W#1 Adv. Psychopharma

W# 1: Prescriptive Practice in Psychiatric Nursing

To complete this discussion

• Compare the Ted Talk video (see link & attached video transcript) to the NY Times article by Danial Carlat, Mind Over Meds, and answer the following questions:

Ted Talk Video link: https://hls.ted.com/talks/1714.m3u8?preroll=newshortintro_053119&qr

1. How do you view the role of psychiatric medication in the promotion of patient well-being?

2. What are the advantages and disadvantages of being a psychopharmacologist versus also integrating psychotherapy in your practice?

3. What does the literature say (that is, support for or lack of evidence) for integration of therapy and prescribing by the same clinician (APRN or MD)?

Instructions:

– Carefully read the questions presented.

– Reflect on the assigned materials from this week and consider experiences from your own practice to support your ideas. Please use proper citations and APA format.

– You may wish to refer to outside sources as well to support your statements.

Background: I am currently enrolled in the Psych Mental Health Nurse Practitioner Program (APRN), I am a Registered Nurse, and I work in a Psychiatric Hospital.

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NU643: Advanced Psychopharmacology
Toward a New Understanding of Mental Illness Video Transcript
00:12

So let’s start with some good news, and the good news has to do with what do we know based on biomedical research that actually has changed
the outcomes for many very serious diseases?

00:26

Let’s start with leukemia, acute lymphoblastic leukemia, ALL, the most common cancer of children. When I was a student, the mortality rate was
about 95 percent. Today, some 25, 30 years later, we’re talking about a mortality rate that’s reduced by 85 percent. Six thousand children each year
who would have previously died of this disease are cured. If you want the really big numbers, look at these numbers for heart disease. Heart
disease used to be the biggest killer, particularly for men in their 40s. Today, we’ve seen a 63-percent reduction in mortality from heart disease —
remarkably, 1.1 million deaths averted every year. AIDS, incredibly, has just been named, in the past month, a chronic disease, meaning that a 20-
year-old who becomes infected with HIV is expected not to live weeks, months, or a couple of years, as we said only a decade ago, but is thought to
live decades, probably to die in his ’60s or ’70s from other causes altogether. These are just remarkable, remarkable changes in the outlook for
some of the biggest killers. And one in particular that you probably wouldn’t know about, stroke, which has been, along with heart disease, one of
the biggest killers in this country, is a disease in which now we know that if you can get people into the emergency room within three hours of the
onset, some 30 percent of them will be able to leave the hospital without any disability whatsoever.

01:58

Remarkable stories, good-news stories, all of which boil down to understanding something about the diseases that has allowed us to detect early
and intervene early. Early detection, early intervention, that’s the story for these successes.

02:17

Unfortunately, the news is not all good. Let’s talk about one other story which has to do with suicide. Now this is, of course, not a disease, per se. It’s
a condition, or it’s a situation that leads to mortality. What you may not realize is just how prevalent it is. There are 38,000 suicides each year in the
United States. That means one about every 15 minutes. Third most common cause of death amongst people between the ages of 15 and 25. It’s
kind of an extraordinary story when you realize that this is twice as common as homicide and actually more common as a source of death than
traffic fatalities in this country. Now, when we talk about suicide, there is also a medical contribution here, because 90 percent of suicides are related
to a mental illness: depression, bipolar disorder, schizophrenia, anorexia, borderline personality. There’s a long list of disorders that contribute, and
as I mentioned before, often early in life.

03:20

But it’s not just the mortality from these disorders. It’s also morbidity. If you look at disability, as measured by the World Health Organization with
something they call the Disability Adjusted Life Years, it’s kind of a metric that nobody would think of except an economist, except it’s one way of
trying to capture what is lost in terms of disability from medical causes, and as you can see, virtually 30 percent of all disability from all medical
causes can be attributed to mental disorders, neuropsychiatric syndromes.

03:53

You’re probably thinking that doesn’t make any sense. I mean, cancer seems far more serious. Heart disease seems far more serious. But you can
see actually they are further down this list, and that’s because we’re talking here about disability. What drives the disability for these disorders like
schizophrenia and bipolar and depression? Why are they number one here?

