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Medical Book Reviews

 


Review of The Checklist Manifesto by Atul Gawande

Reviewed by Andrew Nepo

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Ten Influential Discoveries:

  1. When constructing a large building, engineers of 17 different specialties use two giant checklists: one that enumerates all of the specific checks that need to be done, and a "submittal schedule" that indicates which people need to talk to whom and by when.

    The submittal schedule ensures that no one person attempts to solve a problem or make an important decision without making the necessary consultation. I thought the idea that making a checklist out of communication was not necessarily intuitive, but it is a great idea.
  2. "If the American government had responded like Wal-Mart has responded, we wouldn't be in this crisis." -Aaron Broussard, top official of Jefferson Parish

    During Hurricane Katrina, Wal-Mart decided to attempt to help out the New Orleans victims, and its upper management decided to leave a significant portion of the decision making in the hands of the middle managers on the ground in New Orleans. Gawande contrasts this strategy with that of FEMA, which he asserts was paralyzed by its centralized decision making strategy. He goes on to argue that in situations of extreme complexity "the required knowledge exceeds that of any individual and unpredictability reigns." The basic idea is that in these situations, namely surgery and hurricane relief efforts, individual freedom to act, tempered by the precision of checklists is a desirable quality.
  3. "By 2004, surgeons were performing some 230 million major operations annually... Worldwide, at least seven million people are left disabled and at least one million dead--a level of harm that approaches that of malaria, tuberculosis, and other traditional public health concerns."

    These statistics reinforced the idea that reducing surgical complications is worldwide matter of importance.
  4. "The secret... was that the soap was more than soap. It was a behavior-change delivery vehicle." In an intrepid public health study sponsored by Procter & Gamble, citizens living in the slums of Karachi, Pakistan, were given P&G's Safeguard soap with instructions to use the soap in six specific situations. As a result of this study, in the neighborhoods involved, diarrhea in children fell 52percent, pneumonia fell 48 percent, and the incidence of impetigo, a bacterial skin infection, fell 35percent. However, these households all had soap. Gawande asserts that the two important effects of the study were that it made soap readily available instead of a financial burden, and it systematized the use of soap, further supporting the idea that checklists are an effective means of achieving a goal.
  5. "Global multinational corporations are really focused on having a good consumer experience, which sometimes public health people are not." Another comment on the effectiveness of the study was the fact that the soap smelled good and lathered better than the usual soap people bought.

    When trying to effect a public health change, human values in design are critical.
  6. "He designed a pre-incision "Cleared for Takeoff" checklist that he put on the whiteboard in each of the operating rooms." Columbus Children's Hospital's director of surgical administration was also a pilot, and he designed a system in which the surgeon's surgical tools were covered by a six-inch stainless steel tent until a nurse deemed the "cleared for takeoff" checklist to be complete.

    Having a physical barrier to starting surgery that must be removed by a nurse ensured that the specified pre-surgical preparations would be complete. It also notably shifted the balance of power and reduced nurse's fears of questioning the surgeon.
  7. Another checklist implemented at Johns Hopkins involved all the individuals involved in surgery (i.e. surgeon, resident, nurses, anesthesiologists) speaking up before the surgery to discuss their concerns. This practice allowed the surgical teams to avert unexpected disaster--the open-ended kind that does not appear on checklists.

    I found this to be strikingly similar to the submittal schedule used by engineers to ensure construction safety and also to be a generally good idea.
  8. Brian Sexton, a pioneering Johns Hopkins psychologist, conducted a number of studies that showed that, "although 64 percent of surgeons rated their operations as having high levels of teamwork, just 39 percent of anesthesiologists, 28 percent of nurses, and 10 percent of anesthesia residents did. Sexton also found that one in four general surgeons believed that junior team members should not question the decisions of a senior practitioner."

    It's kind of scary how surgical culture in some ways prevents progress for the better.
  9. It is generally accepted that when team members take the time to know each other's names, they usually work as a team better. At Johns Hopkins, eleven surgeons agreed to make as a part of the pre-operating itinerary time for everyone to know each other's names. "After three months, the number of team members in their operations reporting that they functioned as a well-coordinated team leapt from 68 percent to 92 percent.

    This seems like common sense, but I bet this practice is far from standard. Yet another supporting reason to implement surgical checklists.
  10. The first time that Atul Gawande actually tried using a pre-surgical checklist himself, the nurse who read it aloud was confused as to what the checklist even meant. Gawande later studied good checklist qualities with a checklist expert at Boeing and learned that good checklists are precise, efficient, to the point, minimalistic, and, above all, practical. He later revised his checklist design.

    The take-home point is that, even for something as simple as a checklist, creating a good one requires considerable experience, insight, and trial and error.

