Rozycki, Grace S. MD, MBA

During an interview with Oprah Winfrey, Gene Siskel (Eugene “Gene” Kal Siskel, 1946–1999), American film critic, asked her the following question: “What do you know for sure?” At that time, she was stumped and could not answer the question. But the question prompted her to think deeply, and the last page of O, The Oprah Magazine, is now devoted to a different answer to that question each month.¹ Having read several of these insightful commentaries, I have asked myself the same question. In my life, what do I know for sure? Although there are several answers that come to mind, this occasion has provided me with the opportunity to share one of my important beliefs with you, something that I know for sure.

THE BIRTH OF THE MENTOR PROGRAM

In March 1997, two first-year medical students expressed an interest to participate in a research project with me during the upcoming summer. At that time, the Emory University School of Medicine offered scholarships to rising second year medical students in the hope of stimulating their interest in research. I was quite pleased to know that Scott and Aaron chose to work with me. Not having a research assistant, I knew that this could be a mutually beneficial relationship. In preparation for their arrival, I began writing a research proposal and completing the paperwork for the Institutional Review Board. But I wanted to offer them something more than just a clinical research project as neither had any clinical experience as yet. I designed a series of short clinical rotations on select services for Scott and Aaron. In this way, they would be able to participate in rounds, in-house calls, and clinics and observe operations and procedures when rotating on a surgical specialty. They underwent training in the basics of ultrasound as part of their research projects, and all our conferences, medical student lectures, and the Department of Surgery Grand Rounds were open to them. Finally, they were given a list of assigned nonmedical books to read. The goals and objectives of the program are outlined in Table 1.^2–4 As time progressed, I was surprised that the students were so energized by the program. They just could not get enough of the clinically related activities. However, what surprised me more was that their presence rejuvenated me, and I felt as though I was doing something special. It was fun and rewarding to watch them tackle assignments and bring their research projects to completion. Throughout the summer we had one-on-one in-depth discussions about life, careers, setting goals, and making time for reflection and renewal. By the end of the summer, my relationship with the students had changed considerably. Looking back, I suppose that these were mentoring moments. A mutual respect and a strong bond had developed among us, and hence, the Mentor Program was born. Throughout the years, I have kept in touch with Scott and Aaron and have seen them through residency, marriage, family illness, the birth of children and several other remarkable moments in their lives. Today, Scott is a practicing orthopaedic surgeon and Aaron is a practicing general surgeon.

Table 1

Since then, I have had students every summer in my mentor program, although it has undergone several changes. The experiences of the students are similar to those of Scott and Aaron, but now each student keeps a journal, and at the end of the summer submits a paper about his or her experiences. In 2004, I received a grant from the Frances Wood Wilson Foundation to help support out-of-state premedical students who wanted exposure to the medical profession but were not in close proximity to an academic medical center. Another change was the addition of younger students to our program. Three high school students and one middle school student have now participated in the program in a selective manner; that is, the program was tailored to suit their age and to meet their particular needs. For example, they observed only select surgical procedures, and the middle school student did not observe an autopsy or the birth of a child. Further, their nonmedical reading list was different from that of the other students. While they did keep a daily journal, the program was tailored to meet their age-appropriate goals. Because they were young, they were much less independent in the medical environment and had to be personally escorted by me when they were in the hospital. Building and sustaining this program has required support from senior leadership, participation from my colleagues, and passionate dedication from its leader. To fully understand this, it requires some discussion about mentorship; that is, what is it and why it is important.

MENTORSHIP

The Mentor

The origin of the word “mentor” is found in Greek mythology. Mentor was the wise and faithful servant of Odysseus (or Ulysses as the Romans called him).⁵ When Odysseus departed for the siege of Troy, he entrusted the direction and teaching of his son Telemachus to Mentor. According to mythology, Telemachus became an effective and beloved ruler through Mentor's guidance. Mentor's job was not merely to raise Telemachus but to teach him about the responsibilities he would assume in his life.

Although the word “mentor” encompasses numerous qualities, all would agree that the most essential qualities are the following: role model, able advisor, supporter, counselor, critic, teacher, and good listener. Mentors expand their mentee's awareness, insight and perspective and help them gain wisdom, resilience, and self-reliance. However, to be effective, mentoring must be anchored in respect and trust so that the mentor could thoughtfully invest his time, energy, and personal know-how, and the mentee could be receptive enough to absorb, digest, and use those lessons appropriately. Only then does an empowering link develop between them; that is, an intangible bond that goes beyond the lessons learned in the classroom.