04:16

Well, there are probably three reasons. One is that they’re highly prevalent. About one in five people will suffer from one of these disorders in the
course of their lifetime. A second, of course, is that, for some people, these become truly disabling, and it’s about four to five percent, perhaps one
in 20. But what really drives these numbers, this high morbidity, and to some extent the high mortality, is the fact that these start very early in life.
Fifty percent will have onset by age 14, 75 percent by age 24, a picture that is very different than what one would see if you’re talking about cancer
or heart disease, diabetes, hypertension — most of the major illnesses that we think about as being sources of morbidity and mortality. These are,
indeed, the chronic disorders of young people.

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05:09

Now, I started by telling you that there were some good-news stories. This is obviously not one of them. This is the part of it that is perhaps most
difficult, and in a sense this is a kind of confession for me. My job is to actually make sure that we make progress on all of these disorders. I work for
the federal government. Actually, I work for you. You pay my salary. And maybe at this point, when you know what I do, or maybe what I’ve failed to
do, you’ll think that I probably ought to be fired, and I could certainly understand that. But what I want to suggest, and the reason I’m here is to tell
you that I think we’re about to be in a very different world as we think about these illnesses.

05:49

What I’ve been talking to you about so far is mental disorders, diseases of the mind. That’s actually becoming a rather unpopular term these days,
and people feel that, for whatever reason, it’s politically better to use the term behavioral disorders and to talk about these as disorders of behavior.
Fair enough. They are disorders of behavior, and they are disorders of the mind. But what I want to suggest to you is that both of those terms, which
have been in play for a century or more, are actually now impediments to progress, that what we need conceptually to make progress here is to
rethink these disorders as brain disorders.

06:31

Now, for some of you, you’re going to say, “Oh my goodness, here we go again. We’re going to hear about a biochemical imbalance or we’re going
to hear about drugs or we’re going to hear about some very simplistic notion that will take our subjective experience and turn it into molecules, or
maybe into some sort of very flat, unidimensional understanding of what it is to have depression or schizophrenia.

07:00

When we talk about the brain, it is anything but unidimensional or simplistic or reductionistic. It depends, of course, on what scale or what scope you
want to think about, but this is an organ of surreal complexity, and we are just beginning to understand how to even study it, whether you’re thinking
about the 100 billion neurons that are in the cortex or the 100 trillion synapses that make up all the connections. We have just begun to try to figure
out how do we take this very complex machine that does extraordinary kinds of information processing and use our own minds to understand this
very complex brain that supports our own minds. It’s actually a kind of cruel trick of evolution that we simply don’t have a brain that seems to be
wired well enough to understand itself. In a sense, it actually makes you feel that when you’re in the safe zone of studying behavior or cognition,
something you can observe, that in a way feels more simplistic and reductionistic than trying to engage this very complex, mysterious organ that
we’re beginning to try to understand.

08:15

Now, already in the case of the brain disorders that I’ve been talking to you about, depression, obsessive compulsive disorder, post-traumatic stress
disorder, while we don’t have an in-depth understanding of how they are abnormally processed or what the brain is doing in these illnesses, we
have been able to already identify some of the connectional differences, or some of the ways in which the circuitry is different for people who have
these disorders. We call this the human connectome, and you can think about the connectome sort of as the wiring diagram of the brain. You’ll hear
more about this in a few minutes. The important piece here is that as you begin to look at people who have these disorders, the one in five of us
who struggle in some way, you find that there’s a lot of variation in the way that the brain is wired, but there are some predictable patterns, and
those patterns are risk factors for developing one of these disorders. It’s a little different than the way we think about brain disorders like
Huntington’s or Parkinson’s or Alzheimer’s disease where you have a bombed-out part of your cortex. Here we’re talking about traffic jams, or
sometimes detours, or sometimes problems with just the way that things are connected and the way that the brain functions. You could, if you want,
compare this to, on the one hand, a myocardial infarction, a heart attack, where you have dead tissue in the heart, versus an arrhythmia, where the
organ simply isn’t functioning because of the communication problems within it. Either one would kill you; in only one of them will you find a major
lesion.

