American College of Physicians: Internal Medicine — Doctors for Adults ®


How can internists respond in the wake of Sept. 11?

From the November ACP-ASIM Observer, copyright 2001 by the American College of Physicians-American Society of Internal Medicine.

By William J. Hall

"Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has."
— Margaret Mead

We will all forever remember vividly what we were doing the morning of Sept. 11. I had just finished presenting at grand rounds when news of the terrorist attacks brought my session to an end. Ironically, I had been talking about patient safety.

Subsequently, I've tried to find some point of reference to get on with life. Judging from the correspondence I've received, many College members are going through a similar process. These events seem so antithetical to our professional efforts to preserve life.

We are not facing this tragedy alone. The College has received an extraordinary outpouring of messages of condolence and concern from physician organizations throughout the world. Many members have expressed their views on the College's Web site and at chapter meetings. This outpouring of shared grief should remind us of the unity of the global family of physicians.

While offering solace, this unity begs the question, "What shall we do now?" I believe we must master new skills, and perhaps more importantly, reinvigorate the fundamental humanistic values of our profession.

Recognizing bioterrorism

Certainly internists will now need to be more skilled at recognizing clinical signs of bioterrorism. How many of us have any experience diagnosing and managing the most probable biological threats: anthrax, smallpox, pneumonic plague, tularemia, botulism, filoviruses and arenaviruses? Likewise, most of us have never seen the effects of chemical weapons such as mustard gas, nitrogen dioxide or sarin.

Experts point out that after initial exposure to many of these agents, clinical manifestations present somewhat nonspecifically. Failing to recognize the early signs of such an attack could prove disastrous for individual patients and for public health.

In these emotionally charged times, we need to develop the ability to differentiate illnesses caused by exposure to unthinkable agents from stress-induced ailments or even imagined symptoms. We are also highly likely to see a new form of post-traumatic stress syndrome and recurrent anxiety attacks in our patients for years to come.

Calming fears

Even if no bioterrorism attacks occur, patients will come to us out of a fear that they will become victims. Hysteria can ensue based on sketchy information in newspapers, Web pages and conversations, often leading to misdirected initiatives, some involving physicians. For example, a ciprofloxacin shortage occurred in the New York City area because asymptomatic individuals demanded the drug "just in case" bioterrorism occurred.

Internists' communication skills are now more important than ever, especially because of time pressures. We will be challenged to find the time and ability to counsel these individuals without undermining their confidence in the health care system and the doctor-patient relationship. Our professionalism will be strained to maintain "balance and equanimity," as Osler frequently emphasized.

The College has developed a number of resources to help physicians deal with bioterrorism. A special section on ACP-ASIM Online ( provides comprehensive primary sources and links to helpful Web sites. When necessary, the College will disseminate information by mail and at regional meetings. We will also take advantage of the professional expertise among members in the College's uniformed services and international chapters.

Become a hero

In previous columns, I've written about internists whom I described as heroes in their communities. Most attribute at least part of their success to serendipity: Their world was ready for change, and they had the insight to recognize what needed to be done.

Could it be that the rest of us now have a similar opportunity? These times may offer us a chance, however small, to change our world.

Perhaps this is the time to look around our changed world and take stock of where we can make a positive contribution to healing our communities. Local social agencies might need your expertise, in the form of informative talks or treating patients who find themselves with no health care because of hard times. Perhaps you can help your neighbors better understand cultural and ethnic differences and teach tolerance by example.

If you do get involved in these types of activities, I'd like to hear about them. Please e-mail me at and share your experiences. Help us identify new heroes among our membership as you become one yourself.

Finally, let us be reminded of the preciousness of life and health and make time to be with our own family and loved ones.


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