Tonight the New York Times reported on very sad story about an Australian woman who went to a self-help course called Turning Point with her husband in hopes of improving their marriage. Over the next few days, according to her husband, her behavior became increasingly strange until without warning, she jumped out of her office window and successfully committed suicide while stunned paramedics watched unable to move fast enough.

According to the article, the Turning Point program by People Knowhow run by unlicensed staff and includes group induction of hypnosis and/or regression where persons in the audience are encouraged to imagine themselves as children and encouraged to re-experience trauma.

Hypnosis and regression are powerful therapeutic techniques I have come to respect. One of my training experiences included a demonstration of group hypnotic induction. Most in the audience were thoroughly amazed including myself because in no way did we cooperate with an induction. We didn't even know it happened until we went on break and became acutely aware of the change in perceptions in the beautiful atrium of the hotel.

After the break, the workshop leader told the story of the previous conference he taught when a woman in the class was found after the break psychotic and nearly incoherent. The leader had to suspend the conference while the woman was hospitalized. Gradually, the reality of what happened dawned on me. The workshop leader, though highly regarded, was taking an unnecessary risk with conference attendees. Although, such an extreme reaction may be rare, in my experience, the techniques are so powerful that it is necessary to screen participants in this sort of workshop. But according to an inquest now in progress in Sydney, leaders had no relevant formal qualifications, the screening process to complete the course, and the support offered during and after the course as "woefully inadequate".

A member of the volunteer support staff present during the five-day Turning Point program attended by Ms Lawrence told the inquest the course was like a "pressure cooker".

This program uses techniques that should be reserved for intensive treatment programs like the one where I work. We screen people with a complete diagnostic work up, and then work with them intensively six hours a day for 16 days. I have witnessed amazing progress in some people. But without a daily intensive setting with psychiatric staff readily available, I would never attempt this sort of work with people who are already unstable. While it may be true that most healthy people could benefit from this sort of fearless self-review, some people cannot readily integrate this sort of experience.

There have been three deaths associated with this program, the first 18 years ago in a group lead by the program's founder, Walter Belin.

These deaths were avoidable.

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Apparently, one of his previous counselors has spoken up anonymously. I believe that confidentiality is still required despite the client now being deceased. Duley spoke of her court case for a restraining order.

We also get more details of Ivin's drug and alcohol abuse. Mental illness and drug abuse makes both problems much worse.

WaPO

Ivins was abusing vodka, sleeping pills and anti-anxiety medication, according to a fellow scientist who is in recovery from addiction. The scientist told a Washington Post reporter that he was in contact with Ivins through Ivins's two stints in psychiatric and detox facilities this spring.

Ivins's psychiatric problems and homicidal threats predated Duley [his most recent therapist], according to a counselor who saw Ivins for four or five sessions in 2000 at the same Frederick clinic. In an interview with The Post last week, the counselor, who spoke on the condition of anonymity, said that the scientist was obsessed with a young woman and had "mixed poison" that he brought when he went to watch her play a soccer game. The counselor contacted the Frederick police but was told that unless Ivins had provided the full name of his intended victim, there was little that could be done.

More information in the anthrax case have emerged, questions about security of US weapons development, the story of his last couple years under the FBI investigation, and details about Dr. Ivins psychiatric condition in the past year and his treatment.

Associated Press

Privacy concerns, bureaucratic loopholes, the demands of a criminal investigation -- all combined to let Ivins keep his job and stay out of jail for years. And in the high-security lab until last November.

Or was it just that the government's evidence was too weak to act? That's what Ivins' attorney says.

"If it's such earth-shattering stuff, what's been going on since 2005?" Paul F. Kemp asked Wednesday after the government made its case with a news conference and a pile of documents. "Why is he on the street if they think it's that important?"

That question goes beyond the criminal investigation. It goes to the heart of how secure the nation's nearly 1,400 biological defense labs are and whether the estimated 14,000 scientists working with deadly toxins are being screened for the kind of mental illness Ivins exhibited.

The Army Medical Research Institute of Infectious Diseases, known as USAMRIID, follows strict security measures meant to weed out troubled scientists. It has offered no explanation for why Ivins was allowed to work with some of the world's most dangerous toxins while taking antidepressants and receiving counseling to control his inner demons.
[..]
It wasn't until November 2007, after the FBI raided his home, that Fort Detrick revoked his laboratory access, effectively putting him on desk duty for the past year.