09:46

As we think about this, probably it’s better to actually go a little deeper into one particular disorder, and that would be schizophrenia, because I think
that’s a good case for helping to understand why thinking of this as a brain disorder matters. These are scans from Judy Rapoport and her
colleagues at the National Institute of Mental Health in which they studied children with very early onset schizophrenia, and you can see already in
the top there’s areas that are red or orange, yellow, are places where there’s less gray matter, and as they followed them over five years, comparing
them to age match controls, you can see that, particularly in areas like the dorsolateral prefrontal cortex or the superior temporal gyrus, there’s a
profound loss of gray matter. And it’s important, if you try to model this, you can think about normal development as a loss of cortical mass, loss of
cortical gray matter, and what’s happening in schizophrenia is that you overshoot that mark, and at some point, when you overshoot, you cross a
threshold, and it’s that threshold where we say, this is a person who has this disease, because they have the behavioral symptoms of hallucinations
and delusions. That’s something we can observe. But look at this closely and you can see that actually they’ve crossed a different threshold.
They’ve crossed a brain threshold much earlier, that perhaps not at age 22 or 20, but even by age 15 or 16 you can begin to see the trajectory for
development is quite different at the level of the brain, not at the level of behavior.

11:10

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Why does this matter? Well first because, for brain disorders, behavior is the last thing to change. We know that for Alzheimer’s, for Parkinson’s, for
Huntington’s. There are changes in the brain a decade or more before you see the first signs of a behavioral change. The tools that we have now
allow us to detect these brain changes much earlier, long before the symptoms emerge. But most important, go back to where we started. The
good-news stories in medicine are early detection, early intervention. If we waited until the heart attack, we would be sacrificing 1.1 million lives
every year in this country to heart disease. That is precisely what we do today when we decide that everybody with one of these brain disorders,
brain circuit disorders, has a behavioral disorder. We wait until the behavior becomes manifest. That’s not early detection. That’s not early
intervention.

12:11

Now to be clear, we’re not quite ready to do this. We don’t have all the facts. We don’t actually even know what the tools will be, nor what to
precisely look for in every case to be able to get there before the behavior emerges as different. But this tells us how we need to think about it, and
where we need to go.

12:31

Are we going to be there soon? I think that this is something that will happen over the course of the next few years, but I’d like to finish with a quote
about trying to predict how this will happen by somebody who’s thought a lot about changes in concepts and changes in technology.

12:45

“We always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next ten”, Bill Gates

12:54

Thanks very much. (Applause)

1/4/21, 10:21 AM

Mind Over Meds

– The New York Times

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By Daniel Carlat

April 23, 2010

One day several years ago, I was reaching the end of my first visit with a patient,

J.J., who had come to see me for anxiety and insomnia. He was a salesman for a

struggling telecommunications company, and he was having trouble managing

the strain on his finances and his family. He was sleeping poorly, and as soon as

he opened his eyes in the early morning, the worries began. “I wake up with a

list of things to worry about,” he said. “I just go through the list, and it seems to

get longer every day.”

A psychiatric interview has a certain rhythm to it. You start by listening to what

your patient says for a few minutes, without interrupting, all the while sorting

through possible diagnoses. This vast landscape of distress has been mapped

into a series of categories in psychiatry’s diagnostic manual, DSM-IV. The book

breaks down mental suffering into 16 groups of disorders, like mood disorders,

anxiety disorders, psychotic disorders, eating disorders and several others. As I

listened to J.J. (a nickname that he agreed I could use to protect his privacy), it

was clear to me that he had one of the anxiety disorders, but which one? In order

to systematically rule in or rule out the disorders, I asked J.J. dozens of

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questions. “Do you have panic attacks?” “Do you get fearful in crowded

situations?” “Have you ever experienced a traumatic event that later caused

flashbacks or nightmares?”

Each of J.J.’s answers provided me with a clue, closing off one possibility while

opening up others. At its best, when you are working with an intelligent,

insightful patient, the process is fun, involving a series of logical calculations,

much like working a Sudoku puzzle. Finally, toward the end of the hour, I felt

confident that I had arrived at J.J.’s diagnosis. “I think you have what we call

‘generalized anxiety disorder,’ ” I told him. It may start with a defined series of

causes, as was true for J.J., but then it spirals outward, blanketing the world with

potential threat. J.J. worried about what the future would bring and experienced

a predictable series of physical symptoms: insomnia, muscle tension, irritability

and poor concentration.

“I’m going to write you a prescription for a medication called Zoloft,” I said,

picking up my prescription pad. He asked what was causing his anxiety, and I

began one of the stock neurochemical explanations that psychiatrists typically

offer patients about low serotonin levels in the brain. The treatment involved

“filling up the tank” by prescribing a medication like Zoloft, Celexa or Paxil.

