Showing 1 - 10 of 175 annotations tagged with the keyword "Racism"

Primary Category: Literature / Nonfiction

Genre: Treatise

Summary:

This important and much needed book describes the psychological difficulties of doctors in training and in practice and the woeful lack of support to them from teachers, colleagues, and institutions. When there are over 50 percent of doctors suffering burnout (or depression, even suicide), shouldn't we see and ameliorate this "significant public health crisis" (p. 263)?
Carolyn Elton is a vocational psychologist who has spent the last 20 years working with doctors in England and the U.S.  She has worked with over 600 doctors in a wide variety of specialties. 
  
 
Introduction: “Medicine in the Mirror”
Elton starts with a real-life email from a desperate medical student. She cites examples of med. students who commit suicide, studies of depressed doctors, and surveys that show impacts on medical care for all of us when it is given by doctors suffering from poor morale.

Ch. 1, "Wednesday's Child" discusses young doctors suddenly thrown into clinical practice; many are unready for the stress, and many training programs do not support them sufficiently.

Ch. 2,  "Finding the Middle." Many senior doctors are inhospitable to young doctors, especially those trained in other countries, for example India. There’s hope for sharing and support in  Schwartz Rounds, where staff (clinical and nonclinical) meet and discuss issues.

Ch. 3,  "Which Doctor." We learn that many troubled doctors have chosen the wrong specialty for them, often because of a specific illness in their families. They should have more time to chose or, even, to change specialties.

Ch. 4, "Brief Encounter."  Psychological concepts of transference and counter-transference are helpful in understanding sexual issues (examining patients' sex organs, homosexuality, sexism, inappropriate humor, attraction to a patient, even past sexual abuse). Many of these are common but so taboo that they are ordinarily—and unfortunately—not discussed in training. 


Ch. 5, “Role Reversal.” The book’s title “also human” is front and center here, because doctors become sick, injured, or otherwise compromised so that they must have medical assistance. Regrettably, other doctors often dismiss such problems or even blame the doctor for causing them or not overcoming them. Further, doctors often try to avoid a sick role. Psychological dilemmas and physical disabilities are often stigmatized.

Ch. 6, “Leaky Pipes.” Women doctors are often ill-treated, especially in surgery, where “surgical culture embodies masculinity” (p. 152). Women wishing to have children and family life in general are seen as slackers. Women doctors often “leak out” from hospital work to part-time community-based roles.


Ch. 7, “Risky Business.” Once again, we read that there is bias against Asian, black, disabled, or female doctors.  Specific examples and studies from social science make this dramatically clear. This unfortunate dynamic makes careers in medicine for such doctors “psychologically risky” (p. 192).

Ch. 8, “No Exit.” For many reasons it is hard to quit medical school, later training, or work in medicine, even when this is the best choice. Doctors often feel pain, even guilt when patients die, and they have little support.

Ch. 9, “Natural Selection.” Reviewing many problems already discussed, Elton summarizes: “sometimes the dream of training as a doctor turns out to be a nightmare in reality” (p. 229).  There’s bias in selection of students, reliance on tests with limited accuracy, insensitivity to the whole person, and inappropriate retention of students who should not become doctors. The Darwinian chapter title is ironic; much of the medical world as structured today is not natural.

Epilogue, “There’s No Such Thing as a Doctor.” This arresting subtitle brings us back to the personhood of doctors, who have psychological needs right along with the rest of us. Regrettably, “doctors’ psychological needs are denied, ignored, not thought about. Unmet” (p. 258). Sexism and racism are common. Lister’s reforms took a long time but are now pervasive and standard; can we similarly expand better care for doctors?  “Improving the emotional well-being of the medical workforce requires interventions that tackle three interconnected levels—the individual, the organization, and the culture of medicine as a whole” (p. 265).

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Summary:

This is an important contribution that analyzes, critiques, and aims to correct structural inequalities (racism, sexism, capitalism) that influence contemporary medicine, with particular attention to the technical influences of computers, “big data,” and underlying values of neoliberalism, such as individualism, exceptionalism, capacity, and progress through innovation.  

