Pulse

THE MEDICAL STUDENT SECTION OF JAMA

Medical Student Mistreatment

Breaking Bad News to Patients

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 Pulse Membership Has Its Costs
Co-Editors
Francis S. Lee, University of Michigan Medical School
Amy D. Crawford-Faucher
Medical College of Pennsylvania
No one will dispute that medical self-reports of mistreatment is to
Francis S. Lee
University of Michigan Medical School training is a demanding, arduous consider them in the context of
process with inherent stresses. As the the broader medical environment.
Senior Editors least experienced members in the By stepping back to consider the
Mark D. Fox, MA medical hierarchy, medical students entire social and educational milieu
Vanderbilt University School of Medicine are particularly vulnerable to that medical students are placed in,
feeling
the rigors of clinical training. Adding one may gain fresh insights into the
Preeti N. Malani, MSJ
Wayne State University to the tensions of training, a growing high rate of perceived mistreatment
School of Medicine literature suggests that medical or abuse.
students are subjected to disturbing A metaphor commonly used to
Associate Editors levels of verbal and physical mistreat¬ describe the institution of medicine is
Arlrian G. Battoli, MS ment as well as sexual harassment.1 "3 that of an exclusive, private club or
UCLA School of Medicine
Most studies of medical student guild. To gain entrance and accep¬
Beverly M. Calkins, DrPH abuse use self-reported surveys and tance within the guild one has to go
Loma Linda University School of Medicir anecdotal accounts, which have inher¬ through a series of hidden, punitive
ent limitations. Still, the consistent rituals that would ostensibly confirm
Gregory R. Schwartz finding that a majority of medical the ability of new members to with¬
Yale University School of Medicine
students perceive themselves under¬ stand the demands of a guild career.
Stephen G. Schwartz going some form of mistreatment or To reveal or resist these rituals would
New York University School of Medicine abuse must be taken as a serious and lead to rejection from the guild.
Art Editor
startling indication of the nature of Medical students and residents
medical training. In one longitudinal have published accounts suggesting
James D. VanHoose study, self-reported incidents of abuse that such an atmosphere of hostility
University of Kentucky correlated positively with the develop and exploitation is acceptable in
College of Medicine
ment of psychopathology such as the training process.8"10 The use of
¡AMA Staff depression and escape drinking.4 humiliation, rejection, and alienation
Charlene Breedlove In this issue of Pulse we add to the in these punitive hazing rituals is
Managing Editor growing body of research on medical readily observable by insiders during
Kate Whetzle student mistreatment a study by undergraduate and graduate medical
Production Uhari and colleagues5 of Finnish training. In this context, it is under¬
medical students given the same ques¬ standable why medical students
AMA-MSS Governing Council tionnaire used in many US studies of report such high levels of mistreat¬
Elaine Holstine, Chairperson medical student abuse. Similar to that ment in anonymous questionnaires,
Heidi Dunniway, Vice Chairperson observed in US studies, the majority
Stephen Bayles, Delegate yet few report mistreatment to their
Anneke Schroen, Alternate Delegate of Finnish medical students reported medical schools.2-3
Amber Chatwin, At-Large Officer episodes of mistreatment, including The broader question remains
Thomas Dalagiannis, Speaker a high rate of sexual harassment why such an environment of accept¬
Charles Rainey, Vice Speaker of female medical students. able hostility exists at all. Ironically,
Jane L. Uva, MD,
Immediate Past Chairperson Previous studies in British and most people enter the medical pro¬
Australian medical schools reported a fession to help patients and to treat
Pulse is prepared by the Pulse editors and JAMA lower incidence of mistreatment. How¬ them compassionately, but the educa¬
staff and is published monthly from September ever, these studies used a narrower tional process is imbued with a dehu¬
through May. It provides a forum for the ideas, definition of mistreatment and did not
opinions, and news that affect medical students manizing component. One has to
and showcases student writing, research, and include specific examples in the ques¬ wonder about the implicit lessons our
artwork. The articles and viewpoints in Pulse are
not necessarily the policy of the AMA or ¡AMA. All tionnaire.67 The study by Uhari and teachers are imparting to medical
submissions must be the original unpublished
work of the author. Work submitted to Pulse is colleagues highlights the importance students.
subject to review and editing. of using uniform definitions of abuse In the 1950s the medical educa¬
as well as established instruments to tion process was studied from a
Address submissions and inquiries to Pulse measure self-reports of abuse. descriptive sociological and anthro¬
Editor Amy D. Crawford-Faucher, 3572 New One way to evaluate documented
Queen St, Philadelphia, PA 19129; phone and pological perspective.1112 As any
fax, (215)843-3563. (Continued imp 1049.)
The cover photograph, Mennonite Girl, is by Pulse Art Editor lames D. VanHoose, University
of Kentucky College of Medicine.