"If he really was the guy and he acted alone, then that's pretty scary because that's a lot of damage that can be done by one person," said Gigi Kwik Gronvall of the Center for Biosecurity at the University of Pittsburgh Medical Center. "USAMRIID is not like being in a shack in the wilderness. It's interacting with people in a pretty secure place."

Anything Ivins discussed with his therapists, doctors or at Alcoholics Anonymous meetings would have been protected by privacy policies. But David Fidler, an Indiana University law professor and expert on biosecurity, said he didn't understand how a scientist spending late nights in a secure lab could go unnoticed.

Ivins' explanation -- that he wanted to escape a troubled home life -- should have also raised questions.

"Didn't his superiors notice this odd behavior?" Fidler said. "That ought to have set alarm bells ringing."

It's unclear from the documents whether those bells went off, and the military has not said how long it knew of Ivins' problems. Mental health reviews are a key part of the military's security program, but at least one former colleague at Fort Detrick has said it's usually up to scientists themselves to report their problems.

Ivins had no trouble purchasing weapons. Jack Moberley, manager of The Gun Center in Frederick, Md., said he sold two Glock pistols to Ivins in 2005. The following year, Ivins traded in one of those guns and bought a different Glock, Moberly said.

Moberley said Ivins had passed the background check conducted by the Maryland State Police. "If I even suspected that he was anywhere close to being mental, I would not have done the paperwork at all. The state of Maryland approved him," Moberley said. "No gun gets out of here unless there's a background check."

Lawmakers have pledged to investigate the anthrax case and lab security generally. Bills in the House and Senate would order a review of how scientists work with deadly toxins.

"If we don't have a good handle on this at USAMRIID, it's probably true we don't have a good handle on it across the board," Fidler said.

Clearly this has stirred a hornets nest within the security community and probably among all employers concerned about having a dangerous person in their midst. The chance of this situation doing damage to an already delicate perception of mental illness by the general public is very high.

And we have more information about his therapist and his treatment in the last year.

Associated Press

Bruce E. Ivins, the late microbiologist suspected in the 2001 anthrax attacks, told his psychotherapist after learning he was about to be indicted that "he was going to go out in a blaze of glory, that he was going to take everybody out with him," she said.

Social worker Jean C. Duley also said Ivins left her a telephone message in mid-July, after she had alerted police to his threats, telling her that that her actions had made it possible for the FBI "to now be able to prosecute him for the murders."

Duley testified at a Frederick County District Court hearing July 24 in a successful bid for a protective order from Ivins. The New York Times obtained a recording of the hearing and posted on its Web site Saturday.

Duley testified that Ivins had tried to poison people even before the 2001 attacks.

"As far back as the year 2000, the respondent has actually attempted to murder several other people, either through poisoning ... He is a revenge killer. When he feels that he's been slighted or has had -- especially toward women -- he plots and actually tries to carry out revenge killings," Duley said.

She added that Ivins "has been forensically diagnosed by several top psychiatrists as a sociopathic, homicidal killer. I have that in evidence. And through my working with him, I also believe that to be very true."

Duley told the judge she was "scared to death" of Ivins.

Duley told the court that she had known Ivins for six months and had been meeting with him for group sessions weekly and for individual counseling every other week.

She said that on July 9, Ivins showed up for a group session "extremely agitated, out of control." She said that when she asked him what was wrong, he said he had obtained a gun and described to the group "a very long and detailed homicidal plan" to kill his co-workers.

Duley said she called Ivins' two lawyers and the city police, who went to Ivins' workplace and had him committed to Frederick Memorial Hospital for a psychiatric evaluation.

She said Ivins was transferred the next day to a high-security, psychiatric treatment center and placed on "homicidal and suicide watch."

Duley said Ivins' scheduled release from the hospital on the day of the hearing prompted her to seek the protective order.

Duley said that on July 11, Ivins left her two ranting voice messages, blaming her for his commitment.

On July 12, he left another "rather scary" voice message from a hospital in which "he very calmly thanked me for ruining his life and opening -- allowing the FBI to now be able to prosecute him for the murders, and that it was all my fault and it's going to be my fault that they can now get him."

It appears that Ivins was a dangerous man, someone who should have been better contained. What's missing is what happened in his treatment before February of 2008. He had lost his job in November of 2007 after the FBI raided his home. He had been in many treatments since 2001. Perhaps more details will emerge.

Here is a very interesting discussion of the obligation of therapists to protect the public from their dangerous clients.

