1998 forward and a host of useful features
Activate your current subscription (AMA members and current subscribers)
Purchase Online Access to this article for 24 hours
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 1
Customize your page view by dragging & repositioning the boxes below.
and access these and other features:
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.