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 Medicai Student Abuse: An International Phenomenon
Matti Uhari, MD, Jorma Kokkonen, MD, Matti Nuutinen, MD, Leena Vainionpaa, MD, Heikki Rantala, MD,
Pentti Lautala, MD, Marja Väyrynen, RN, Department of Pediatrics, University of Oulu, Finland
Objective.—To evaluate the prevalence of physical and
psychological mistreatment of medical students at two
medical schools in Finland.
Study Design and Setting.—To enable comparison
between Finnish and American students, we used the
American Medical Association's Office of Education
Research questionnaire.
Results.—Three of every four students surveyed reported
experiencing some kind of mistreatment during their medi¬
cal education. Students most commonly reported sexual
mistreatment, usually as slurs and sexual discrimination,
from classmates, preclinical teachers, clinical teachers,
clinicians, nurses, and patients. Other forms of verbal
abuse, psychological mistreatment, and physical threats
were also reported.
Conclusions.—All forms of mistreatment were reported
occurring less frequently than in the United States; still, the
level of such behavior was high. The results suggest the
need for more international awareness and debate regarding
the habits and behavior of teaching staff in medical schools.
Medical training is frequently a stressful experience that
may lead to alcohol and drug abuse among students,1"3 and
the amount of stress is inversely correlated with academic
performance.4 Among the external factors contributing to
student stress are a lack of administrative responsiveness to
students' needs and an unsupportive learning atmosphere
engendered by attending physicians and a lack of faculty
role models.1
Recendy, disturbing levels of verbal and physical mis¬
treatment of medical students have been reported.25"8 Since
most reports of student abuse come from the United States,
Membership Costs (Continued from p 1048.)
insider on the wards is aware, many private rituals take
place in the training process that cannot be fully examined
with neat, scientifically controlled studies. Descriptive re¬
search on mistreatment of medical students may begin to
flesh out what the various self-reported numbers and anec¬
dotal accounts have been suggesting over the past decade
and shed light on the level and nature of mistreatment.
Let us hope a thoughtful dialogue will emerge that distin¬
guishes those aspects of the ritual-laden "curriculum" that
genuinely enhance medical training from those that are
demeaning and undermine the profession.
References
1. Silver HK. Medical students and medical school. JAMA. 1982;247:309-310.
2. Silver HK, Glicken AD. Medical student abuse: incidence, severity, and signifi-
cance. JAMA. 1990;263:527-532.
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and because there are marked social and educational
differences between European and US students, we used
the same survey questionnaire that had been used in the
United States to discover how students in two Finnish medi¬
cal schools would report their experiences.6-7
METHODS
Since we wished to elicit as fully comparable data as
possible, we used the survey designed by Baldwin and col¬
leagues6 in 1988 and later used by several US researchers.
In translating the questionnaire, we kept the format as
close to the original as possible, omitting only questions
irrelevant to the Finnish medical education curriculum.
We surveyed students in their third and fifth academic
years (the first and third years of clinical work) at two medi¬
cal schools in Finland. After briefly introducing the survey
and its purpose, we distributed the questionnaires following
a clinical lecture. In Oulu, 108 (65.1%) of the 166 students
in these years attended the lecture, and only one did not fill
in the questionnaire. At Tampere Medical School, 148
(80.4%) of the 184 students were present and all of them
completed the questionnaire. This gave a total number of
255 student participants.
Students' ages varied from 21 to 41 years, with a mean
