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Letter from the Dean
So Far, So Good

I am pleased to introduce the Winter 2011 edition of Brown Medicine from snowy Providence.

On a recent cold Friday afternoon,I walked through the new Medical School building. The workmen and women featured in these pages are doing an outstanding job.

Almost all the windows are in place, the framing of the rooms has been done, and the drywall is about to be put up.You can clearly see where the auditoriums, academies, seminar rooms, and anatomy suites will be. I started to imagine our students in August, walking down the student commons(atrium), going into the lecture rooms and other classrooms.They will be studying and relaxing in their Academy spaces.We hope to have the fourth-floor terrace open, too, where in the nice weather they can enjoy the view of the city and College Hill.

The opening of the building in August 2011 will begin a new era for Alpert Medical School, Brown University, and the City of Providence. So far, cross our fingers, we are on budget and on schedule.This edition also highlights some of our outstanding faculty who focus their research on end-of-life care.This area is under appreciated and under studied in our universities. The quality and cost of medical care in both hospitals and nursing homes is of vital interest to our culture. For example, a very high percentage of our health care dollars goes to providing acute care in our hospitals during the last six months of life. Our society's approach to end-of-life care can be exemplified by hospice and other programs. Many of these programs are outstanding,
others are not, and in many cases people have no access to organized end-of-life care. The scholars at Brown lead the field in analyzing our current situation and in coming up with solutions and policies to improve these areas.
Letter from the Editor
Rage, rage

What could be more personal--or more fundamentally important--than how we think about dying? Listen closely to what people say about death, after all, and you'll hear what they think about life. And since so many of us are likely to be faced with some decision making about how we or someone we love dies, the question bears contemplating.

I was with my father when he died, of lung cancer. While I remember that experience as entirely terrible and sad, Kris Cambra's article reminded me that there were some positives. He was home with his family. He had "fought" as much as he wanted and stopped fighting at a point that was right for him. And we all benefited from hospice care. I couldn't tell you the name of my father's oncologist or what he looked like, but I do  remember the hospice nurse--her sensible clothes and noiseless shoes, her kind voice and the way the lenses of her glasses glinted when she talked. Her wise and quiet presence.

The thoughtful people quoted in the article also made me realize that often when we talk about our wishes we address the issue only at its most obvious and least nuanced. Of course I wouldn't want to be kept alive if I couldn't breathe on my own, we might think. But what if you could breathe but not swallow? Breathe and swallow but not talk? Would you tell that to your kid?

A happier memory of my father: we have made the annual trek to New England. The Boston skyline looms. Driving through the city in our Ford Esquire station wagon, my father, who worked for Pittsburgh Plate Glass, points out a gleaming skyscraper. "That's PPG glass in that building," he says proudly. This  happened more than once during my childhood, in different cities, and I always shared my dad's pride. I also inherited his admiration and respect for the hardworking people who built the buildings. So of course it was a thrill to visit the construction site of the new Medical School, and meet some of the workers and watch and listen and sidestep and generally try not to get in the way. It's a special honor to include them in these pages.
Letters to the Editor
He Begs to Differ

I am writing this letter in strong opposition to Dean Wing's vision of the future of medicine ("A New Day?"
Fall 2010).

The facts are accurate. My bone of contention has to do with the "employment by larger organizations, as opposed to the historic solo or small group practices." Our group practice sets out to provide high quality obstetrical and gynecologic care. [We employ] five board certified ob/gyns, splitting expenses, with one of the five acting as "laborist"each and every day.

We are physicians, but we are also small business owners providing a valuable service to our community. This is called competition. We are not the only group practice in Harrison County, and women can choose to take their business (of their own health care) elsewhere. We also can choose to change the hospital we take our patients to, because we are not owned by anyone.

Interest rates and real estate prices are both rock bottom, and physicians have a golden opportunity to embrace competition, and thereby enhance the quality of medical care for patients. The model of physician-owned multispecialty groups is far more attractive than hospital-owned practices that act like Walmart.

Lastly, just what is wrong with doctors focusing on cash flow, malpractice or office operations? We spend all
day caring for patients in an office; why wouldn't I want to own the office? If the secretary is continuously rude to patients at the front desk, I can choose to fire her and hire someone else more pleasant. When patients complain about the care they receive, the owners of the business are immediately aware of the unfiltered complaint. In short, we like being the boss!

Dean Wing is entirely correct when he discusses teams of health care providers; however, every team needs a quarterback. The all-knowing, autonomous "perfect" doctor is what we should all aspire to be. When a patient crashes at 3 a.m., every team needs its leader to buckle up the chinstrap and take over ... and that burden will always fall on us, the physicians.

John F. Pappas
Gulfport, MS

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