 

Summary:

The Checklist Manifesto is a chronicle of a surgeon's efforts to reduce preventable error. Early on in the book he notes that philosophers make a distinction between errors of ignorance and errors of ineptitude. This difference is highlighted in medicine by the fact that for the majority of human history, medical errors were errors of ignorance; more recently, however, clinicians have begun to commit a larger percentage of errors of ineptitude. His explanation for this phenomenon is the fact that, although scientific knowledge has made leaps and bounds, the fidelity and precision with which we apply science to heal patients has not kept up. The sheer amount of knowledge required in order to execute surgery while avoiding preventable complications 100% of the time now exceeds that of any single individual. Surgery, then, is a situation of extreme complexity. In light of this somewhat discomforting observation, Gawande also notes that many other industries and trades that deal with extreme complexity, notably construction and aviation have long since embraced the concepts requiring that experts communicate with each other in a specified and systematic way and that practicing experts religiously use checklists. By availing themselves of these two things, Gawande asserts that surgical teams can significantly reduce the occurrence of avoidable complications.

Recommendation:

I would highly recommend this book to anyone. Gawande has a natural and readable writing style, and the book is a page-turner. Moreover, the breadth of discussion reflects Gawande's comprehensive fact-finding journey. Another interesting aspect of this book is the fact that it also delves into issues of the psychology of behavior change, which I find to be an interesting subject. People interested in achieving excellence, eliminating mistakes, and increasing team performance will find this book informative, regardless of their vocation or field of specialty.

Searchable Database:

Keywords: Surgery, quality of care, complications, medical culture, nurse-doctor power balance, checklist, communication, teamwork, behavior change, medical anthropology, excellence.

Questions: How can I be a consistent peak performer? How do surgery and world health relate? How is psychology applicable to the practice of medicine? What are some unmet improvements that need to be implemented in medical practice?

 


 

Review of Complications: A Surgeon's Notes on an Imperfect Science, by Atul Gawande

Reviewed by Hank Shih

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Ten Influential Discoveries:

  1. When we think of great surgeons, we commonly envision great hands, talent, and intelligence. The author, however, claims that these associations are not the vital aspects of a great surgeon. Instead, it is their willingness to stick with practicing one difficult thing day and night for years on end that proves to be most important. This observation provides great comfort to aspiring surgeons because it suggests that as long as you work hard and persevere, you can become a great surgeon.
  2. A dark secret among doctors is that learning must be stolen. Patients want both the expertise and progress that are usually given by more experienced doctors. However, it is imperative that novice doctors get trained or the entire foundation of medicine would crumble. Despite compromising patient care, attendings will supervise the residents/interns who perform the procedures, while never telling the patient it would be statistically better if the attending did it himself. Although this is an inevitable result since skills and expertise can only be acquired through practice, residents and interns must prepare themselves for the moral dilemma that surrounds this situation. For the future good, these novices must compromise (within limits) patient care.
  3. A Swedish study determined that the individualized and intuitive approach of modern medicine is flawed. It has been shown that given exact information, a computer often gives more accurate diagnosis than an experienced doctor. This happens because the doctor will incorrectly place more emphasis on different factors based on experience and intuition. Since this is the case, one must wonder why computers have not taken over diagnosis. I believe a very good reason is that patients expect someone to be their healer and caregiver, two roles that a computer cannot play. Patients want guidance along with a caring hand to tell them what is happening to them.
  4. Although we would like to think that malpractice centers statistically on bad doctors, that is just not the case. Instead, malpractice follows a bell-shaped distribution. It is a fact that virtually everyone who cares for patients will evenly make a serious mistake or even commit acts of negligence. In fact, an estimated 3 to 5 percent of practicing physicians at a given time are unfit to see patients. This logical, yet disturbing fact causes me to consider what will happen to my mental state if I believe I played a hand in killing a patient. Will I accept it as a lesson and persevere or be burdened with guilt? It's a difficult question to answer until the time actually comes.
  5. Doctors go through rigorous training to become skilled at what they do. It is logical to assume that they should be steadier, tougher, and mentally strong to handle the pressure that comes with the job. However, the evidence claims otherwise. Alcoholism is no less common in doctors than in the general population. Doctors are even more likely to become addicted to prescription narcotics due to ease of access. This evidence should get the premed student to consider if they have the strength of character to withstand the grueling stress that comes with the job.
  6. It should come to no surprise that the common cold is the leading cause of lost work time. The second leading cause is chronic back pain and it accounts for about 40 percent of worker's compensation payments. We would logically suspect that poor posture or lifting techniques are the prime culprits, but that is not supported by evidence. In the United States, the number of people who perform manual labor has steadily decreased, but more people have chronic back pain than ever before. Attempts to explain this epidemic through mechanical means have yielded insignificant results. It has been suggested that perhaps a psychological or social reason may be at hand. I found this information on chronic back pain to be quite surprising. As someone who studied engineering, I would have logically suspected mechanical stress as the primary reason. In addition, this would have probably influenced my diagnosis of chronic back pain. Perhaps this is a great example of why computers are more accurate than humans. By using our intuition and experience, we unknowingly weigh different factors more than others.
  7. At some point, a woman must wonder what evolutionary benefit pregnancy sickness brings. Margie Profet, an evolutionary biologist, suggested that pregnancy sickness may have evolved to reduce a developing embryo's exposure to natural toxins. By vomiting, women will expel ingested toxins. For example, the potato is a natural food that is safe for adults, but unsafe for embryos. In fact, the toxin in potatoes has been shown to cause disorders of the nervous system in rats. Perhaps this explains the relatively high rate of nervous disorders in infants in Ireland, which considers the potato as a staple in their food supply. This information is quite fascinating. As doctors, we treat the signs and symptoms while also trying to find an underlining cause. However, we often run into uncertainties like pregnancy sickness. Doctors treat the nausea and the vomiting, but also conclude that this is normal.
  8. We often think that it is the doctor's job to preserve life and do no harm. Perhaps it is surprising then that there are palliative specialists who are experts in the care of dying patients. Their job is not to prolong life, but to improve the quality of life. While other doctors see pain as a symptom, a palliative specialist sees it as a problem in itself. I imagine that pain is one of the most common chief complaints given by patients to doctors. Logically, wouldn't it make sense to judge a patient's progression based on his pain? Yet pain is not included in the vital signs that get monitored every 4 hours. In a sense, doctors see pain as only a symptom and not an underlining cause.
  9. There is a surgery known as endoscopic thoracic sympathectomy. The purpose of the surgery is to sever different fibers of a person's sympathetic nervous system, which controls breathing, heart rate, sweating, digestion, and interestingly enough, blushing. Despite side effects, perfectly healthy people have taken the surgery to remove their ability to blush for personal reasons. This type of surgery reminds me of the people who purposely break their legs to grow taller. If there is anything to learn from this, it is that people who are desperate for personal perfection will be willing to do anything, even risk their lives.
  10. During the 1950s, doctors did not give options to their patients. If there were multiple treatments, the doctor chose what he considered the best course of action. This steadily changed as patients demanded more autonomy. Soon, the doctors gave the patient all possible options along with the possible results, while hoping that the patient chose what he considered to be the right one. The awkward truth is that patients frequently do not want the freedom that was given to them. A study found that 64 percent of the general public wanted to select their own treatment if they developed cancer, but only 12 percent of them actually chose to do so. I found this fact to be quite revealing. I feel that the patients just want to feel in control of their lives, while also hoping their doctors will make the decision. This is like the rebellious teenager who wants to make his own decisions, and when given all the options, still follow the parent's recommendations.