age of 24.9 years. The majority were female (63.9%); 55.5%
were unmarried, 23.8% were married, and 19.5% were
living with a partner. Three were divorced. Many of the
students planned to work as general practitioners (16.8%);
other specialty choices included surgery (11.7%), pediatrics
(7.8%), internal medicine (7.8%), gynecology and obstet¬
rics (7.4%), neurology (5.9%), and anesthesiology (3.9%).
Almost half said their academic performance ranked in the
second best quarter of their class.
The data from the questionnaires were analyzed using
(Continued onp 1050.)
3. Sheehan KH, Sheehan DV, White K, Leibowitz A, Baldwin DC Jr. A pilot study of
medical student 'abuse': student perceptions of mistreatment and misconduct in
medical school. JAMA. 1990;263:533-537.
4. Richman JA, Flaherty JA, Rospenda KM, Christensen ML. Mental health conse-
quences and correlates of reported medical student abuse. JAMA. 1992;267:692\x=req-\
694.
5. Uhari M, Kokkonen J, Nuutinen M, et al. Medical student abuse: an international
phenomenon. JAMA. 1994;271:1049-1051. Pulse.
6. Firth J. Levels and sources of stress in medical students. BMJ. 1986;292:1177-1180.
7. Harth SC, Bavanandan S, Thomas KE, Lai MY, Thong YH. The quality of student
tutor interactions in the clinical learning environment. Med Educ. 1992;26:321\x=req-\
326.
8. Klass P. A Not Entirely Benign Procedure: Four Years as a Medical Student. New
York, NY: Signet; 1987.
9. Reilly P. To Do No Harm: A journey Through Medical School. Dover, Mass:
Auburn House; 1987.
10. Litwin MS. A resident's reflections on medical education. JAMA. 1991;266:926.
11. Becker HS, Geer B, Hughes EC, et al. Boys in White: Student Culture in Medical
School. Chicago, Ill: University of Chicago Press; 1961.
12. Merton RK, Reader G, Kendall PL, eds. The Student-Physician: Introductory Studies
in the Sociology ofMedical Education. Cambridge, Mass: Harvard University
Press; 1961.
Medical Student Abuse (Continued from 1049.)
Windows software (SPSS version 5.0). The differences be¬
tween the frequencies were tested with the chi-square test.
RESULTS
Three of four medical students (74.2%) reported having
experienced some kind of mistreatment during their medi¬
cal education. There were no significant differences in the
frequency of reported mistreatment between the two medi¬
cal schools evaluated.
Sexual mistreatment was reported by 95 students (37%).
Sexual mistreatment by nurses was reported by male
students (5%) and by female students (15%). The most
common forms of sexual mistreatment were slurs and
sexual discrimination (Table 1). Male students reported
harassment from classmates (P<.01), preclinical teachers
(P<.05), clinical teachers, (P<.01) clinicians (P<.01),
and patients (P<.01) more often than female
students (Table 2).
Teachers and clinicians had shouted at about 10% of
the students. One of every four medical students reported
being yelled at or shouted at by nurses; 39% had experi¬
enced nurses being inappropriately nasty, rude, or hostile.
These figures are about twice as large as those reflecting
clinicians' behavior and represent the most common
source of verbal abuse (Table 3).
Patients had yelled or shouted at 24 (9%) of the
students and had been nasty, rude, or hostile to 37 (15%).
Threats of physical violence were rarely made by teachers
or by clinical staff, but patients had threatened 16 of the
students (6%) and had physically attacked 7 students (3%).
Although patients had physically threatened only a few
students, 18% regarded the possibility as a serious problem
in medical practice.
About 15% of the students reported derogatory or of¬
fensive remarks about medicine or the choice of a medical
career, and a fourth of them considered this bothersome.
Derogatory remarks were most commonly heard from
fellow students (25%) and nurses (22%), but also from
family members (17%) and teachers (17%). Only 11% of
students reported hearing clinicians make derogatory
remarks about medicine or a medical career.
Sleep deprivation while studying for courses was