Salon

The 1996 Supreme Court case Jaffee v. Redmond officially recognized psychotherapist-patient privilege in federal courts. That decision, concerning a police officer accused of excessive force who sought to keep his social worker's notes out of a trial, states that "effective psychotherapy ... depends upon an atmosphere of confidence and trust in which the patient is willing to make a frank and complete disclosure of facts." Patients, in other words, should feel secure that what they reveal in a clinical setting is between them and their psychologists. Although all states recognize some form of this privilege, 27 of them, including Maryland, require therapists to breach confidentiality if the patient poses a serious danger of violence to others. (In some other states, psychologists have explicit permission to warn the cops but aren't obligated to do so.)

The exact nature of this requirement varies slightly from state to state, but the general formulation is that a mental-health professional must warn either the police or the potential victim if a patient makes a specific threat against an identifiable third party. That is, the patient has to be doing more than just blowing off steam ("God, I'm gonna kill my boss!"). He has to have an actual plan ("I'm going to buy a gun") and an actual victim ("and shoot my neighbor") in mind. But it's up to the therapist to decide if the patient truly intends violence and is capable of carrying out the threat. Arguably, Duley could have kept quiet if she thought Ivins' apparent plan to kill his co-workers was really just a fantasy.

The "duty to warn" concept dates back to the 1974 case Tarasoff v. The Regents of the University of California - Supreme Court of California, 1976. In Tarasoff, a patient told his therapist that he intended to kill a young woman who had spurned him. A couple of months later he did so, and her parents sued the therapist for failing to warn their daughter. The case ended up in the Supreme Court of California, which ruled that therapists have a "duty to warn" not just the police (which the therapist had done) but the potential victim as well. In a 1976 rehearing, the court replaced the phrase "duty to warn" with "duty to protect."

So there is much information missing to know if there was a breach of the law in the treatment of Ivins. There is no reason to expect that more information about his treatment will emerge unless there has been other court involvement in this treatment. That part is public record. But his death removes any compelling reason for his treating professionals to come forward legally to release information.

Just as I say this, more information emerges.

Associated Press

A microbiologist claims she was stalked for decades by Bruce Ivins, the suspect in the deadly anthrax mailings of 2001 who, according to court documents, was obsessed with the sorority she joined in college.

Nancy L. Haigwood and her former husband, Carl J. Scandella, also think Ivins may have wanted to get close to her when he moved in down the street from the couple in the suburbs of Washington in the early 1980s.
[..]
Haigwood, now the director of the Oregon National Primate Research Center, said she suspected Ivins in the anthrax mailings as early as November 2001, when he e-mailed her, his immediate family and other scientists a photo of himself working with what he called "the now infamous 'Ames' strain" of anthrax, which was used in the attacks. She reported her suspicions to the FBI in 2002 and, at the behest of investigators, kept in touch with Ivins by e-mail and shared their correspondence with investigators.

Haigwood, 56, met Ivins in the late 1970s when he was doing a postdoctoral fellowship at the University of North Carolina, where she earned her doctorate. She was cordial to him, but she noticed that he took an unusual interest in her Kappa membership.

In the summer of 1982, Haigwood moved in with Scandella, then her fiancee, in a townhouse in the Washington, D.C., suburb of Montgomery Village. On Nov. 30 that year, Scandella awoke to find the Greek letters "KKG" spray-painted on the rear window of his car and on the sidewalk and fence in front of the home. Although a police report filed by Scandella does not mention any possible suspects, Haigwood quickly concluded that Ivins was responsible.

"My address wasn't published, and I only lived there a short while before Carl and I got married and moved out of state," Haigwood said Friday. "No one knew my address or my phone number. You had to stalk me to figure this stuff out."

Records show that Ivins was living on the same street, about a block away, shortly after the incident. It was not clear when he moved in. Scandella did not know that Ivins had been their neighbor until he was told Friday by a reporter.

"I was blown away by that," Scandella said. "I had no idea he lived anywhere in the vicinity ... I wonder if it's possible that Ivins moved to that location to be close to Nancy."

Soon after the vandalism, Haigwood bumped into Ivins -- she doesn't remember where -- and accused him.

"I said, 'This happened and I'm sure you're the one who did it,' and he denied it," Haigwood said. "And I said, 'Well, I'm still sure you did.' What can you do at that point?"

Ivins kept in touch with Haigwood via phone calls, letters and e-mails, and while some of the correspondence made her uncomfortable, she never cut off contact with him, a decision she later regretted. She said she sent him polite but curt replies.