A mentor is more than a coach or teacher who gives a lecture, conducts a journal club, or guides a resident through an operation. Mentors have a talent to see latent potential in others and foster it to maximize that potential. They set high performance expectations for mentees, offer challenging ideas, help build self-confidence, and model professionalism, which is at the core of the art of medicine.^6,7 Finally, they inspire us to give back, not out of obligation, but rather because of gratitude. The process of mentoring is a work in progress, which parallels the mentor's and mentee's commitment to continuous self-development, learning, and the balance between professional and personal life.

The Mentee

As the person who is mentored, the mentee should understand that mentoring includes the art of establishing and maintaining a productive and interpersonal communication with the mentor, especially relative to learning.⁸ In doing so, the mentee can grasp better the dynamics of the one-on-one mentoring relationship and is, therefore, more likely to make substantial contributions to the process. With this understanding, the mentee is better prepared for what the mentor requires, that is, realistic expectations, mutual respect and effort, and readiness for challenges.⁸

Although most mentees have general needs, they also have individual values, perceived limitations, and aspirations. Sound mentoring respects the uniqueness of the mentee by allowing the protégé to adapt the mentor's help in a style that best suits the mentee's own situation. Through this approach, the mentee discovers personal talents and strengths, thereby enhancing growth and development. The mentoring process involves dealing with change, and this can be especially stressful to the mentee. Change may present itself as a challenging opportunity, but there may be a sense of loss as the mentee steps outside of the comfort zone and faces the possibility of failure. Ironically, even when successful, the mentee may experience anxiety about not measuring up to the mentor's expectations. A good mentor should be able to strike the right balance by encouraging self-confidence but tempering excessive optimism. Often, this requires wisdom to know when to intervene or just be there to listen.

The Mentoring Culture

Understanding an organization's culture clarifies how and why things get done the way they do. The two essential components that constitute a mentoring culture are its (1) infrastructure and (2) mentoring hallmarks.⁹ To sustain a vital mentoring program, the infrastructure or organizational process should be rooted in the best practices of education that have a high priority within a department. Further, mentoring hallmarks, such as shadowing, research, conferences, etc., should be in alignment with the infrastructure. This creates value for the department, its faculty mentors, and the mentees. It is the fostering of a mentoring culture that enables a department to create, sustain, and grow a vibrant mentor program. At the core of this culture are the faculty and fellow mentors and mentees, but passionate leadership ensures its long-term effectiveness and sustainability. In our program, the surgical faculty and fellows mentored students, oversaw research projects, and allowed the mentees access to patients. Having these elements in place has allowed us to have a successful program for the past 12 years.

PROGRAM EVALUATION

Similar to other programmatic initiatives, a critical evaluation should be performed periodically to determine whether the goals of the program are still being accomplished successfully. A 17-point questionnaire was distributed to our mentee alumni. The questionnaire focused on how the mentees heard about the program, why they applied to it, their expectations, what they acquired from it, and their suggestions for program improvement. Other information on the questionnaire included their current position, future career plans, and their current level of interest or involvement in mentoring.

Of the 39 mentees who have completed the program since its inception in 1997, 37 (94.9%) answered the questionnaire. There were 22 male and 15 female mentees. At the time of answering the questionnaire, the mentees included the following information: 10 undergraduate students, 8 medical students, 5 residents (4 surgical; 1 anesthesiology), 4 practicing physicians (3 surgeons; 1 radiologist), 3 nonphysicians (2 paramedics; 1 attorney), 3 middle or high school students, 2 graduate students, and 2 fellows. To relate their answers to an age-appropriate experience, the mentees were grouped at the level they entered the mentor program; that is, middle or high school (4), undergraduate (18), and medical school (15) students. The following questions required a rating on a Likert scale with one being the lowest and five being the highest rating: (1) What was the most important expected outcome you were hoping to achieve by being in the program? (2) To what extent would you recommend this program to someone potentially interested in medicine? Results from the questionnaires showed an average of 4.57 for expected outcomes met and 4.85 for recommending the program to potential mentees. Also, 44% of the mentees who entered the program as undergraduates were mentors versus only 20% of those who entered as medical students (Table 2). Additionally, all but two of those who entered the program as undergraduates were currently working in or were students of the medical profession. Other points that emerged from the results included the following: (1) As the program progressed, almost all the students had heard about it by word of mouth, usually from a friend; (2) the completion of a research project was considered to be an important goal for the medical students as they believed it would confer a competitive advantage when applying for a residency program; (3) the friendliness of the faculty, fellows, residents, medical students, and staff significantly eased the concerns of the most junior mentees. This confirmed that we had succeeded in creating a comfortable environment and a mentor culture that fostered education.