“So Dr. Freud, the causes are all in the brain? Isn’t there some explanation in my

childhood?” It was a good-natured tease.

“I specialize in prescribing medications,” I said with a smile. I was a

psychopharmacologist and specialized in medication rather than psychotherapy.

“I can refer you to a good therapist in the area if you’d like.”

After J.J. left my office, I realized, uncomfortably, that somehow, over the course

of the decade following my residency, my way of thinking about patients had

veered away from psychological curiosity. Instead, I had come to focus on

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symptoms, as if they were objective medical findings, much the way internists

view blood-pressure readings or potassium levels. Psychiatry, for me and many

of my colleagues, had become a process of corralling patients’ symptoms into

labels and finding a drug to match.

Leon Eisenberg, an early pioneer in psychopharmacology at Harvard, once

made the notable historical observation that “in the first half of the 20th century,

American psychiatry was virtually ‘brainless.’ . . . In the second half of the 20th

century, psychiatry became virtually ‘mindless.’ ” The brainless period was a

reference to psychiatry’s early infatuation with psychoanalysis; the mindless

period, to our current love affair with pills. J.J., I saw, had inadvertently

highlighted a glaring deficiency in much of modern psychiatry. Ultimately, his

question would change the way I thought about my field, and how I practiced.

I originally became interested in psychiatry primarily because of my father: he

is a psychiatrist practicing in San Francisco. But there was a darker side to my

career choice. My mother suffered severe mental illness, with debilitating

depressions and paranoid thoughts. One autumn day during my junior year in

college, she committed suicide. Psychiatry then became personal, a way for me

to come to terms with her illness.

I majored in psychology at U.C. Berkeley, and at U.C. San Francisco I labored

through medical school’s rites of passage in order to qualify for a psychiatric

residency. Eventually, on a steamy July day in 1992, I stood on a Boston street,

far from home, gazing at Massachusetts General Hospital (known as M.G.H.),

where I was about to start my training.

This was a momentous time at M.G.H. Prozac was introduced four years earlier

and became the best-selling psychiatric medication of all time. Zoloft and Paxil,

two similar medications, were in the pipeline, and many of the key clinical trials

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for these antidepressants were conducted by psychiatrists at M.G.H. who were

to become my mentors. M.G.H. and other top programs were enthralled with

neurobiology, the new medications and the millions of dollars in industry grants

that accompanied them. It was hard not to get caught up in the excitement of the

drug approach to treatment. Psychopharmacology was infinitely easier to

master than therapy, because it involved a teachable, systematic method. First,

we memorized the DSM criteria for the major disorders, then we learned how to

ask the patient the right questions, then we pieced together a diagnosis and

finally we matched a medication with the symptoms.

But learning the formal techniques of therapy was like navigating without a

compass. While I learned how to form an alliance with my patients and begin a

good dialogue, becoming a skillful therapist requires much more practice than

busy psychiatry residencies allow.

When my father did his residency at U.C.S.F. in the 1950s, he learned therapy

well, because, with few medications available, it was the main treatment

psychiatrists could offer their patients. Psychiatric residencies focused on

therapy, and many residents extended their training further by enrolling in

postgraduate psychoanalytic institutes. When modern medications came on the

scene, my father adapted by incorporating them into his therapy practice, as did

many of his colleagues. I call this the “golden” generation of psychiatrists, those

currently approaching retirement age, who were skilled at offering the full

package of effective psychiatric treatments to patients.

The newer generation of psychiatrists, who graduated in the 1980s and

afterward, trained in programs that were increasingly skeptical of therapy and

that emphasized a focus on medications. M.G.H. was by far the most influential

of these modern programs. Graduates of the M.G.H. program and its sister

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program at nearby McLean Hospital have fanned out throughout the country,

becoming chairmen of departments and leaders of the National Institute of

Mental Health.

A result is that psychiatry has been transformed from a profession in which we

talk to people and help them understand their problems into one in which we

diagnose disorders and medicate them. This trend was most recently

documented by Ramin Mojtabai and Mark Olfson, two psychiatric

epidemiologists who found that the percentage of visits to psychiatrists that

included psychotherapy dropped to 29 percent in 2004-5 from 44 percent in 1996-

97. And the percentage of psychiatrists who provided psychotherapy at every

patient visit decreased to 11 percent from 19 percent.