Summary:

We would like to think that medicine, which is based on science, is logical and systematic. However, through various complications, this is simply not true. Doctors look for physical reasons to explain a patient's symptom, but the symptom may have resulted from a combination of non-physical stresses such as mental stress or social stress. What may explain one patient's illness may fail to explain another. A question can be asked: Are humans more like hurricanes or ice cubes? There are scientific models that describe the behavior of a hurricane. However, it is impossible (at the moment) to predict all its movements due to all the various factors that contribute to the formation of a hurricane. On the other hand, if you throw ice into the fire, it will just melt. Perhaps humans are a combination of the two. This may explain why a doctor's intuition can trump a computer. Nonetheless, doctors must be able to forge ahead, hoping that they will do the patient good, regardless of the uncertainty.

Recommendation:

I would definitely recommend this book for premeds to read. Not only is the narrative engaging and unpredictable, Gawande also reveals a world unknown to premeds. Some of the reality revealed may make or break a premed's desire to be a doctor.

Searchable Database:

Keywords: surgery, uncertainty, imperfect, physician's dodge, contradictory, patient care, machines, computers, intuition, healers, malpractice, negligence, mistakes, conferences, conventions, kinship, congress, alcoholism, addiction, flawed, chronic back pain, stress, manual labor, Margie Profet, pregnancy sickness, morning sickness, toxins, nausea, vomiting, motion sickness, palliative, suffering, embarrassment, blushing, endoscopic thoracic sympathectomy, ETS, sympathetic nervous system, appetizer effect, obesity, gastric bypass, autopsies, misdiagnosis, autonomy, patient autonomy.

Questions: Is medicine the right career for me? What is the learning environment like in residency? What are some moral dilemmas that I might experience in medicine? What are medical conventions like? Should I be worried about malpractice? How is chronic back pain viewed in the medical community? How do doctors usually treat vomiting and nausea? What is the purpose of motion sickness? Is it better to give a patient all the possible options or be definitive and push for one? How much does intuition play in the medical field?


Review of The House of God: The Classical Novel of Life and Death in an American Hospital, by Samuel Shem

Reviewed by Harrison Truong

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Ten Influential Discoveries:

  1. One influential discovery that I made while reading this book was the importance of medicine. Though this discovery was existent before stumbling on this book, The House of God, reading through and experiencing the perspective of our protagonist and narrator, Roy Basch, I have gained a better sense as to why medicine is such a tough and necessary field. Health is something very hard to keep constant through the process of aging, as demonstrated by the many occurrences of death throughout the book (i.e. the multiple MIs (myocardial infarctions), the odd occurrences of cancers, congestive heart failures, strokes, etc.) There simply exist so many instances of bad luck that can destroy someone's normal and healthy life, and it is the field of medicine that must address such cases.
  2. A second influential discovery was the difficulty of having a life outside of medicine. I always wondered how doctors or anyone in the field of medicine who was highly committed could have a life outside of their work. The intensity of medicine displayed through The House of God gave seemed to confirm that people involved in medicine did not have healthy lives outside of what they did. Roy Basch's life, along with the other interns like Chuck and Potts, were suffering, and as a result, they were losing their humanity and enjoyment of life. Their ties were completely to the hospital, the work involved in it, the patients involved in it, and the stress involved in it. As a pre-med, what worries me the most is first, the path of medicine, but secondly, once I conquer this path, having a family life outside of work. Having read this book really put the idea of life outside of medicine into perspective, making me reconsider how much of my life I am really willing to give up to medicine.
  3. The third influential finding was the life of an intern and its intensity. Honestly, now I am afraid. I am scared of the workload involved in being an intern. This does not even include my fears of getting into and through medical school, something in the near future. Roy, Chuck, Potts, Chuck, Howie, and Eddie experienced all as interns, the most intense and dramatizing year of their life. They went from being enthusiastic interns in the beginning to being sarcastic, cynical, and sad human beings.  I am afraid of the amount of work that threatens to crumble my emotions, destroy my happiness, and create a machine out of me.
  4. A fourth influential discovery was the difficulty of remaining compassionate in medicine. When I was reading the book, all I read about was Roy and his path towards sadness in medicine. The chronic ill treatment of patients as if they were simply objects that needed to be out of the way, the continuance of ignoring the needs of patients, the system existent in medicine, and so on, created an image for me of medicine as a machine. Patients serve as the oil to fuel work, and doctors as the engine doing the work and processing the patients.  Roy came to see that his compassion and love were deteriorating, and this was something that the hospital and its staff really needed to correct in order to change the image of a hospital as a cruel and cold system.
  5. A fifth discovery, although influential, was depressing – the depravation in the field of medicine. It deprived the characters of life, of emotion, of happiness. It destroyed their confidence, it ruined their relationships, and it created hate in their hearts. My understanding is that no kind of work is easy, and each field of work has its ups and downs. As for medicine, it seems that its ups are extremely obvious. There exists a well-paid salary as well as the benefit of saving people. However it seems that the cons really outweigh the pros in this book.  Medicine can be beneficial, but at the same time, it can have an ironic outcome of destroying the people who work in it.
  6. A sixth poignant discovery was the arduous nature of path to becoming a physician. Having a naive idea that it was going to be easy, my views were corrected by this book as well as by my mentors. The path to becoming a physician is hard work; it is intense, stressful, saddening, and as always, long. There was no easy way around it and that the path to be taken was only through what these interns had experienced in the House of God. I am afraid of what I want to do now, seeing that the path of medicine might not be suitable for my own personal needs and wants.
  7. The seventh discovery was the necessity of having a place of comfort, of nurturing. Roy had Berry, and The Runt had his sexual adventures with Angel. And Fats developed his keen way of dealing with everything. But whoever it was, there was a necessity for a level of comfort existent in the work of medicine. For example, Potts jumped out the window, committing suicide as he was consumed by the work in the House of God; Roy did not know how to help, and Potts did not talk to people to seek for help, and eventually, it got the best of him. This suggests to me that medicine is demanding, and that one really needs to have something to keep them intact with not only the world, but with themselves. There should be some kind of check.
  8. An eighth poignant discovery was my decision on practicing medicine in the future – I mean, is this what I really want to get myself into? As a sophomore on the pre-med track, I feel the pressure as well as the stress from the work involved to get to medical school. Having read the House of God, and going through many conflicting issues in life, I keep questioning myself if medicine in the sense of a hospital atmosphere was really what I wanted. Roy in the end never stuck with it, and began to diverge from hospital work. Is that what I should do and follow my interests? What is it that I am really interested in? I question myself continuously, and now have something to base part of my decision on.
  9. The second to last most influential discovery was the meaning of death – its impact, its effects, and its consequences. Death has always been an escaping topic because of its seriousness, but its existence in the hospital really put death into perspective for me. On my part, I have never experienced the death of someone I know or seen anyone die before my eyes. Working in the field of medicine will really put me in situations where death is commonplace and where I will eventually see it firsthand. How will I handle it? How will I process it?  In the House of God, death played a dramatic role in putting out lessons to the interns, such as Potts death and Dr. Sanders unfortunate fall. How will death play a role in my life? Will I be able to handle it? This is something I know I must experience to answer.
  10. The last discovery was the idea of taking a break – a gap year or gap quarter or anything relevant to this idea.  Having been in school since the age of four, I have been considering a gap year after graduating college. I do not know exactly what I would do – take a complete break like Roy to develop my personal life, or to follow my desires and explore the world through community service or research or something of that manner.  It seemed that what Roy did made sense; after all those years under pressure, he finally called time-out to have a period where he could recover, recharge, and reorganize his life. I mean, what is it to live when all you do is work? Much consideration has been put into this gap year for my own self-development.

Summary:

A key theme was the idea of compassion in medicine. Roy realized that what was missing in medicine, and what was needed to prevent the deprivation of their lives, was implementing compassion in their work. A second theme was the importance of death. Death was not simply something that occurred no matter what, but something that brought people to their knees, made them change their lives, and taught them lessons they will never forget. Death was a tool used to help life. A third theme was the idea of loneliness. It is something we cannot escape from, but it is something we must inevitably go through to learn lessons that we would miss if we were blinded by love or friendship.