Introduction: Theorizing Communicative Biocapitalism
Banner writes, “biocapitalism is comprised by the new economies and industries that generate value out of parts of human bodies” (p. 12). Parts include DNA, ova, and organs, but there’s also data from medical care, where patients are reduced to their physical bodies and/or to their “digital status” in medical records, research, even personal information volunteered on the Web, all which is indicated by the term “communicative.” As an example, Banner cites the large realm of patient on-line groups that are exploited by large companies as free labor, thus reducing the voice of the patients. Approaches of narrative medicine and medical humanities have not dealt with digital health, market forces, and the implied power relationships. Perhaps the new subfield of health humanities has promise to do so, if not also captive to “the logic of the market” (p. 17).   

Ch. 1. Structural Racism and Practices of Reading in the Medical Humanities
Banner writes, “Medical racism is a product of structural and institutional racism” (p. 25). She finds that current approaches from interpretive reading are insufficient because “the field’s whiteness has contoured its hermeneutics” (p. 25). Instead of the “reading-for-empathy” model, we should read for structures of racism, sexism, privilege, as well as economic and political inequality. She illustrates such reading with texts by Junot Dìaz, Audre Lourde, and Anatole Broyard.  

Ch. 2. The Voice of the Patient in Communicative Biocapitalism
 Patients have flocked to networking websites, voluntarily posting much personal information. Banner analyzes how technocapitalists mine these sites for data to use or sell. Patients’ information, given voluntarily, amounts to free labor and, even, work-arounds for companies that avoid expensive double-blind controlled studies. Rhetoric for these sites speak misleadingly of the “patient voice,” “stakeholder,” or “story sharing” and hide the exploitation involved. The chapter is specific for websites, drugs, and drug companies.  
Banner discusses (1) the “feminized labor” involved with sites for fibromyalgia and chronic fatigue syndrome (both “contested diagnoses”) and (2), more abstractly, the medicalization of the clinical gaze on patients who participate in websites and yearn for “an imagined state of purity,” and/or “an ableist vision of norms and reparative medicine” (p. 61). Overall, the digitalized-patient voice is colonized by forces of whiteness and should be decolonized. She discusses writing by Octavia Butler and Linda Hogan, both women of color.

Ch. 3. Capacity and the Productive Subject of Digital Health
This fascinating chapter describes and critiques “digital self-tracking,” or the use of devices such as Fit-Bits that help create and maintain the so-called “Quantified Self” (or “QS”). Banner finds this fad within the tradition of the Enlightenment (Ben Franklin) so that “exact science” may “optimize” individuals by being “responsibilitized” in a “self-sovereign” way. QS users understand that “Everything is data” (p. 83). She argues that this trend emphasizes “masculine objectivity” while “disavowing debility” (p. 85). Collected data may contribute to a “worried well” status or conditions of “precarity” or “misfitting.” She writes, “QS practice remains an inscription of the self as a self-surveillor, engaged in masculinized practices of neoliberal self-management” (p. 91). She discusses the technologies of the devices Scanadu, Melon, and Scarab. She provides and interprets photos of visual arts representations by Laurie Frick, who is a “self-tracker.”  

Ch. 4. Algorithms, the Attention Economy, and the Breast Cancer Narrative
Banner discusses Google Analytics, later Alphabet, which includes Calico and Verily, which have partnered with pharmaceutical companies. Such combinations of algorithms, capitalism, and media aim to capture the public’s attention, especially online. Messaging about breast cancer becomes reductive, emphasizing medical solutions, not prevention, and it avoids discussion of causes such as environmental pollution. Some critics decry “pinkification” of breast cancer. Public stories, such as Angelina Jolie’s, emphasize individual empowerment, a “hegemonic construction of illness”’ (p. 112), and these are amplified by mass media, both print and electronic. More diverse messages would value “heterophily over homophily” (p.121).   

Ch. 5.  Against the Empathy Hypothesis
Drawing on several commentators, Banner critiques the notion of empathy as a goal for caregivers as condescending to the patient and suspect when allied with productivity and efficiency for institutions. Further, the notion of “resilience” (in a “bleed” of neoliberal rhetoric into health humanities) has been misused in applied literature, parallel to notions of self-help and self-management. Some hermeneutics still support values of “state and capitalism” and ignore writers of color. Banner discusses the work of African-American poet Claudia Rankine, some of whose work is “postlyric,” and J. M. W. Turner’s painting “The Slave Ship” that illustrates “necropolitics.”  

