What did Mary have? In the original version of my article [1], the probable diagnosis was included. Mary began taking penicillin 5 days before the onset of her mononeuritis. After the onset of pain, she discontinued penicillin, but unbeknownst to me, restarted it 2 days later. This strong antigenic stimulus may have induced a vasculitis and marked eosinophilia. Eosinophils can lead to a hypercoagulable state, which may have explained her venous thrombosis and pulmonary emboli. Biopsies of the skin lesions as well as a sural nerve biopsy were done after she had stabilized in the intensive care unit. Unfortunately, these biopsies were late and followed steroid therapy. The pathology was consistent with, but not diagnostic of, a vasculitis. On discontinuing steroids, Mary had no recurrence of eosinophilia or vasculitis. The most likely diagnosis is self-limited, penicillin-induced vasculitis. I agree with Dr. Pierach that doctors should not treat family members. I included these details to illustrate this important point. My purpose was not to assign blame (aren't we all to blame?) but rather to illustrate in personal terms the consequences of laissez-faire medicine.

Dr. Stemp's and Dr. Blumberg's letters are like the 80 personal letters I received from physicians in the past 2 months. Many complain of feeling like outcasts and claim to be looked on as "bizarre" for being concerned about their patients. Others have described discouraging personal experiences with ill family members in academic medical centers. Mary's case illustrates that attitude, not aptitude, often determines whether a patient receives excellent clinical care.

How do we reward and retain the outstanding clinician in our academic medical centers? Perhaps the promotion database should include a series of peer-reviewed patient charts in addition to a list of peer-reviewed articles, as well as letters from former patients and referring physicians, not just from academicians. Evaluations of clinical expertise by residents and fellow academic physicians might be scored in a similar fashion to the teaching evaluations provided by medical students. Mary's case has struck a raw nerve. Everyone agrees that there is a problem. Now we must all work together to forge a realistic and constructive solution.