Recommendation:

Yes, I would definitely recommend this to other premeds because it depicts the future that they are getting into. The lessons of being an intern are displayed vividly through the lens of Roy. It really gives premeds how and what medicine is at the highest level at a perspective straightforward and truthful. Basically, it is a yes.

Searchable Database:

Keyword: "Career Exploration," "Compassion and Medicine"

Question: "Is medicine the right field for me? (specifically for hospital-related work), "How does medicine affect my personal life?," "Where does compassion come into play in the medical field?


Review of The Lives of a Cell by Lewis Thomas

Reviewed by Ann Leu

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Ten Influential Discoveries:

  1. In his opening essay, Thomas points out that man has a bad habit of believing himself to be above all other forms of life, when in fact, he is much more akin to nature and interdependent on it than he would like to admit.  On a couple occasions, he compares humans to insects, but admits it could be perceived as "bad form."
  2. Thomas defines three levels of technology in medicine: 1) "nontechnology" - supportive therapy for patients who suffer from diseases that current technology is unable to treat effectively, 2) "halfway technology" - treatments for diseases that delay death but don't resolve the actual issue, and 3) effective cures.  The first two levels take up most of the doctor's time, but the third is most important.  Thomas's analysis of technology in the 1970's is still very relevant today and illustrative of the necessity of research.  Research allows for the thorough understanding of disease mechanisms, which is the only way to produce effective cures.
  3. Thomas explores the olfactory abilities of various animals and discusses the importance of olfactory sensing as a form of communication.  This type of communication allows for each form of life to announce its presence, claim its territory, and form symbiotic relationships.  In a sense, odorants are an indicator of identity, and Thomas suggests that schizophrenics may have a compromised ability to perceive their own and others's signals, which could be a potential explanation for their disorder.  I thought it was very interesting how Thomas tied our olfactory ability with a psychiatric disorder.  He really thinks outside the box and encourages the reader to seek less obvious explanations to understanding the mechanism of a disorder.
  4. Thomas spends one essay discussing the misconception of germs.  Not all germs are harmful, and most have symbiotic relationships with their host.  We incorrectly perceive that it is the germs that are most harmful to us when in fact it is our defense mechanisms to the invader that largely constitute the disease.  "We live in the midst of explosive devices; we are mined."  Since I have not taken any immunology classes, Thomas's perspective has made me really look forward to learning more about our body's defense mechanisms.
  5. Although there are many disorders out there, Thomas believes that most people underestimate the durability of the human body and that "most things get better by themselves."  With excessive media coverage about cancer and other diseases, the general population is overcome with fear and has become more paranoid about their health anytime they experience a minor symptom.  Thomas suggests having a better system for educating the public about their health.  This made me think about the dynamics of the ER and how it could change if the public had better health education.
  6. Thomas notes that language is the only form of communication that allows for ambiguity.  He uses several examples to illustrate how imperative it is for non-language communication to proceed by a precise mechanism.  On the other hand, language-based communication necessitates ambiguity in the transmission of information.  I admit I don't fully understand his argument but it inspires me to further contemplate communication.
  7. Although death is an inevitable part of life, it is a concept we like to ignore and treat as an abstraction.  Death is happening around us, all the time - we are just not conscious of it.  When walking through a park, plants, insects, and birds are dying all around but our focus lies elsewhere.  However, when we do see death, we are still taken aback by it.  "A dead bird is an incongruity, more startling than an unexpected live bird, sure evidence to the human mind that something has gone wrong."
  8. Thomas notices the philosophical notion of identity and self in the symbiotic relationships between prokaryotes and eukaryotes, and between animals, and in immunology.  It makes me wonder, how would one define identity and self in biological terms?  Mitochondria, which long ago were separate organisms, are now an integrated part of eukaryotic cells.  At what point did they become part of the identity of the eukaryotic cell?
  9. Basic science research and applied science research are both essential to develop effective therapies to treat disease.  But how do you balance the two to maximize progress?  Planning and organization is necessary on the national scale (i.e. NIH).  The essay on the "Planning of Science" made me wonder about the strategies and methods employed by institutions such as the NIH to facilitate medical advancements.
  10. In an essay titled "Computers," Thomas talks about how the world is connected by telephones, radios, newspapers, airplanes, televisions, etc. and states, "We are becoming a grid, a circuitry around the earth."  Over thirty years later, with the invention of the Internet, smart phones, Facebook, and Twitter, Thomas has demonstrated tremendous foresight.  If Thomas were still alive, I wonder what insights he would have.  He also compares the collective thinking of human minds to a coherent, living system.

 

Summary:

This book is a collection of twenty-nine essays written by Lewis Thomas, a physician who wrote a regular column for The New England Journal of Medicine from 1972-1974.  Each essay covers a different topic but several themes do appear throughout the essays.  One major theme is that man is not above nature and that everything is intertwined.  Each essay takes an interdisciplinary approach to a particular topic, and Thomas points out similarities that the casual observer may not notice.  Thomas has a keen ability to identify recurring themes across seemingly unrelated topics and describe very eloquently their hidden relationships.  The topic of identity and self also arises in a number of essays.