Conclusion
Throughout the book Banner illustrates reading “for structure” in her interpretation of texts and visual images but also in medical institutions and practices and, still further, in the enormous and pervasive world of government forms and programs, big data, computers, and beyond. She finds structures of capitalism, sexism, and neoliberalism within existing “heteropatriarchal, ableist, and racist frameworks” (p. 154) despite claims of neutrality. She urges medicine and the humanities to develop new methods. She mentions specific collectives and communities that now challenge such norms (such as Gynepunk and CureTogether), and she calls for thinkers in many disciplines to confront demeaning technology and to “engender spaces in which care is more just, and more humane” (p. 156).      

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Summary:

This powerful—even disturbing—book examines the state of Louisiana, a home of the Tea Party, multiple polluting industries (oil, chemicals), environmental degradation, bad health for all, including children, and politics and economics that favor corporations not local business. 

In Part One, “The Great Paradox,” sociologist Hochschild interviews locals, attends civic events, sits in cafes, and listens to stories. Bit by bit she understands that right-leaning people believe in Republican notions of less governmental regulation despite suffering from the ill effects of living in “red” states, even individual counties, that are the most polluted in the U.S. (pp. 79-80).  She calls this disparity “the great paradox.” Locals call a portion of the Mississippi between Baton Rouge and New Orleans “Cancer Alley” (p. 62), but there is no popular demand for control of pollution.

Part Two, “The Social Terrain” discusses history. Earlier, Louisiana had economies of fishing and farming in tune with the landscape. New industries, including Big Oil changed all that, with promises of jobs and wealth for all—neither of which occurred, because oil is largely mechanized, and wealth went to corporations, some headquartered in other countries. Further, there was not just pollution but also large sinkholes and the BP Horizon blow-out of 2010. Problems of on-going pollution were ignored by the Press, especially Fox news, and the “Pulpit” (evangelistic Christianity) took the longer view, urging continued human exploitation of nature, patience for ultimate rewards, and the hope that “the rapture” would ultimately save the most worthy Christians.

Part Three is “The Deep Story and the People in it.” Hochschild formulates an unspoken but motivating narrative of values in Louisiana. This metaphoric story represents deep feelings, including urges for a success that is always thwarted. In the story, there is a long line of white, Christian people, mostly male, often with limited education, waiting in line patiently to climb a hill. On the other side is a good job, wealth, security, and reward for the long waiting. Tragically, there are “line cutters,” symbolized by President Obama and other blacks who had various preferments, but also women, also immigrants, also refugees, even the brown pelican, the Louisiana state bird that needs clean water and fish to survive. The people in line feel betrayed. Where is progress toward the American Dream? Fair play? There is hatred toward the line cutters, and loyalty toward the similar people in line and the industries that will save them. Pollution is unfortunate but a necessary cost.

“Going National” is the fourth part. Hochschild reviews the plantations of the South that not only brutalized slaves but also caused poor whites to move to non-productive land, while the wealthy always improved their lot. People from the North were (and are) suspect, with policies of integration, abortion, gun control, etc. The North cut in line. People in Louisiana became “strangers in their own land” and therefore glad to support not only Governor Bobby Jindal (who “left the state in shambles,” p. 232) but also Trump who would “make American great again.” The “strangers” have gone national in the U.S. and even in some other countries. Hochschild drafts two short “letters,” one to the liberal left and the other to the Louisiana people. She suggests that the two polarized groups have more in common than they currently imagine.  



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Summary:

This engaging memoir describes Pearson's medical training at the University of Texas Medical Branch (UTMB) on Galveston Island from 2009 to 2016. During these years her personal values become clear, and she finds fault in her training, in medicine as practiced in Texas, and even in her own errors in treating patients.

Having left a graduate writing program, Pearson took a "postbac," a year of pre-med courses in Portland, Oregon. She interviewed at medical schools "all over the country" and writes satirically about them; she concludes "nothing out of Texas felt quite right," having lived there and done her undergraduate work at University of Texas at Austin. She's a Spanish speaker with a working-class background. When her classmates provide the annual “white-trash”-themed party, she wonders, “do I go as myself?” (p. 21).

Pearson's education continues on three tracks: the formal UTMB courses in medicine, a simultaneous Ph.D. program at the Institute for the Medical Humanities at the University of Texas, and her volunteer work at the St. Vincent's Student Run Free Clinic. The Ph.D. program is off-stage, not mentioned, but the St. Vincent's Clinic becomes pivotal to her development as a doctor and a moral person.