reported by 36% of the students, whereas 67% experienced
sleep deprivation while preparing for examinations. Two
thirds of the students regarded loss of sleep as an unneces¬
sary aspect of medical training, 54% thought it had no
value for learning, and 45% felt that doing without sleep
had sometimes impaired their ability to care for patients.
COMMENT
Reports of abuse during medical education were surpris¬
ingly common among the medical students surveyed, since
almost 75% had experienced at least one episode of mis¬
treatment. In the study by Baldwin and colleagues8 the
figures for various forms of mistreatment were generally
three to five times higher than ours, and US students
reported worse experiences with clinical teachers and clini¬
cians than with preclinical teachers. In a study by Silver
and Glicken,5 which surveyed all students at a US medical
school in 1985, respondents reported most abusive experi-
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Table 1.—Frequencies of Different Forms of Sexual Mistreatment
Reported by Female Students (n=163)
Form of Sexual Female Students
Mistreatment %
Denied opportunities 19 12
Sexual reward 1 1
Advances 12 7
Slurs 52 32
Malicious rumors 2 1
Other sexual discrimination 38 23
enees during their junior year, ie, during the first clinical
contact. More than two thirds could recall one episode
from that year. Of those who had been abused or mis¬
treated, 70% had experienced at least one episode they
considered "of major importance and very upsetting."
In three British medical schools 34% of the fourth-year
students described relations with consultants as most stress¬
ful because they felt humiliated in front of their peers.3
Relations with academic staff (13%) and clinical staff
(11%) were less often reported to be particularly stressful.'
The fact that students recalled most negative experi¬
ences from their first clinical year is understandable—it was
the first time they were taking responsibility for patients. As
most students had anxiously awaited that opportunity for
years, and many had no prior patient contact whatsoever,
some disappointment was unavoidable. Since their clinical
self-esteem is not firmly established, students may easily
blame their teachers or clinical staff for their first problems
with patients or even for what they feel to be their psycho¬
logical failures.
Sheehan and colleagues7 reported verbal abuse directed
toward students to be equally dispensed from nurses, clini¬
cians, clinical teachers, and patients; whereas in our study
the nurses were clearly the most common source of verbal
abuse. Conceivably, medical students found it easier to
report derogatory comments made by nurses than those
made by physicians; more likely, the results reported here
reflect problems in professional relations between nurses
and physicians and nurses' felt need to exercise control
over "young doctors." We found no differences between
male and female students in their experiences with nurses,
contrary to Spiegel and colleagues,9 who reported more
conflicts involving women than men.
Sexual harassment and mistreatment were considerably
less frequent in Finland than in the United States.6·7 The
tradition of women working outside the home in Nordic
countries, and a recent increase in the proportion of
women in medical schools may have led to their greater
acceptance as medical students. Even so, 37% of students
reporting some kind of sexual mistreatment is high, show¬
ing that sexual mistreatment is a problem in medical educa¬
tion in Finland, too. Women's consistently higher stress
scores may also be due to the more frequent sexual mis¬
treatment of female students.9
Although sleep deprivation is a major Stressor during
residency training,10 Finnish students reported it less than
Table 2.—Frequency and Source of Episodes of Sexual Harassment or Mistreatment Reported by Female (n=163) and Male (n=92) Students
_Rarely I
Sometimes Often
I
Female Male Female Male Female Male
Source of Abuse (%) (%) (%) (%) (%) (%)