"He seemed to know a lot about myself, my children, things I never remembered telling him, which always disturbed me," she said. "I kept him at arm's length as best I could."

She also suspected Ivins of writing a letter in her name to The Frederick News-Post that defended hazing by Kappa members.
[..]
Haigwood said she was not aware of Ivins stalking any other Kappa sisters.

In an interview Friday, Kappa Kappa Gamma executive director Lauren Sullivan Paitson said the FBI asked in August 2007 for help documenting decades' worth of Ivins' contacts with the sorority, including breaking into the now-closed chapter house at the University of Maryland. The sorority disbanded at Maryland in 1992.

But before being contacted by the FBI, Paitson had been engaged in an editing war on Wikipedia.com with a writer by the name of "jimmyflathead" who threatened to post secret rituals and bad publicity about the sorority on the Web site. Court affidavits listed "jimmyflathead-at-yahoo.com" among Ivins personal e-mail addresses.

Only after the government asked for the sorority's help did Paitson realize that the online Kappa nemesis was the top suspect in the anthrax investigation.

He was apparently potentially dangerous for many years. It appeared to be just a matter of time before his actions would manifest. And they did, tragically so.

Mental Nurse posted a wake up call for caregivers today. Please note she writes with tongue firmly inserted in cheek.

Service users are time-wasters. They want to be in hospital, are happy to be dependent on professional carers and are ready, willing and eager to become institutionalised as soon as they fall into our grasping hands.

Sound familiar to anyone out there?

…probably not, but now replace the general with the specific, and I wonder how many staff have either heard these words uttered from the mouths of colleagues…or even, dare I say it, have said it themselves:

“Patient x shouldn’t be here, s/he’s just wasting our time…..not mad, but bad. S/he really likes being in hospital/getting a community service, and (the final convincer for anyone who thinks this is just prejudiced opinion……..) we need to discharge him/her before they get institutionalised/too dependent on us.”

The last comment of course refers to the mystical processes of institutionalisation and dependence that have nothing to do with the behaviour of the professionals who are supposed to care for them. I’ve heard these comments all my nursing career, and have always thought...[GEEZ!]. How bad do their lives’ have to be that they would want to live in a mental health unit or have the likes of you visiting them at home?”

I'm afraid both caregivers and consumers have witnessed this phenomena. It's called countertransference.

Freud introduced the term countertransference a few years before he wrote the bulk of his papers on technique, although he never devoted a special study to it. It was considered roughly as the obverse of transference, the repetition of the analyst's irrational, previously acquired attitudes, now directed toward the patient, and was assumed to be absent except in situations in which the therapist was inadequately analyzed. Freud deemed it to be the obligation of the analyst to eliminate such unconscious reactions as obstacles to treatment.

Caregivers, being human beings, get frustrated and overwhelmed and tempted to blame others for their feelings. Unfortunately, despite all the admonitions about "unprofessional behavior" in graduate school, in my experience, it's a topic that comes up in the professional setting less often than it should.

As students, at least some professionals are humbled by the experience of intensive supervision. Topics such as the students' mood, recent stressors, feelings about their clients, as well as tone and choice of words come up as a routine part of supervision. I had that experience and am forever grateful, as are, I'm sure, my clients.

After graduating and becoming licensed, I thought everyone experienced this level of supervision. How wrong I was. It was a baptism of fire when I discovered as a budding supervisor, few professionals are prepared to tolerate that level of feedback. That is not suprising if one considers that so many never experienced it before. Instead of seeing it as another opinion in the context of doing one's best to provide quality service, too many react as if their competence has been challenged.

Indeed, the license says we are competent to provide independent professional practice, and many professionals think that means they don't need supervision or personalized feedback. Most readily accept they must seek consultation with their peers on a regular basis.

I'm sure there are settings where co-workers are more trusting and supportive and such topics do come up. Perhaps I'm coming to this discussion from an unusual point of view and I've worked in relatively hostile work environments. But I don't think so. I don't know many friends who would dare to offer the feedback we all need from time to time. Hopefully, most of us have someone in our lives who will tell us when we've crossed the line, because we all do.

I believe part of what it takes to provide quality service requires one to seek out intensive consultation. Without that regular personal check up, the intuitions we gain from our emotional responses to our clients can quickly impose themselves on the treatment process, as Mental Nurse effectively reminds us.

This is a cross-posted comment to this article in THOUGHTS From the HEADoc.