As for medical school, she finds the relentless "truths of biochemistry and anatomy" so reductive that the suffering of people and surrounding politics seem "not to matter at all" (p. 70). Among the politics are: the lack of safety nets for poor people, the use of uninsured (including prisoners) for students to practice on, failures to extend Medicare, pollution (notably from the oil industry), losses of charitable care, and income disparities that include crushing poverty for many. Something of a rebel, she writes that medical school "felt like junior high" (p. 44). She does enjoy the "clinical encounters" with real patients.

St. Vincent's, by contrast, was “a relief.” Her pages sparkle with her conversation with clinic patients, some homeless, all poor, and all suffering. She reports--confesses, she even says--her errors that had consequences for patients. She writes that errors are an unavoidable part of medical education, but that it's wrong that they should routinely happen to the poorest members of society.  

Chapter 8 discusses depression, which she felt after the second year. She writes about high rates of suicide among medical students and doctors; indeed a close friend killed himself during the "post-doc" year. Because some states require doctors to report psychiatric care, some doctors avoid such care. This consequence “drives a suicide-prone population away from the help we may need" (p.92).

The last two years are the rotations through specialties: surgery, dermatology, trauma, rural medicine, neurology, internal medicine, and so on. These are clearly and insightfully described. In one case (internal medicine), she allows the reader to see the irony of a doctor providing hair removal by laser, diet foods, and Botox treatment for wrinkles, “a pure luxury transaction” (p. 183).

Pearson describes the storms, hurricanes, and floods that hit Galveston Island, also the pollution from the oil industry that causes a “cancer belt” along the Louisiana and Mississippi coasts (p. 104).
At last she finishes her program, understanding that her identity is simultaneously a person, a physician, and a writer (p. 248). 

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The Story of Beautiful Girl

Simon, Rachel

Last Updated: Aug-07-2017
Annotated by:
McEntyre, Marilyn

Primary Category: Literature / Fiction

Genre: Novel

Summary:

On a stormy night in 1968 a retired, widowed schoolteacher in rural Pennsylvania opens her door to find a young couple, she white, he African American, wrapped in blankets, drenched, and silent.  Letting them in changes her life.  They have escaped together from a nearby mental institution most locals simply call "The School."  The young woman has recently given birth.  When Martha lets them in, her life changes forever.   Supervisors from "the School" show up at the door, the young man escapes, and the young woman, memorably beautiful, is taken back into custody.  The only words she is able to speak out of what we learn has been a years-long silence are "Hide her."  Thus she leaves her newborn baby to be raised by a stranger.  The remaining chapters span more than forty years in the stories of these people, linked by fate and love and the brutalities of an unreformed system that incarcerated, neglected, and not infrequently abused people who were often misdiagnosed.  Homan, the young man who loved Lynnie, the beautiful girl from the institution, was deaf, not retarded.  Lynnie was simply "slow," but a gifted artist who recorded many of the events of her life in drawings she shared only with the one attendant who valued and loved her.  Though her pregnancy resulted from being raped by a staff member, the deaf man longs to protect her and care for the baby.  Years separate them; Homan eventually learns signing; Lynnie's sister befriends her and an exposé results in the closure of the institution.  Over those years Lynnie and Homan witness much cultural change in treatment of people like them who were once systematically excluded.  They find social identities that once would have been entirely unavailable to them.  And eventually, after literal and figurative journeys of discovery, they rediscover each other.   

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Primary Category: Literature / Nonfiction

Genre: Memoir

Summary:

Volck’s memoir describes his medical practice and learning in a variety of settings (Cleveland, Baltimore, Cincinnati), but, more importantly, in non-metropolitan places, such as Tuba City on the Navajo Reservation in Arizona and rural clinics in Honduras. He suggests that his knowledge of medicine has largely come as he has practiced it and not from his formal education. Further, he believes that best medical practice is not primarily high-tech, urban, or industrial. Each of the 15 chapters has a title—a topic, a person, or a theme—but also one or more locations specified. For example, we have “Chapter One, A Wedding, Navajo Nation, Northern Arizona,” suggesting the importance of culture and locale. Further, the chapters include personal associations from several realms beyond the topic and place as Volck seeks to understand medicine, healthcare, and how we live in the world.           