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

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

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

Clinicians 28(17) 0 11 (7) 4(3)
Nurses 13(8) 2(2) 8(5) 3 (3) 4(3)
Patients 26(16) 4(4) 6(3) 2 (2) 2(1)

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

Type of Abuse Preclinlcal Clinical Clinicians Nurses

(%) (%) (%) (%)

Verbal abuse
Yelled or shouted 33(13) 28 (11) 23 (9) 61 (24)

Nasty, rude, or hostile 51 (20) 74 (29) 54 (21) 100 (39)

Psychological mistreatment
Assigned tasks as punishment 18 (7) 15 (6) 15 (6) 15 (6)

Took credit for your work 10 (4) 5 (2) 8 (3) 23 (9)

Unjustifiable bad grades 15 (6) 5 (2)

Physical threats or abuses

Threatened with physical violence 13 (5) 10 (4) 5 (2) 3 (1)

Subjected to physical violence 0 3 (1) 3 (1) 18 (7)

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

did their US counterparts, all of whom had experienced References

sleep deprivation on clinical rotations.7 Students do not
have night duties during clinical rotations in Finland and
did not feel that a lack of sleep impaired their ability to
care for patients as often as did US students.
The fact that only about one tenth of the medical stu¬
dents had experienced verbal abuse from patients reflects
the social respect patients in Finland generally have for the
medical profession. Patients understand that they are being
examined by medical students and accept that they are
object lessons for teaching.
The number of medical students reporting abuse in
Finland, the United States,3-5 and Britain8 " indicates that
although the prevalence and forms of student abuse vary,
the phenomenon is common. Even if all the experiences
reported here and elsewhere were merely single, isolated
episodes, the cynical attitudes of the clinical staff toward
students and toward medicine in general are alarming and
require a response.2,78 We need to press for more interna¬
tional awareness of the climate endorsed in medical educa¬
tion and more debate on the subject.
1. Lloyd C, Gartrell NK. A further assessment of medical school stress. Med Educ.
1983;58:964-967.
2. Richman JA, Flaherty JA, Rospenda KM, Christensen ML. Mental health
consequences and correlates of reported medical student abuse. JAMA.
1992;267:692-694.
3. Firth J. Levels and sources of stress in medical students. BMJ. 1986;292:1177\x=req-\
1180.
4. Spiegel DA, Smolen RC, Hopfensperger KA. Medical student stress and clerkship
performance. Med Educ. 1986;61:929-931.
5. Silver HK, Glicken AD. Medical student abuse: incidence, severity, and
significance. JAMA. 1990;263:527-532.
6. Baldwin DC Jr, Daugherty SR, Eckenfels EJ, Leksas L. The experience of
mistreatment and abuse among medical students. In: Research in Medical
Education. Proceedings of the 27th Conference. Washington, DC: Association of
American Medical Colleges; 1988:80-84.
7. Sheehan KH, Sheehan DV, White K, Leibowitz A, Baldwin DC Jr. A pilot study
of medical student 'abuse': student perceptions of mistreatment and misconduct
8.
in medical school. JAMA. 1990;263:533-537.
Baldwin DC Jr, Daugherty SR, Eckenfels EJ. Student perceptions of mistreatment
and harassment during medical school: a survey often United States schools.
9.
West J Med. 1991;155:140-145.
Spiegel DA, Smolen RC, Jonas CK. Interpersonal conflicts involving students in
clinical medical education. Med Educ. 1985;60:819-829.
10. McCue JD. The distress of internship: causes and prevention. N Engl J Med.
1985;312:449-452.
11. Wolf TM, Randell HM, Alen von K, Tynes LL. Perceived mistreatment and
attitude change by graduating medical students: a retrospective study. Med Educ.
1991;25:182-190.