I have witnessed first hand our Mental Health Centers insidiously disappear under the name of reform. The State Hospitals are next on the chopping block. Our citizens have been totally eliminated from knowledge of what is really happening with that situation. Also first hand, I watched the jail population become almost exclusively of those with mental illnesses and chemical dependence, effectively keeping those people from public site for the most part.

Most people don't appreciate the severity of the drug culture and how deeply it has penetrated our society at least until a family member becomes affected. It is no longer a ghetto problem only. Maybe my view of the situation is skewed because of the concentrations of populations I've worked with. The main difference I really have seen is that the blacks are treated in jail and most whites are treated outside of jail for the exact same problems. This situation seems to give the impression to the general public that all is well. Doctors are basically divided into two groups. The largest group are those who take no risk and treat no patient with history of high risk behaviors. The smaller group of physicians are those who haven't learned to join the larger group yet. I learned this difficult lesson over the past year. There is essentially no protection for a solo practitioner who will see higher risk patients. Like a sitting duck, that practitioner may be targeted by pharmacists and those sociopathic doctor shoppers I have written about many times before.

I have felt like Mudbone, many times, guarding the levy. The levy is weakening every day. The public in the valley are dry and unknowing. The politicians on the hill are dry and really don't give a damn. The levy is going to break and the people will feel the force of the metaphorical water. Many will drown. I must accept that it is not my purpose to address social issues because there are just too many and those in control at this time are indifferent, at best, to such issues.

I understand your discouragement. I've been there myself. After 30 years in this business, I find myself still shocked by the stories of deprivation, abuse and trauma I hear too regularly. I've come to accept that I have little influence on the big picture. I take my swings in the political sphere, but I have to retreat from there and focus on what I can do or I risk falling into a dark hole as deep as some of my clients'.

I figure I impact the world one person at a time. So I do the best I can with those who care to listen long enough to benefit. I celebrate and take credit for those that succeed. I quickly let go of those who are "falling elephants". With all those people out there who have benefited, I figure I have had more impact on the world than most people do. I'm grateful that my job is interesting, challenging and never boring. I learn something new everyday. And I meet some incredible people. And I learn who I don't want to know and how to protect myself from them.

I'm not sure I'd want to work as a solo practitioner in a high risk setting. That population demands a team approach. Solo practitioners really do have to limit their practice. There is no shame in that. It's good for the practitioner and the client.

I work as a team member in a partial hospital program in a large public hospital in the inner city (an endangered species, I know). It is probably the closest thing there is to an ideal setting for therapy with high risk individuals. The program model quickly weans out those who are not serious about changing their lives. We see them all, 2/3s don't make it by self-selection. A few are kicked out. Those that stick it out are forever changed. Many crack, meth, alcohol and heroin addicts actually make it. People who have suffered deep trauma often find peace. And I see my share of people with lots of potential and skills as well, many with their first time in treatment. I feel very fortunate to witness the beginning of their metamorphosis.

Keep the faith. The world needs more of you.

An informed consumer is critical to ensure quality care. The mental health professional needs feedback from the client to ensure care is effective. That is as much true for counselors as it is for psychiatrists.

Insurance companies and now Medical Assistance have been increasingly using medication "formularies" to control the cost of their medication budget. Formularies limit the choice of medication for which the insurance company will pay. Often that is because there are a choice between brand name and generic medications or a choice among a number of equivalent brand names. Formularies also limit access to newly developed medications that are considered "experimental." While there may be some notable exceptions, formularies exist primarily to save money. Insurance companies and generic medication manufacturers insist that generic are as high quality as name brands.

The Federal Drug Administration (FDA) sets standards that say generics must be equivalent in quality and potency. However, as with all things, you get what you pay for. Generic manufacturers have to cut corners to be able to offer a cheaper product. Generics may work just fine for most people and most medications, however, there will be exceptions.

Psychotropic medications are no exception. WebMD's Anxiety and Stress Management Blog has an introduction to the topic.

Patients have been telling me for years that there's a problem with their medications when they are switched to generics. I've heard this when I worked in psychiatric hospitals and in private practice and, sometimes, on the board.

[...]The journal Clinical Therapy in both 2003 and 2004 noted that there is a difference between brand and generic medications. The journal Hospital Practice also looked at the differences between generics and brand benzodiazepines. The differences can, according to psychiatrists I've heard from, be as much as 20-30% in the bioavailability of the medication.

Simply put. this translates into the percent of a medication that can be absorbed and utilized. Some psychiatrists have noted that they've had to increase the dose of a generic as much as 50% to get the same effect they would get with the brand name.