Of the first seven chapters, five are set in Navajo land, where Volck is an outsider by his cultural heritage and his profession, a doctor with a pediatrics specialty. From time to time he reflects on his training, the English verb “to attend,” and specific patients, such as two-year-old Alice in Tuba City and eight-year-old Brian in Cleveland. Both children died while in his care. Working on the front-line of medicine, he considers the weaknesses of our modern attitudes toward death and our wishes for control. He also wrestles with personal lifestyle issues of balancing medicine, family, and an urge to write.
 
           
Other chapters describe restlessness in his profession, the growth of his family (including the adoption of a Guatemalan baby girl), hiking in the Grand Canyon, camping in the rain, and a retreat with Benedictine monks. Chapter 11 “Embodying the Word” discusses literature and medicine, lectio divina (a Benedictine reading practice), and the need to listen carefully to patients’ stories.
           
The final chapter returns to Cincinnati, Honduras, and Tuba City. Volck has found more projects in the Navajo Nation, including a youth service project from his church. With permission, he conducts interviews and plans a book on the Navajo, “drawing on cultural history, anthropology, history, medicine, and politics” (p. 201).

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Infidel

Hirsi, Ayaan

Last Updated: Apr-13-2017
Annotated by:
Saleh, Mona

Primary Category: Literature / Nonfiction

Genre: Autobiography

Summary:

This is an autobiographical work that describes the remarkable life of Ayaan Hirsi Ali. The book begins in Somalia, where Hirsi Ali was born and spent the early part of her childhood. It is here that Hirsi Ali discusses the second-class status of girls and the harrowing practice of female genital cutting, which she describes as it happened to her and her younger sister. Although her parents were against the practice, Hirsi Ali undergoes female genital cutting by the arrangement of her maternal grandmother, who states that if the clitoris is not cut, it will grow and end up dangling between the knees of the girl. This situation speaks to the variety of immediate reasons why different cultures engage in female genital cutting. They all revolve, however, around the disempowerment of girls and women and denying their basic human right to bodily integrity and sexuality. 

Due to civil unrest, Hirsi Ali and her family move around quite a bit while she is growing up, in places as distant as Saudi Arabia (where Hirsi Ali describes her childhood horror at seeing women clad in all black from head to toe), Ethiopia, and Kenya. Throughout her travels as a child and then a teenager, Hirsi Ali vacillates between being a staunch believer in Islam to questioning her faith, all while experiencing emotional, verbal, and savage physical abuse at the hands of her mother and, at one point, her Qur’an teacher. 

The action quickens at an incredible pace when Hirsi Ali’s father and community arrange for her to marry a Somali man who lives in Canada, even though Hirsi Ali does not consent to the marriage. It is telling when, on the day of her wedding ceremony, Hirsi Ali has a normal day at home while her father, her new husband, and the other men in her community have a celebration without her. In the Islamic ceremony, the bride only needs to be represented by a male guardian (father, brother, uncle, grandfather, etc) and does not physically need to be present. Hirsi Ali’s husband goes back to Canada and sends for her to join him. Rather than meeting her husband in Canada, Hirsi Ali manages to make her way to Amsterdam and apply for asylum. It is here that the reader watches Hirsi Ali confront a great amount of cognitive dissonance between what her Islamic upbringing has taught her about right and wrong versus what she personally experiences in the Netherlands, 

“The next morning, I decided to stage an experiment. I would walk out of the door without a headscarf. I was in my long green skirt and a long tunic, and I had my scarf in a bag with me in case of trouble, but I would not cover my hair. I planned to see what would happen...Absolutely nothing happened. The gardeners kept trimming the hedges. Nobody went into a fit...Nobody looked at me. If anything, I attracted less attention than when I was covering my head. Not one man went into a frenzy” (p. 195). 

Hirsi Ali is forthcoming about having lied on her asylum application to make her more likely to be approved. In the Netherlands, Hirsi Ali works as a Somali interpreter and, against all odds, goes on to attend college and obtain a degree in political science. While all of this is happening, Hirsi Ali is repeatedly impressed by Dutch society in their social order and equality between the sexes. She sees a glaring contrast between Dutch society and the lives of immigrant and refugee communities in the Netherlands. The Dutch, in an effort to be tolerant of immigrants and engage in multiculturalism, allowed Islamic religious schools to be established. Hirsi Ali, however, sees this as a way to sanction the systematic oppression of women in a democratic country. 