Table 2

The remarks in the questionnaires revealed some deep personal insights of the mentees. One example was the profound sadness felt while watching a surgeon tell a mother that her son had died. Another student expressed her appreciation for the exposure to complex ethical situations often encountered during busy surgical services. She commented, “I honestly find these lessons learned very important because I saw another … side of the medical profession. It's the side which tests your character, ethics, and integrity. This program has honestly given me much more respect for doctors.” Such insights underscored our belief that the program offered intangible benefits and valuable lessons that are not taught to the mentees in the classroom.

Lessons Learned

On the basis of the results of the survey, I reflected on five lessons that we learned about mentoring over the years and decided to modify the program.

First, there is a special value when one practices in a public hospital and has the best and brightest attendings, fellows, residents, and medical students from the Emory University School of Medicine participate in this program. As a tertiary care facility, the Grady Memorial Hospital has a long-standing reputation as a center of expertise in the care of injured, burned, and critically ill patients. The hospital admits a large and diverse patient population, providing the residents with more than adequate exposure to all types of diseases. There is a unique opportunity to care for patients with advanced diseases and complex problems that is not present in most community hospitals. The importance of this type of hospital in the setting of education is no surprise. In his presidential address to the Southern Surgical Association (SSA), Dr. R. Phillip Burns reviewed the history of four major public hospitals, the Philadelphia General Hospital, the Charity Hospital of New Orleans, The Regional Medical Center at Memphis, and the Erlanger Health System.¹⁰ He also surveyed the membership of the SSA to determine the value of public hospitals in their training. He found that these hospitals played a prominent role in enhancing community development and were the foci around which large medical schools and health science centers developed. His survey findings were noteworthy in that many of the SSA members received a substantial percentage of their primary hospital-based education in public hospitals and continued to educate their surgical residents in these hospitals. Also, centers of excellence frequently emerged from these public hospitals, providing a fertile opportunity for medical education. Most of the mentees in our program quickly appreciated the wide variety of patients not just in the field of surgery but in other specialties as well. One student explained why she recommended the mentor program with enthusiasm when she wrote, “I think this is because the exposure to the trauma setting—particularly at Grady—changed the way I think about the medical profession and about societal problems in the nation at large. I think that spending time in a trauma center can be a part of any person's education: the future politician, writer, historian, or doctor.” They also saw the components of the hospital's bureaucracy and how it served as an imperfect safety net hospital for the uninsured. This affected one student who wrote “I have gained an invaluable understanding of very real public health issues, and I hope that in the future I will be able to act upon these issues.” Another student remarked: “… While my clinical experience in Maine had provided me with outstanding role models, I had become eager to explore care at hospitals with more advanced facilities that provide for patients presenting with a broader range of conditions.”

Second, mentoring is a two-way street.¹¹ I have learned more out of organizing and directing the process than the mentees have learned in the program. The benefits that I have received include gratification in seeing others succeed and grow, enjoyment in the loyalty of protégés, joy in helping others accomplish their goals, an opportunity to share in contagious energy, an appreciation for an increase in knowledge, empathy, and skills relating to diverse groups, and the opportunity for self-reflection. Devotion of my time to this program has not enhanced my CV nor has it increased my stature within our department or nationally, but rather, it has provided me with an inner satisfaction and an intangible reward that I would not trade for the world.