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 Breaking Bad News to Patients
Margaret L. Campbell, RN,
Delivering bad news is a difficult and unavoidable responsi¬
bility for medical practitioners. Students may have limited
exposure to this sensitive and demanding task, and few
health care professionals have had formal training in this
area.1 The following strategies for health care providers
may prove helpful.
Prepare in Advance
What do the patient and his or her family already know
about the patient's diagnosis and prognosis? Is this new
information, or is it building on previous conversations?
How have the patient and family coped with the hospitaliza-
tion, diagnostic workup, and earlier meetings? Are there
support people in the patient's social network, or will
hospital personnel fulfill that role?
Reading the chart, especially the detailed nursing notes,
may answer these questions and provide clues to the
patient's concerns and questions. Review earlier conversa¬
tions with the patient or family before sharing new informa¬
tion. The presence of a support person—from either the
patient's social network or the hospital—should be sought
in advance. The patient's nurses, hospital social workers,
chaplains, and medical students who know the patient well
can provide this support.
Practical aspects also need to be considered. Arrange a
mutually convenient time for the meeting, considering the
patient's care schedule, level of fatigue, and availability of
supports. Schedule the meeting for a time of day with few
interruptions, or hand off your beeper to a colleague for
the duration. These meetings may require up to an hour,
depending on the complexity of the news being conveyed,
and on the preparedness of the patient and the family.
Establish a Therapeutic Environment
Sensitive information will be shared more readily and
effectively if the discussion occurs in a private, quiet setting.
Consider asking an ambulatory patient roommate to leave
for a time, or moving the patient and family to another
area for the meeting—preferably a space with a closed door
and sufficient seating for all concerned. If the patient and
family are seated, the person delivering the news should
also be seated to minimize the physical and psychological
distance. Avoid artificial barriers such as desks and tables
between the provider, patient, and family. Also, sit close
enough to the patient so that you can easily be seen and
heard and so that you can extend a comforting touch to
the patient's shoulder or hand if appropriate.
No matter how difficult a challenge for the provider, the
information delivered must be honest, reliable, and com¬
prehensible. The health care provider must avoid euphe¬
misms, jargon, and acronyms, as most patients are not
familiar with medical terminology.
Euphemisms for dying are often employed to make the
news more comfortable for the speaker. These
ambiguities
block effective understanding and impair subsequent
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Detroit Receiving Hospital
discussions and decisions, as this dialogue illustrates:
Physiaan: 'Your mother's condition is deteriorating and
we don't expect her to do very well."
Family: 'Thank you, Doctor, we know you are all doing
your best."
Family to each other. 'Thank goodness, he didn't say
she's dying."
A direct approach that prepares the patient and family
without misleading them is best. Prefacing your remarks
with "I'm afraid I have bad news" is a simple yet effective
way to introduce the subject.
Dealing With Patient and Family Reactions
Patients and families react differently to bad news,
depending on their preparedness, culture, and coping
skills. Initially they may remove themselves, either physically
or emotionally, from the discussion to avoid hearing any
more. The patient or family may become openly hostile
and aggressive at the news; it is important not to personal¬
ize their response or to react defensively. Supportive replies
from the health care provider may calm them; "I know this
news can make you angry, but I want to help."
They may display anticipatory grief, characterized by
somatic distress, guilt, preoccupation with the patient,
emotional displays, and dysfunctional conduct.2 These are
normal grief reactions and should not be suppressed.
The patient and family may challenge or question the
information, which should be viewed as a need for more
information and not as a challenge to the integrity of the
messenger or the validity of the news. Denial may indicate
the patient or family's inability to accept the news and is a
common coping strategy. Again, avoid defensive responses.
Repeat the information, ask the patient and family to
explain their understanding of the situation, and then
clarify any points of confusion.
The patient or family may calmly accept the news. They
may have been anticipating the news and feel prepared for
it. On the other hand, they may not have understood the
news and may be unable to articulate their lack of under¬
standing, or they may be shocked into passivity. Acknowl¬
edging their reaction, "I notice that you are taking this
news very calmly; many people react differently," may elicit
an explanation.
Additional meetings with the patient and family are
often required. Patients may need information repeated
since the initial shock of the bad news can interfere with
their attentiveness and comprehension. These simple yet
important points may make a difficult and necessary task
a little easier.
References
1. Quill TE, Townsend P. Bad news: delivery, dialogue, and dilemmas. Arch Intern
Med. 1991;151:463-468.
2. Lindemann E. Symptomatology and management of acute grief. Am J Psychiatry.
1944;101:141-148.
 Epilogue
Adam J. Ratner, Columbia University College of Physicians and Surgeons

