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Singular Intimacies: Becoming a Doctor at Bellevue. By Danielle Ofri. Boston. Beacon Press. 2003. 240 pages; $24.00.

Like so many physicians, I have always believed that I have an important story to tell about my training experience, if I could just get around to writing it. After reading Danielle Ofri's memoir, Singular Intimacies: Becoming a Doctor at Bellevue, I am happy that she has done justice to what it's like to train at New York City's oldest public hospital. (In the spirit of full disclosure, I should mention that I trained with Ofri at Bellevue.) This book is a powerful and often poignant collection of linked essays that describe her experiences as she grows from a novice third-year student to a self-confident senior resident. Each essay is framed around a significant encounter with a single patient.

In Drawing Blood, Ofri, at that time a third-year medical student on her first rotation, is repulsed when an elderly patient tries to kiss her. Despite having a resident who at least gives lip service to the importance of good doctor-patient communication, Ofri—like most novice students on the wards—does not discuss the disturbing experience with her or with anyone, presumably due to the lack of role modeling for this type of experience. A little later in her training, in Stuck, she suffers a needle stick; here, she does find a person with whom to discuss it and cry about it. The person who comforts her is not a resident or attending but the very patient whose blood now mingles with hers.

From the outset, she yearns to connect with her patients, yet she lacks the skills. In AA Battery, an essay about a stonily quiet prisoner who swallows a battery, Ofri—then a medical student—is initially awed by her intern's speed and ease in diagnosis and management, but quickly realizes that neither the intern nor the GI team has tried to find out why the patient swallowed the battery in the first place. She tries to engage the patient but has no idea how to get the reticent young man to open up. Ofri aptly describes her own awkwardness at the moment. The overwhelming mix of desire to help and the complete lack of knowledge about how to do it is a feeling that will resonate with many students and residents.

Ofri's honesty is one of the most appealing aspects of the book. She is honest about her foibles, her mistakes, her gut instincts that turn out to be wrong, and her fear of appearing foolish in front of her team or a patient. In Positive, she is frank about an unsavory sentiment that many of us have probably shared in some form: when she rotates off a service and is released from bearing witness to a patient's inevitable suffering, she is relieved. In In Charge, she admits to a great dislike for a particularly difficult patient. He tests and baits her constantly and tries to humiliate her in front of her intern. Fed up with his shenanigans and rudeness, she eventually throws him out of the hospital. Though she wins in the end, it's a hollow victory. Yet Ofri still cares about the patient; after all, she devotes a whole chapter to him and continues to wonder about his fate long afterward.

The best essay is Merced. As a cockey and conficent senior resident, cocky and confident, Ofri realizes that medicine is not a science and that mistakes and failures are an inextricable part of it. Without giving too much away, there is a wonderful moment where she realizes that being in touch with her own emotions is the key to good doctoring.

Ofri's descriptions of Bellevue are colorful and accurate—the prisoners, the immigrants, the tourists, the coffee shop, the locked TB wards, the crumpled pink progress notes and other detritus of the filthy call room. Many of her depictions of difficult moments of medical training are unique and right on target: the rude feeling, for example, of being awakened by pager from one of those deep, rare on-call naps in the wee hours in a freezing dirty room to draw blood on an angry patient.

Though Ofri's personal life is not a major part of the book, she writes movingly about a childhood friend, Josh, who suddenly dies in the middle of her training. Right after she learns about his death, she finds herself furious at a patient whose IV is hard to replace and realizes that she is unfairly taking out her anger about Josh on the patient. Josh's death permeates her thoughts about other patients from then on; it's an effective way to show how a doctor's personal life can both interfere and inform, and how it can make us more sensitive and better doctors.

The book has few weaknesses. Parts of some essays read as though Ofri's editor wanted to make sure she included certain aspects of medical training. Though these descriptions of training are generally interesting, they are not always integrally related to the theme of the essay. In a few of the essays, I was left wanting to know more about the patients described.

Overall, though, Ofri (who is also the editor-in-chief of the Bellevue Literary Review) has written compassionately about a number of compelling experiences during her training. Despite her lack of role models, she is smart enough to figure out how to be a caring and effective physician. Physicians, students, residents, and laypeople will not only enjoy a series of absorbing stories but will learn much about the art of doctoring from this book. I am grateful that Ofri has put words to our shared experience as students and residents in that amazing, chaotic universe that is Bellevue.—Anna B. Reisman, MD,Yale School of Medicine, New Haven, Conn.

ATP III Cholesterol Management Implementation Tool for Palm OS. The National Institutes of Health National Heart, Lung, and Blood Institute.

The Cholesterol Management Implementation Tool is a clinical decision aid for personal digital assistants using the Palm operating system.

Reference Information

  1. Top of page
  2. Reference Information
  3. Description
  4. Limitations
  5. Ease of Use
  6. Additional Programs Needed to Run Application
  7. PDA Operating System
  8. PDA Memory Requirement
  9. Overall Rating

The National Institutes of Health National Heart, Lung, and Blood Institute (NHLBI) developed this program to help healthcare providers implement the new Adult Treatment Panel III (ATP III) cholesterol guidelines into their clinical practice. The program is available free of charge from the NHLBI's website: http://hin.nhlbi.nih.gov/atpiii/atp3palm.htm.