As always, medication decisions should be a joint decision with your physician. The more the client understands her needs and her medications, the better the discussion and decision will be.

"Conscientious Objection" by professionals seems to me to be a practice whose ethics is tied to the setting in which one practices and the nature of the limitation one wishes to set. Julian Savulescu, writing about "Conscientious Objection" by physicians in The New British Medical Journal seems to have a much narrower and blanket view.

blog.bioethics.net

A doctors’ conscience has little place in the delivery of modern medical care, writes Julian Savulescu at the University of Oxford. If people are not prepared to offer legally permitted, efficient, and beneficial care to a patient because it conflicts with their values, they should not be doctors.

Imagine an intensive care doctor refusing to treat people over the age of 70 because he believes such patients have had a fair innings. Or imagine an epidemic of bird flu or other infectious disease that a specialist decided she valued her own life more than her duty to treat her patients. Such a set of values would be incompatible with being a doctor.

The argument in favour of allowing conscientious objection is that to fail to do so harms the doctor and constrains liberty. This is true, says the author, but when conscientious objection compromises the quality, efficiency, or equitable delivery of a service, it should not be tolerated.

He believes that doctors who compromise the delivery of medical services to patients on conscience grounds must be punished through removal of licence to practise and other legal mechanisms.

Values are important parts of our lives. But values and conscience have different roles in public and private life, he writes. They should influence discussion on what kind of health system to deliver. But they should not influence the care an individual doctor offers to his or her patients.

The door to “value-driven medicine” is a door to a Pandora’s box of idiosyncratic, bigoted, discriminatory medicine. Public servants must act in the public interest, not their own, he concludes.

Every health care worker at some point in their training becomes aware that their right to deny treatment is limited most often by the setting in which they choose to work. Each person knows when they enter a particular position that their right to deny treatment is restricted.

The right to deny treatment based on political or moral values is often contrary to the mission of the setting in which the professional practices. A health care worker working for an agency would tacitly accept the mission of the agency for which they work. Health care agencies often serve the community with limitations only based on payer. Many public settings may allow an acceptable work around, such as referring to a colleague. If such accommodation is not available, the concerned health care worker should understand that when he/she accepts the job.

I'm not that familiar with the British medical practice design, but I'm hard pressed to believe that a professional in private practice has the same limitations as someone working in an agency that serves the whole community.

If the desired limitation is based on a particular procedure, then it seems to me that private practice enables a professional to limit their practice. As long as the private practitioner wishing to limit his/her practice operates by fully informing the client of all treatment alternatives, regardless of any qualms and without prejudice or proselytizing his/her beliefs, and offers a good faith referral to a professional which is willing to perform the service, no harm is done.

However, a limitation based on a particular client characteristic is much more complicated. It seems likely if a professional chose to limit their practice to caucasians based on a bias towards other races, the practitioner would likely be subject to civil litigation and could correctly be censured by their licensing agency for discrimination.

However, many professionals limit their practice to particular illnesses, problems, genders and age groups. One could justifiably assert a limitation in his/her cultural competency. They would be obligated to inform a client of their lack of expertise and competence and could appropriately refer them elsewhere.

This a very important and complex topic and one that will surely receive more attention in the future. My opinion seems likely to evolve.

Grand Rounds is a tradition in many hospitals around the country. Here is an on-line version. A touching story from hospital impact. This is one weeks post from Grand Rounds 2.05, a rotating column of medical professionals.

I once spoke with one of the most famous hospital CEOs in America. Out of all the things he could have shared with me that day, he talked to me about a cleaning lady in his hospital. This is the story he told...

A patient was in a coma and her grieving family sat around her. The patient had been completely unresponsive for weeks. Then, a particular cleaning lady unknowingly and deeply moved this family - simply by doing her job with a smile and by singing/humming a sweet tune under her breathe. The family noticed that the patient actually responded to this far-off cleaning lady's humming ever so slightly - a twitch of the eye, a tear. The family asked the cleaning lady to come in and sing to their loved one in the coma. Without hesitating, the cleaning lady put down her mop, came into the room, and sang an angelic tune. It was a tender, moving moment for the whole family - another tear flowed down the patient's face. A few days later, the patient died, but the family was so moved by the event, that they wrote the hospital, wanting to thank that anonymous cleaning lady.

This week's grand rounds is dedicated to that unnamed hospital cleaning lady, and to all those in healthcare who do their job with a smile on their face and a sweet tune on their hearts.