Recommendation:

This book does not offer advice or information that a premed would immediately find helpful in getting into medical school.  However, Thomas offers a refreshing and unique perspective in his observations across various topics and how it ties with biology.  He notices similarities in seemingly unrelated situations and reminds us to keep an open mind when analyzing situations.  Varying topics are covered including music, language, death, insects, and medicine.  His essays allow the reader to make new connections in various fields of study.  Because he uses real examples from biology in his discussions, the reader can use his essays as a springboard to do additional reading and learning.  Although it is a short book, I wouldn't recommend it as a quick read.  The reader would benefit from spending some time to contemplate the topic after each reading.

Searchable Database:

Keywords:  'biology', 'philosophy', 'collection of essays', 'New England Journal of Medicine', 'man and nature', 'music', 'language'
Questions:  "What are some major themes in biology?"  "How is biology tied to other areas of study?"


Review of Do No Harm, by Lisa Belkin

Reviewed by Caroline Bank

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Ten Influential Discoveries:

  1. The Composition of an Ethics Committee:

    When I imagined an Ethics Committee, I pictured a committee made up of doctors and lawyers alone. I did not think that this combination would always be very effective. The Hermann committee, however, is made up of many doctors, nurses, social workers, an ethicist, a priest, a rabbi, a minister, the head of quality assurance, the head of Patient Relations, the hospital lawyer, and one ordinary, non-hospital affiliated citizen.
  2. The Role of a Hospital Ethics Committee:

    Before I read Belkin's book, I thought that the role of an Ethics Committee was not to make decisions, but to judge the decisions doctors had made on their own. I was under the impression that the principle goal of an Ethics Committee was to reprimand or praise doctors for their decisions, and to decide whether the actions taken should be repeated in the future. However, after I finished the first chapter, I understood that the purpose is to make decisions beforehand, and then to advise the doctors and families about a recommended course of action. I also did not know that it was normal to hold a meeting at least every month; I thought the committees were called only when deemed necessary.
  3. The Involvement of the Ethics Committee in Important Decision-Making:

    I had always thought that the patients (if they were able to make the choices) and their families were left almost entirely alone to make the important sort of decisions discussed in First, Do No Harm. I felt that this seemed unfair, in a way, as it left the ones who knew the least about the facts of the situation and who were in the most emotionally unstable position to make such difficult choices. However, as I quickly learned, at least at Hermann Hospital, the Ethics Committee has a great deal of influence, lessening the burden of the decisions on the families.
  4. Alternative Care for Permanent Disabilities:

    I used to wonder what happened to people like Armando Dimas, permanently paralyzed, with a family unable to support him. Belkin describes a place called the Total Life Care Center, where such patients can stay. Run by a single individual, Hermina Bartkowski, the Total Life Care Center offers services for the uninsured and those unable to pay. The bills are paid for by the hospital, but the costs are much lower than the exorbitant costs of staying in the hospital itself.
  5. Cost of Care in Hospital:

    Although I knew the cost of medical care was high in the United States, I did not realize how expensive everyday items such as sponges and oxygen were. Although it makes sense that hospitals would need the money to pay for all of their employees, the prices described seemed incredibly inflated. I feel that this is something to be aware of as I enter a hospital setting.
  6. Research on Forced Bowel Growth:

    I thought the idea of the "surgeon at Baylor who's experimenting with stimulating the bowel to make it grow" (Belkin, 9) was fascinating. I still do not quite understand, but this kind of generation, or regeneration, would be incredible if it were possible. The full gut transplants, which so far have resulted in death, mentioned on the same page are similarly interesting.
  7. The Reactions and Relationships of Patients with the Hospital:

    I found the difference between Patrick's attachment and Armando's hatred very interesting. While Patrick would purposefully contaminate his line in order to come back to the hospital, Armando would spit at nurses and doctors.
  8. The Rate of Improvement in Keeping Premature Babies Alive:

    Although I knew that preemies were surviving at a much higher rate, I did not realize the rate of progress. In 1975, only 6% of babies weighing less than 2lbs, 2oz survived. During the beginning of the 1980s, this percentage reached 50%. Although this is an amazing rate of improvement, it also results in much higher costs and in the survival of babies with serious permanent mental and physical conditions.
  9. Measures Taken for Preemies:

    An especially fascinating example of the extensive system developed to care for the preemies is the map showing the distance from Houston in 25 mile units, so that the time it will take for a helicopter to bring a new baby can be predicted almost exactly.
  10. Government Involvement in Hospitals:

    Before I read this, I was under the impression that governments rarely involved themselves with hospitals. I always believed that hospitals were left to function independently, and the government was only involved if something terrible happened. However, Hermann was monitored quite closely by the government.