Description

  1. Top of page
  2. Reference Information
  3. Description
  4. Limitations
  5. Ease of Use
  6. Additional Programs Needed to Run Application
  7. PDA Operating System
  8. PDA Memory Requirement
  9. Overall Rating

The core of the program is the Interactive Guideline Tool that assesses a patient's 10-year coronary heart disease (CHD) risk and suggests a lipid management strategy. The initial screen of the guideline tool cues users to enter the patient's lipid levels and age. Gender and specific cardiovascular risk factors are entered using check boxes. If needed to calculate CHD risk, the program then asks for the patient's systolic blood pressure and whether or not they are on an antihypertensive. After all data is entered, the program calculates the patient's 10-year CHD risk and recommends a goal LDL level. Tapping the “LDL lowering tx” button on the bottom of the screen displays specific recommendations for lipid management therapy.

The program also contains several text-only ATP III references. Users can access a menu of the available references from the program's start screen or by tapping an [i] icon on any screen of the guideline tool. Each reference is a collection of several screens of useful information grouped by topic. Topics include strategies for implementing therapeutic lifestyle changes, information on classes of lipid-lowering drugs, recommendations for the management of specific dyslipidemias, and a review of the metabolic syndrome.

Evidence Base  The program's content is based on the National Cholesterol Education Program's (NCEP) Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III, or ATP III). The full ATP III report (available at http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3_rpt.htm) cites 63 studies and over 1000 other references. The program uses a Framingham risk scoring equation to calculate 10-year CHD risk. The program does not report the strength of evidence supporting each recommendation.

The NHLBI periodically updates the program to accommodate new versions of the Palm operating system. To date, no one has reported a content error that would require an update. The NHLBI does not plan to change the clinical content of the program unless the NCEP issues new guidelines.

Limitations

  1. Top of page
  2. Reference Information
  3. Description
  4. Limitations
  5. Ease of Use
  6. Additional Programs Needed to Run Application
  7. PDA Operating System
  8. PDA Memory Requirement
  9. Overall Rating

Healthcare providers must be familiar with the ATP III guidelines prior to using the program. For instance, risk factors such as “other atherosclerotic dz” and “Fm Hx early CHD” are not clearly defined on the check box screen, and users must know what qualifies for these categories.

Ease of Use

  1. Top of page
  2. Reference Information
  3. Description
  4. Limitations
  5. Ease of Use
  6. Additional Programs Needed to Run Application
  7. PDA Operating System
  8. PDA Memory Requirement
  9. Overall Rating

The NHLBI's website includes helpful instructions for downloading the ATP III software and MathLib.prc. Once downloaded, installing the software to the handheld device requires double-clicking the files and then performing a HotSync. The Interactive Guideline Tool is intuitive and easy to follow. “Back” buttons are included on every screen in case a data-entry error is made. Ease of use could be improved by adding pop-up boxes of definitions for specific cardiovascular risk factors. Although the menu of ATP III references can be accessed from the [i] icon on any screen of the program, turning lipid management recommendations into hotlinks to related ATP III references would improve usability further.

Additional Programs Needed to Run Application

  1. Top of page
  2. Reference Information
  3. Description
  4. Limitations
  5. Ease of Use
  6. Additional Programs Needed to Run Application
  7. PDA Operating System
  8. PDA Memory Requirement
  9. Overall Rating

MathLib.prc must be installed on the PDA device. MathLib, a free shared library of math functions for Palm OS applications, is available at www.radiks.net/~rhuebner/mathlib.html. Users will need an unzipping utility (such as PKZip or WinZip for Windows, StuffitExpander for Mac OS) to “unzip” the downloaded MathLib file.

PDA Operating System

  1. Top of page
  2. Reference Information
  3. Description
  4. Limitations
  5. Ease of Use
  6. Additional Programs Needed to Run Application
  7. PDA Operating System
  8. PDA Memory Requirement
  9. Overall Rating

Users must have Palm OS v2.0 or greater. NHLBI warns that the program may not work with Palm OS 5 (NHLBI is working on an update). Currently, the program is not compatible with Windows CE (Pocket PC) devices.

PDA Memory Requirement

  1. Top of page
  2. Reference Information
  3. Description
  4. Limitations
  5. Ease of Use
  6. Additional Programs Needed to Run Application
  7. PDA Operating System
  8. PDA Memory Requirement
  9. Overall Rating

A minimum of 343 KB (for the ATP III program) plus 50 KB (for MathLib) is required to install and run the program.

Overall Rating

  1. Top of page
  2. Reference Information
  3. Description
  4. Limitations
  5. Ease of Use
  6. Additional Programs Needed to Run Application
  7. PDA Operating System
  8. PDA Memory Requirement
  9. Overall Rating

4½ stethoscopes (using a 5 stethoscope scale)—David P. Miller, Jr., MD, Wake Forest University School of Medicine, Winston-Salem, North Carolina.