Third, mentoring is an art. There is no one thing that makes this process a success but rather it is the whole package. An important part of a successful mentoring culture includes genuine caring, being a good listener and critic, and the creation of a warm, receptive environment. Many students cited that the best part of the program was spending one-on-one time with the surgeons. Currently, a third-year medical student, D.O., started the mentor program as a high school student, and she shared the following thoughts about it at that time: “As my experience continued and I got to know the surgeons … it helped to improve my comfort level around sick patients, which is all … that I could have hoped for as a 16-year-old without so much as a physiology class in my background!” Another mentee, now a practicing radiologist, remarked, “… I think that there is a lot more to learn than anatomy, physiology, pharmacology, etc. There are the human and personal elements to our education—the interpersonal interactions with other physicians, dealing with patients, the stress that becoming a doctor puts on you personally and your loved ones, etc. These are the types of things that I think make a mentor program so valuable.”

Fourth, letting go is a painful but a necessary part of the mentoring process. In some ways, it is the greatest compliment to not be needed as you see your mentees navigate the system and meet their goals. For example, D.A. was accepted as an early decision applicant to the Mount Sinai School of Medicine in New York City and K.J. found that her passion was in optometry, a far cry from general surgery but, none the less, a very rewarding career for her.

And fifth, things do not always work out the way you planned. Not all the students wanted to become surgeons and some, in the end, did not want to become physicians. Some tried to get into medical school but were not successful and eventually gave up to pursue other careers. Upon reflection, they were not disappointments, but rather successes in different packages. Examples include the following: (1) D.H. is a successful attorney in a New York City law firm. He enjoys mentoring his junior associates; (2) T.K. is a paramedic in San Diego who has just completed his master degree in Public Health. He mentors a student in the Public Health Program at San Diego State University; and (3) A.C. is an undergraduate student in biomedical engineering in Atlanta, GA. He came away from the program with a better appreciation of what patients endure and what it means to become a doctor. He wants to design medical equipment to make it easier for physicians to treat patients. Yet to be determined is the impact that the program had on the youngest (11 years) mentee. She enjoyed meeting the patients and still wants to become a neurosurgeon. Having made the decision to become a doctor at age 12, I respect her for having the courage to forge through a program that in many ways was far beyond her years.

Based on the results of our program evaluation, the mentor program will undergo the following changes this summer: (1) only four students will participate in the program and each will have a faculty mentor. The one-on-one mentoring was cited by many of the students as the most beneficial part of the program. One student shared the following insight with us: “The most beneficial part was the one-on-one interaction with the doctors and being able to talk to them about what they actually do in their profession and listen to the feedback and advice that they gave me in regards to starting a career in medicine.”; (2) only undergraduate and medical students will be considered for the program. We anticipate that a more homogeneous group of mentees will facilitate the mentor-mentee relationship and clarify expectations better on both sides. Although the middle and high school students benefited from the program, their insights showed that they were unlikely to perceive the benefits of mentoring, at least initially.

IMPORTANCE OF MENTORING

Now, more than ever, there is a strong need for mentoring. As Thomas L. Friedman¹² reminds us in his book, The World is Flat, we are all connected through technological advances and resulting globalization. The playing field in professional life has been leveled somewhat, allowing almost everyone from nearly every corner of the world to compete. Consequently, the amount of knowledge available to us has grown exponentially; however, there is still a need for the special insight, understanding, and wisdom that is not easily obtainable through the usual learning channels. Mentors help fill in the gaps in the comprehension of complex problems and help their mentees envision worthy goals that will propel them forward. Because mentoring combines the impact of learning with the compelling human need for connection, it serves to expand mentees' potential as they encounter continuous challenges and changes.¹³