Summary:

In First, Do No Harm, Lisa Belkin explores a selection of choices made by the Ethics Committee at Hermann Hospital in Houston, Texas. These decisions range from whether to perform yet another surgery on a young boy with severe Hirschsprung's disease, to whether to keep a brain- and liver-damaged premature infant alive as long as possible when death inevitable, to what to do about a belligerent, uninsured, permanently paralyzed man. Belkin describes the cases, the factors considered in the decision-making process, the decisions made, and, finally, the results of these decisions. Interwoven among these stories is background information on the structure of the hospital and how the hospital functions.

Recommendation:

I would recommend this book for pre-meds, as I believe it illustrates both the difficult ethical choices doctors may be faced with and the support system they will have to make these decisions.

Searchable Database:

Key-words/Key-phrases: ethics committee, ethical decisions, choice, premature, Hirschsprung's Disease, permanent disability, cost of care

Key Questions:

What are the hidden costs of medical care?
How much does it cost to treat a patient?
What support is there for medical decision-making?
How is an Ethics Committee organized?
What is the role of a hospital Ethics Committee?
What happens to uninsured and permanently disabled patients?


Review of Kill as Few Patients as Possible, by Oscar London

Reviewed by Gustavo Chavez

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For my personal exploration project I choose to read the book titled Kill as Few Patients as Possible by Dr. Oscar London M.D., W.B.D. in which he outlines his approach and guidelines for being a doctor. Dr. London makes use of a lighthearted tone, which alleviates the sometimes-somber tone of medicine. The book was recommended to me by a Stanford medical student, so I thought it was appropriate to read it, and present it as my personal exploration project. Once I started reading it, I was amused and excited since the book reminded me that soon I will be dealing with patients. I took many principles from the book, but I will present some of the most interesting, guidelines and stories he presents.

The second chapter of the book is titled, "Have a lovely office" in which he explains the importance of having a decent clinical space and how to approach this aspect of medicine. Upon reading the chapter, this paragraph caught my eye:

He [the physician] must not pipe music into his waiting room. If he has a burning desire to inflict music on his patients, he should bring in a live string quartet and restrict them to Haydn and Schubert. If he has a largely Chicano practice, a mariachi band is acceptable, provided the trumpet player mutes his instrument and the tenor refrains from spritzing during high notes (London 5).

Other than the humorous image of having a mariachi band playing the waiting room of a clinic, I found it profound the argument that he is presenting in the chapter. The argument that London presents is that the physician should tailor his practice, but more specific his workplace to the needs and desires of his patients. The clinic should make them should feel comfortable as well, which places focus on the patient rather on the physician. Often, I feel that a physician forgets this important detail, which has a profound impact on how he or she treats patients.

In reading the book, my image of a physician was brought down from the pedestal and put under a more realistic lighting. What caused this change of perception was one of his cases where London is called upon to give a second opinion of a case. Unable to make a diagnosis, the thought of giving up on the patient crosses his mind; however, he refuses and decides to ask a more experience physician to take a look. Luckily, he is able to correctly diagnose the patient, and with that London is able to understand the importance of experience, yet still maintain confidence in him.

Another chapter that caught my attention was "Don't call a Rose a Rose; Call her Mrs. Schwartz" where the intricate nature of the patient-doctor relationship is described. London describes that he once had a secretary who would refer to the patients by her first name, until one day Mrs. Rose Schwartz was very offended by this practice. Mrs. Schwarz was irreconcilably perturbed and chooses to leave. London goes on to explain that a doctor should always refer to her patients by their last name, and even more so by his staff. A doctor can only refer to his patients by first name if he allows them to call him by first name as well. The nature to how doctors refer to their patients elucidates the level of respect that a physician has towards his patients. That respect will bode well for his practice and career.

One of his most poignant points of advice he gives is that a physicians should always be less anxious than his patients. He says:

If a young doctor wants to live to see his fortieth birthday, he's going to have to learn to mold the gelatin of his emotions into a semblance of the rock of Gibraltar. He mustn't let depressed patients drag him down to their niche in the pits or let nervous patients yank him up into their electrical thunderheads. He must be the eye in the storm of his patients.

As it is well know, a physicians deals with the patients and wellbeing of his patients, positioning him in highly stressful situations in a daily basis. The amount of stress can place a heavy toll on the physician, significantly affecting his performance, personal life, and overall wellbeing of himself and his patients.

London's book, Kill as Few Patients as Possible, presents many pieces of advice, which I believe, any premed, medical students and physician can benefit from. Moreover, the lighthearted tone of the book enriches its reading.


Review of Becoming a Doctor, by Melvin Konner

Reviewed by Robin Chin

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Ten Influential Discoveries:

  1. Age of incoming medical students:

    The average age of students entering medical school is older than I expected (~26).  I assumed that most students enter medical school as soon as they graduate college, but in actuality many students take time off to work or explore other passions.
  2. Most important factor for getting into medical school:

    The standard for entrance to medical school is based heavily on grades in science courses.  Konner notes that a high GPA only indicates how well someone might do in medical school classes; less emphasis is placed on the students' actual capability as a future physician.
  3. Lack of creativity in medical school coursework:

    Konner uses his experience as a professor of anthropology to make contrasts between medical and graduate school.  Graduate school, he claims, encourages individuality and open thought.  Medical school, on the other hand, rewards submissive attitudes and punishes students who try to overstep their roles.  After reading this, I realized that this process starts with the undergraduate premedical course of study.  This track so heavily emphasizes the sciences that there is very little creative thought or exploration of the humanities; rather, students spend much of their undergraduate years focusing on memorization of facts and test-taking skills.
  4. Teamwork:

    Becoming a Doctor emphasizes the necessity of teamwork in the medical field, and the beneficial influence that a partnership among residents can have on both the physician and patient.  This point is important to remember when considering the medical field; the ability to relate to others is crucial to a physician, and those who prefer a more isolated environment may want to consider a field in research instead.
  5. Flaws of the medical school system:

    The medical school system is riddled with flaws and negative consequences.  According to Konner, 20-46% of students require mental health services, and students adopt an unrivaled sense of cynicism not detected among students in law or business school. Konner constantly recounts stories of miserable, sleep-deprived students and the grueling pace kept by doctors who are forced to cut corners in the treatment of their patients.  Konner concludes that this system creates a culture of hostile doctors who treat patients as burdens rather than actual human beings.
  6. The reputation of doctors:

    The general public reveres doctors as almost godlike, a reputation that is undeserved and unchallenged.  Konner spends much of the book recounting stories of his fellow doctors mistreating, ignoring, or discrediting their patients, who almost never protest the rude practices of their physicians.  These doctors were not held accountable for the satisfaction of the patient; rather they were judged on how quickly and efficiently they dealt with their cases.
  7. The value of a physician's skills:

    At the same time, physicians have a certain set of abilities that no other members of society possess.  Konner himself discusses moments when random crises called upon his medical skills in daily life outside the hospital, such as a passenger who collapsed on an airplane, or a victim of a car crash with a head injury.  The ability to lend assistance to those in need in an emergency is a valuable and unique asset that is only acquired through the practice of medicine.
  8. Raising a family during medical school:

    It is possible, though perhaps difficult, to raise a family while in medical school.  Konner, who entered in his mid-thirties, had a wife and two children at home while he was completing his education.  Despite the excessive time commitment, his home life did not appear to suffer significantly during his four years training to be a physician.  It is important to note that a career in the medical field does not necessarily require major sacrifices in one's personal life.
  9. Graduating medical school doesn't necessarily make one a good doctor:

    Just because a person makes it through the rigors of medical school successfully does not mean he or she is necessarily a talented or qualified physician.  Over and over again, Konner notes cases in which highly credited physicians made critical mistakes, or dismissed their patients altogether.  Most of these physicians regarded many patients as wastes of time, and failed to treat major, ongoing problems (such as throwing an alcoholic back onto the street rather than referring him to a psychiatrist).  According to Konner, the main difference between a "good" and "bad" physician is the attitude with which doctors approach their patients, focusing on the choice to treat patients as people, rather than problems to be solved.
  10. Choosing to go to medical school doesn't dictate the course of one's life:

    Most importantly, choosing to enter medical school, graduate school, or the work force does not determine the course of one's life indefinitely.  Konner started as a graduate student, became a professor of anthropology, entered medical school and completed his M.D., decided not to practice, and went into health intervention and disease prevention.  His experience reveals the flexible nature of choosing a career.  While one may choose a profession early on, plans and goals will likely change with time.  Choosing medical school does not necessarily lock oneself into a career in medicine.

 

Summary:

Becoming a Doctor is an anecdotal account of Melvin Konner's experiences in his third and fourth year of medical school.  A former anthropology professor who entered medical school in his mid-thirties, Konner gives an unconventional perspective on the system training today's physicians.  Much of the book spends time discussing his growing disillusionment with his superiors and their failure to emphasize patient care.  Though he notes the flaws in medical education, the book concludes that the system still produces talented doctors who create a superior medical practice unrivaled in most of the world.  In addition, Konner recognizes the slim chance that the current style of teaching in medical school is unlikely to change, despite widespread recognition of the various issues associated with both the classroom and clinical experiences.  Rather, he emphasizes the importance of each individual physician's attitude towards fellow doctors and patients that determines the quality of practice.

Recommendation:

This book is definitely a worthy read for anyone who is currently on the track to medical school.  While it would probably provide little assistance in choosing whether or not to go to medical school, it is more likely to be helpful for those who are already set on being a physician.  Because it focuses on the flaws within the medical school system, rather than the general practice of medicine, its main value lies in the lessons it can teach future doctors.  These lessons stress the importance of approaching medicine with a combination of professionalism and humanity.

Keywords:

Medical school, residency, clinical rotations, medical students, third year, medical profession, memoir.

Questions:

What makes a good doctor?
What is the third year of medical school like?
What are the different paths to medicine?
Do all physicians end up practicing?
Does a background in the humanities make one a better doctor?
When should I enter medical school?
Is medical school the right choice for me?
Is it better to follow the premed track during college?
What is the most effective approach for treating patients?
How do clinical rotations work?
How does the chain of command work in the medical field?
Source: Konner, Melvin.  Becoming a Doctor: A Journey of Initiation in Medical School.  Penguin Group, New York. 1987.

 

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