While it is tempting to blame only the biologically oriented psychiatrists for this

shift, that would be simplistic. Other forces are at work as well. Insurance

companies typically encourage short medication visits by paying nearly as much

Reinhard Hunger; Set Design by Sarah
Illenberger

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for a 20-minute medication visit as for 50 minutes of therapy. And patients

themselves vote with their feet by frequently choosing to see

psychopharmacologists rather than therapists. Weekly therapy takes time and is

arduous work. If a daily pill can cure depression and anxiety just as reliably, why

not choose this option?

In fact, during my 15-to-20-minute medication visits with patients, I was often

gratified by the effectiveness of the medications I prescribed. For perhaps a

quarter of them, medications worked so well as to be nearly miraculous. But

over time I realized that the majority of patients need more. One young woman I

saw was referred to me by a nurse practitioner for treatment of depression that

had not responded to several past antidepressants. She was struggling to raise

two young children and was worried that she was doing a poor job of it. Her

husband worked full time and was rarely available to help. She cried throughout

our initial interview. I started her on Effexor and referred her to a social-worker

colleague. She improved initially, but over the years since, her symptoms have

waxed and waned. When she reports a worsening of her anxiety or depression,

my first instinct is to do one of three things — switch medications, increase her

dosage or add another. Over the course of 15 or 20 minutes, this is about all I can

offer.

My treatment of this young woman follows the “split treatment” model, but a

less charitable description is “fragmented care.” Like the majority of

psychiatrists in the United States, I prescribe the medications, and I refer to a

professional lower in the mental-health hierarchy, like a social worker or a

psychologist, to do the therapy. The unspoken implication is that therapy is

menial work — tedious and poorly paid.

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But over the past few years, research studies have shown that therapy is just as

effective as medications for many conditions, and that medications themselves

often work through the power of placebo. In one study, for example, researchers

did a meta-analysis of studies submitted by drug companies to the F.D.A. on

seven new antidepressants, involving more than 19,000 patients. It turned out

that antidepressants are, indeed, effective, because on average patients taking

the pills showed a 40 percent drop in depression scores. But placebo was also a

powerful antidepressant, causing a 30 percent drop in depression scores. This

meant that about three-quarters of the apparent response to antidepressants

pills is actually due to the placebo effect.

Nobody knows exactly how the mysterious placebo effect works, but it is clear

that it has impacts on the brain that can be seen as clearly as medication effects.

In one study conducted by pain researchers at the University of Michigan,

subjects were given an ache-inducing injection of saline into their jaws and were

placed in a PET scanner. They were then told that they would be given an

intravenous pain treatment, but the “treatment” was merely more saline

solution, acting as a placebo. The PET scan showed that the endogenous

endorphin system in the brains of the subjects was activated. The patients

believed so strongly that they were receiving effective treatment that their

brains followed suit. Presumably, a corresponding brain change occurs when

depressed patients are given placebo pills.

Like placebo, psychotherapy has typically been considered a “nonbiological”

treatment, but it has become clear that therapy, like placebo, also leads to

measurable changes in the brain. In an experiment conducted at U.C.L.A.

several years ago, with subjects suffering from obsessive-compulsive disorder,

researchers assigned some patients to treatment with Prozac and others to

cognitive behavior therapy. They found that patients improved about equally

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well with the two treatments. Each patient’s brain was PET-scanned before and

after treatment, and patients showed identical changes in their brain circuits

regardless of the treatment.

In depression treatment, too, pills and therapy each lead to brain changes, but in

this case they appear to be intriguingly distinct. In studies by Helen Mayberg, a

professor of psychiatric neurology at Emory University, depressed patients

given cognitive behavior therapy showed decreased activity in the frontal lobe,

the brain center that might be responsible for the overmagnification of life’s

problems that leads to depression in some patients. And they showed increased

brain activity in parts of the limbic system, a brain region associated with strong

emotion. But Mayberg found that when patients were given medication, their

brain activities changed in the opposite direction, stimulating the frontal lobe

and damping down the limbic system. “Our imaging results suggest that you can

correct the depression network along a variety of pathways,” she said.