Of more proximate need, mentoring can play a central role in the solution of problems such as the workforce crisis and the recruitment of medical students into general surgery and/or the surgical specialties. This problem was highlighted in the 2008 Physician Specialty Data from the Association of American Medical Colleges (AAMC) and distributed by the Center for Workforce Studies.¹⁴ The 2.3% decrease in the number of total active physicians from 1996 to 2006 is a modest change compared with the data for the General Surgery workforce. This is further corroborated by a recent study by Lynge et al.¹⁵ who examined the general surgery workforce over a period of 25 years. Using the American Medical Association's Physician Master files to identify all clinically active general surgeons in the United States, they found that the general surgeon to population ratios declined steadily across the study period from 7.68 per 100,000 in 1981 to 5.69 per 100,000 in 2005. The overall number of general surgeons per 100,000 population has declined by 25.91% during these 25 years. Further, there was a 4.2% absolute decrease in the number of general surgeons.¹⁵ Data from the 2007 AAMC Graduation Questionnaire to all medical students showed that out of nine factors, the one that influenced their career choice the most was that of a mentor or role model. Therefore, mentoring is a critical component in the recruitment of our successors. In a recent study of female academic surgeons, Wyrzykowski et al.¹⁶ from the Emory University School of Medicine found that of the 266 surgeons in the study group, 73% reported that mentoring was somewhat significant or very significant in their careers and 63% reported having a mentor as a medical student. The women ranked the most important component of mentorship to be that of serving as a role model. Yet, despite the importance of mentorship in their careers, they reported that formal mentor programs were not common in their medical schools or surgery departments. The majority (79%) stated that they acted as mentors in some capacity but most were at the assistant professor level, and they felt that this was not a valued activity within their departments. When asked why they mentored, the most commonly cited reason was “the ability to influence someone's career.” In a recent study conducted by the members of the Department of Surgery at the University of Wisconsin, surgeons attempted to characterize the impact that mentoring had on choices made by graduates from their residency program regarding surgical subspecialty training.¹⁷ The authors had an 84% response rate to their 32-item web survey. They found that 75% of the respondents indicated that an influential mentor was important or very important in choosing their specialty field. Protégés indicated that their decision to pursue a subspecialty was most influenced by the following mentor characteristics: demonstrating expertise, being a role model and practicing professional integrity. Another study conducted by Thakur et al.¹⁸ from the Division of Pediatric Surgery at the University of California, Los Angeles School of Medicine, noted that general surgery residents found mentor guidance to be an important component of selecting a surgical specialty. The effect that a mentor has on a resident mentee has been shown to be very positive, and mentor-mentee interactions were cited as the second most important factor in predicting excellence in the field, second only to strong support from the department chair. So, with increasing concerns about the impending disappearance of the general surgeon, also with the increasing growth of surgical subspecialization, it is essential that all types of surgeons provide early and sustained mentorship to medical students and residents to help shape the future of surgery.^17–19

There is a definite need for mentoring at all levels, especially for undergraduate students who have yet to commit to the medical profession and for medical students who are unsure of their choice of specialty. Hauer et al.²⁰ from the University of California, San Francisco, conducted focus groups with fourth-year medical students to explore what students sought from mentors and what barriers existed to mentoring. These students described the mentoring relationship as a “personal connection with a faculty member invested in helping the student achieve a personal and professional vision.” Further, they identified several barriers to mentoring including the limited exposure to clinicians. Although studies such as this one do not offer definitive solutions for these problems, they raise an awareness about the education of faculty and the empowerment of students. In essence, they suggest that mentorship should receive more attention in the medical school curriculum. As one of the undergraduate students who completed our mentor program wrote to me “As a pre-med student applying for medical school, I am bombarded by the need to see medical practice first hand, the more the better. However, many institutions do not have programs available to assist with this rising need. Thus students are left with shadowing experiences that, when available, are often limited to one service and do not allow a level of participation that is helpful to the student.” Further, as Dr. Kirby Bland and others remind us that the traditional factors which once influenced a student's choice of careers (specialty content, prestige, and financial remuneration) have been replaced by the number of duty hours, the duration of residency, and the overall life-style of practice.^21–24 Several students in our program remarked that before spending the summer with us they had not considered surgery as a career. They obviously saw surgeons in a positive light as one student said, “Not only would these physicians spend the extra hours in the operating room just making sure they had completed the procedure to the best of their abilities, but they also made a point of getting to know their patients and responding to their questions or concerns with patience and respect. My experience in Georgia solidified my goal to provide this level of patient care.”

Finally, another reason why mentoring is so important is that it creates an environment enriched by trust, commitment, and empowerment, that is, it adds value for the mentee, mentor, and department or organization.²⁵ Mentoring is especially important as the mentee attempts to establish him or herself in a new environment, gain the requisite skills to navigate the system, and develop the values and ethical perspective necessary to be an effective contributor to an organization. Additionally, the mentee learns to handle conflicting ideas, overcome setbacks, and acquire a flexible attitude toward learning.²⁶ Finally, mentees learn networking, negotiation skills, conflict management, and writing and presentation skills.

There are numerous rewards for the mentor. These include gratification in seeing a protégé succeed, fulfilling a general need to work with and influence others, acquiring new knowledge and insights, enjoying a feeling of pride, and winning the protégé's respect and loyalty. These intangible rewards come from within and offer a long-lasting and personal satisfaction that is distinctly different from more traditional rewards such as an increase in salary or an enhanced curriculum vitae.