Anton was right, I suppose. He said it would get all of
us, that it was going to empty out the city. So I went to St
Luke's, not Sinai, because Anton and Rachel both got
theirs at Sinai, and I was born at St Luke's. Anyway, that
didn't stop them from giving me the yellow paper, the
middle copy of my triplicate death sentence. It didn't even
bother me, almost like I expected it. Then they wanted me
to hang around, go through their counseling and find out
that I can't get into any of the drug trials until I'm so sick
that it doesn't matter. I walked out, though. Walked out the
front door, with my yellow paper in my pocket.
We used to listen to the doctors. When Anton was in the
hospital the first time and finally got into the ddl trial, he
had to sign a consent form. He asked the doctor, some pale
kid with a shiny stethoscope, what the initials stood for. The
kid fumbled for a while, then admitted that he didn't know.
So I was going to stay there and let them counsel me and
tell me it's okay to be angry and it's okay that I can't get
treatment because they don't know what's going on?
Thanks, I had better things to do.
So I went across the campus to get to Broadway. A pan¬
ther smile on the face of a homeless man reminded me of
Anton. That bookstore where we met was only a block away,
but I kept walking. The Saturday morning line at Zabar's
fish counter was huge, but I took a number and looked
around, remembering when the pots and pans and orange
So Ibought my lox and I stopped to buy bagels—six
sesame and six poppy, but by the time I got home the seeds
would all be mixed. I thought about Rachel. She was really
the one who took care of Anton. Since the day she
announced she was moving in, she kept Anton and me sane,
kept us from staying out too late and killing ourselves or each
other. She used to run in the park every day, but once he got
sick she would run straight to the hospital. I would see her
there later, sitting next to his bed, wearing her green tights.
Rachel used to say that she just hoped she got it last, so
she could take care of me. I told her that by the time we
got it there would be a cure, that it wouldn't matter.
At Anton's funeral she told me she wanted to get tested
again—she needed to know. Then she put her head on
my shirt and it got wet, and I put my arms around her,
and they buried Anton.
When Rachel got her yellow paper, she said she felt worse
for me because I was last. Then she went out for a jog and
came back in 3 days. Anyway, they buried her Monday and
now I have mine.
I walked the extra blocks to the record store and found a
Gershwin album because both of them loved Gershwin.
There was this really huge line at the counter, but I felt the
paper in my pocket and pushed to the front of it.
In the apartment, I put on the album and carefully sliced
one of the sesame-poppy bagels. I toasted it and put more

juicers used to hang from the ceiling and my hair could just
touch the bottom of some of them. The coffee grinders
whirred and sent off their morning smell, and people
pushed by me, but I just stood there, taking it all in. This
old woman was over by the checkout line screaming at her
husband that he forgot to buy coffee, only he was already
on the other side, by the door. So she started lobbing the
bags of coffee beans over the line to him. He tried to catch
them, but he dropped his hat, then the beans spilled all
over the place and he shrugged and picked up his hat and
walked out the door.
cream cheese and lox on it than I should have. I threw the
paper on the table and watched it slowly try to unfold itself.
I made sure the lights in the rest of the house were off and
the windows shut, and I turned the TV on and the sound off
There were cartoons on, and I like cartoons. So now I'm just
sitting on the old, ratty couch, eating my bagel with too
much lox and cream cheese, and watching cartoons with
Gershwin sound and on the table are my keys and the yellow
paper and a picture of me and Anton and Rachel and in the
closet is our gun and I'm getting the feeling that it's going to
be a very short night.

-
Murmurs -

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

Apply now for the medical student seat on the AMA Women in Medicine Advisory Panel. The panel advises the AMA on
policies and programs that affect women physicians and medical students. Statements of interest and curricula vitae must
be postmarked by April 14. Call the DMSS for further information.

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

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