Clearly, mental illness is a brain disease, though we are still far from working out

the details. But just as clearly, these problems in neurobiology can respond to

what have traditionally been considered “nonbiological” treatments, like

psychotherapy. The split between mind and body may be a fallacy, but the split

between those who practice psychopharmacology and those specializing in

therapy remains all too real.

After I saw J.J., I decided that I wanted to try to change my approach to

treatment. I gradually began to carve out room in my schedule for longer visits

with my patients. I endeavored to do what’s called “supportive” therapy, a

technique favored by many therapists and involving basic problem solving and

emotional support. It is a bit like what a friend would do for another friend

offering advice in times of trouble, but more elaborate and with an

accompanying raft of studies endorsing its effectiveness in psychiatry.

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When I started to probe my patients, I realized I barely knew most of them. I

had exuberantly documented their moods, sleep habits, energy levels and

whether they had suicidal thoughts, but I didn’t know what made them tick as

people. For example, I had treated Jane (her middle name), a health care

administrator in her 40s, for depression and bulimia for many years, focusing on

a complicated combination of medications like Effexor, Provigil and Xanax. Then

she had a depressive relapse. This time, rather than simply adjusting her

medication, I asked her what was going on in her life. I found out that her boss

had recently given her an impossible assignment to complete and had berated

her when the results were not to his liking. It seemed clear to me that her

depression was partly triggered by the fact that she blamed herself for her

boss’s poor communication skills and managerial lapses. I encouraged her to

question that assumption each time it popped into her mind. Over the next few

visits, she improved — relating better to her boss, able to take his criticism with

a grain of salt and feeling more confident.

But while my simple therapeutic suggestions were helpful, as Jane and I

continued to explore her work issues in detail, she said that she often lacked

focus on the job. Knowing that poor concentration can be a symptom of

depression, I asked if she associated her distractibility with periods of sadness.

But she said there was no such correlation with her moods.

I wondered if she might have an adult version of attention deficit disorder.

Indeed, carefully reviewing her years in school, I saw she was always easily

distracted but overcame this problem by working extra hard, and managed to

achieve good grades. Even now, her job performance was consistently rated as

excellent, but the extra work this entailed sapped her energy.

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I decided to prescribe her a version of Ritalin, the standard treatment for A.D.D.

The next month, she said she felt that this medication had turned her life around.

Not only did she feel more focused and productive at work, but she was more apt

to get things done at home, which in turn enhanced her mood, indirectly

improving her depression.

Is Jane’s story an argument for psychiatrists providing both medication and

some sort of psychotherapy? I think it is. This does not mean that dedicated

psychotherapists are not crucial — they are, because they can provide the in-

depth therapy that psychopharmacologists will never have time to deliver. When

our patients need more from us than just medication, however, we should be

prepared to provide it. Oddly, managed-care companies discourage us from

doing psychotherapy, arguing that it is cheaper to have psychiatrists do 20-

minute medication visits every three months and to hire a lower paid non-M.D.

for more frequent therapy visits. But the few studies that have analyzed the

economics of these arrangements have found that integrated treatment actually

saves money. Mantosh Dewan, the chairman of psychiatry at SUNY Upstate

Medical University in Syracuse, found that when psychiatrists do both

medication and psychotherapy, the overall amount of money paid out by

insurance companies is actually less than when the treatment is split between

psychiatrists and psychotherapists. When patients see only one provider, they

require fewer visits overall.

It may be time to consider whether the term “psychopharmacologist” is actually

doing damage to the field of psychiatry. The American Society of Clinical

Psychopharmacology defines “psychopharmacology” on its Web site as “the

study of the use of medications in treating mental disorders.” But in a recent

article, three Harvard psychiatrists (interestingly, two of them from Mass

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General) have pointed out that no other medical specialty has carved out a

separate “pharmacology”subspecialty. Good doctoring, they remind us, involves

perfecting all the skills relevant to healing and deploying them when needed.

During my mother’s last months, she isolated herself from her family, so I don’t

know what kind of treatment she was receiving before her death. But I do know

what kind of treatment I would have hoped for her. She needed medication to

combat her paranoia and the emotional pain of her depression. She needed

someone who could expertly probe her thought process, in order to understand

the fateful logic that led her to conclude that the only solution was to end her

own life. She needed treatment that was intensive and exquisitely coordinated.

Such care is not always capable of saving damaged lives. But it is the best that

we can do. It’s what we owe our patients — and ourselves.