Finally, for the department or organization, mentoring emphasizes the value of human capital and the genuinely good feeling that the organization as a whole is contributing to a good and rewarding undertaking. By committing resources to mentoring, the department sends a message to its faculty and personnel that mentoring is a core competence for faculty and residents and that this activity is important for the department's productivity.

SUGGESTIONS FOR GETTING STARTED

Although there is little doubt that mentorship provides value to the mentee, mentor, and the department or organization, the following conditions should be considered before initiating such a program. First and foremost, the mentor should have a genuine desire to participate in the mentoring process and believe firmly in its value. If mentorship is thought of as a well-researched, dynamic, helping relationship, proper preparation will smoothen the pathway toward that goal and produce better results. The following suggestions should be considered while initiating a mentoring program:

1. Restructure your schedule to accommodate the mentoring process. A mentor's devotion of time and energy to the program must be consistent with the seriousness of this responsibility. However, boundaries need to be set, including the amount of time that a mentor commits to the mentee. In an academic setting, residents can be very helpful by assisting with the educational components of mentoring as they relate well to students and are eager to teach them what they know. Also, by doing so, residents may have a significant influence over a student's career choice.^27,28

2. Recognize that the process is one of continuous self-development and offers an opportunity to expand one's own fund of knowledge while helping another.

3. Establish an infrastructure that has support from senior leadership and is based solidly in an educational environment. The mentor culture includes the participation of the administrative assistant who processes the mentee's application, assists with orientation, and helps to create a warm, friendly, and caring atmosphere so that a culture emerges that is receptive to learning.

4. Prescreen the applicants and obtain a good match. A substantial body of research has found that mentors and protégés who are well matched on important personal and professional dimensions form stronger, more enduring, and more beneficial relationships.²⁹

5. Agree on expectations. Have the mentees outline their goals and objectives as a starting point for discussion. The mentor may need to narrow the focus of these goals or add more challenges to maximize the productivity of the mentee.

6. Define the learning process, that is, conferences, lectures, readings, daily or weekly itinerary. Be sure that the mentee understands what is expected and agrees to it.

7. Build in some reflection time so that you can assess your own self-development.

8. Evaluate the mentoring process to determine whether the program is still serving its initial purpose for yourself and your mentee.

9. Avoid potential conflicts by ensuring that the mentee has a separate educational supervisor and that the mentor–mentee relationship stays focused on fulfilling educational needs, not psychologic ones.

“What I Know For Sure”

So, what do I know for sure? As D.C. Tosteson³⁰ said: “We must acknowledge that the most important, indeed, the only thing we have to offer our students is ourselves. Everything else they can read in a book.” This quote resonated with me because I know that our youth are our future and they need our guidance. I know that everyone has a unique gift within, and when you give back from the heart, it helps delineate your purpose here on earth and further defines your identity. You might say that my philosophy of life is “Where your heart is, there your treasure lies” (Luke 12:34). About the mentees, I would offer that each one of their stories is unique but, having come through this program, their destinies are shared. They have helped me to realize “What I know for sure” (Table 3). I am so grateful to all those students because, through them, I have found my gift, my passion, and that is mentoring. It has provided me with numerous intangible rewards and allowed me an opportunity to give back, gain in wisdom, and shine in the light of those whom I have mentored.

Table 3

This leads me back as to why I am so passionate about mentoring. Why do I do this? The answer relates back to Saturday, October 25, 1975, 9:30 in the morning, the moment that I received my letter of acceptance to medical school. Having endured 3 years of rejections, this day was a life-changing moment for me. It was a long and steep climb, but I was finally in. I vowed at that moment that I would help others who wanted to become physicians in the future. Something that I could not see at that time was that my struggle to get there was, in retrospect, a pathway to discovering my gift of mentoring. It resulted in a vow that I would give something back, and I did.

Finally, I am profoundly grateful to have served as the president of the Western Trauma Association, one of my most cherished professional organizations. Much of the joy for me was having the opportunity to serve the organization and interact with so many friends and colleagues—and that is another very special gift!

ACKNOWLEDGMENTS

I thank Richard A. Schieber, MD, MPH, National Center for Zoonotic, Vector-borne, and Enteric Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, GA for his valuable assistance.

REFERENCES