Hirsi Ali becomes politically active and becomes elected to the Dutch Parliament where she rails against this Dutch practice of allowing old-world religious edicts to coexist in a democratic land. As part of her fight against the sanctioning of hard-line Islam, Hirsi Ali writes a short film entitled Submission (which is the translation of the Arabic word “Islam”) that is produced by filmmaker Theo Van Gogh. The film speaks directly to the oppression of women in Islam.  At what is the climax of an already exciting book, Van Gogh is killed by a Muslim man who is clearly insulted by the film. Now, a publicly recognizable figure, Hirsi Ali’s life is in grave and immediate danger, and the Dutch parliament moves her from secure location to secure location (at one point, even as far as Boston) to protect her life. She is temporarily stripped of her Dutch citizenship on the basis of having lied on her asylum application, which effectively ends her political career in the Netherlands.  Hirsi Ali then re-locates to the United States. 

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Dothead

Majmudar, Amit

Last Updated: Jan-06-2017
Annotated by:
Kohn, Martin

Primary Category: Literature / Poetry

Genre: Poetry

Summary:

Dothead is Amit Majmudar’s 5th book (and 3rd collection of poetry). It is far-ranging in its reach and style, perhaps best described by the heading of its table of contents, “Kedgeree Ingredients.” Kedgeree, as one unfamiliar with the word (like me) discovers on the page facing the table of contents (in a photocopy of a dictionary page), is “a mess of rice cooked with butter and dal….” Among other (con) textual surprises in this book are an opening epigraph from Dr. Seuss- “It is fun to have fun/But you have to know how,” a passport photo of the author at about age 3 above his book jacket biosketch, and the title of the final poem in the collection, “Invocation.”  Front and center in a number of poems is the issue of identity, perhaps most tellingly in the title poem, “Dothead,” where an Indian-American teenager confronts his white classmates. In “T.S.A.” the poem’s speaker faces off against the airport screeners claiming solidarity with :
             "my dark unshaven brothers
whose names overlap with the crazies and God fiends,
             ourselves the goateed other”  (p.5)
His identity as a poet is beautifully expressed through “Steep Ascension,” a poem “for John Hollander” (the epigraph unfortunately is not included in this volume) that ends:
          “But John, I told him, beauty is a fire
                    those who burn hardest labor coldly for

and I for one will hold your labors dear,
          the music of meaning, the artistry that dares
                    to conjure walls that it might conjure doors” (p.25). 

Among his “political” poems, are two about children: one gunned down ("Lineage")  and one abused (“Invocation")” that begins:
“The arms I sing. Forget the man. there is
no other epic. Sing the arms of kids,
the ones with pustules all along their veins” (p. 100).
The longest poem, a prose poem, is “Abecedarian” that weaves together Adam and Eve and the speaker’s discovery of oral sex.  



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Ordinary Grace

Krueger, William

Last Updated: Aug-02-2016
Annotated by:
McEntyre, Marilyn

Primary Category: Literature / Fiction — Secondary Category: Literature /

Genre: Novel

Summary:

Frank Drum, 13, and his younger brother Jake are catapulted into adulthood the summer of 1961 in their small Minnesota town as they become involved in investigation of a series of violent deaths.  Their father, a Methodist minister, and their mother, a singer and musician, can’t protect them from knowing more than children perhaps should know about suicide, mental illness, and unprovoked violence.  The story is Frank’s retrospective, 40 years later, on that summer and its lasting impact on their family, including what he and his brother learned about the complicated ways people are driven to violence and the equally complicated range of ways people respond to violence and loss—grief, anger, depression, and sometimes slow and discerning forgiveness.  

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Summary:

This is the third book in a series on the history of medicine and medical education by Kenneth M. Ludmerer, a practicing physician and historian of medicine at Washington University of St. Louis. The first, Learning to Heal: The Development of American Medical Education, published in 1985, dealt with the history of medical schools and medical education in the US from their origins in the 19th century to the late 20th century. In 1999 he published Time to Heal: Medical Education from 1900 to the Era of Managed Care. This book, Let Me Heal: The Opportunity to Preserve Excellence in American Medicine, published in 2015, is a sweeping history of graduate medical education in the United States from its inception to the current day.

In 13 chapters and 431 pages (334 pages of text, 97 of reference and index), Ludmerer traces the residency from early apprenticeship days to its metamorphosis (at Johns Hopkins, of which he is a justly proud medical school alumnus) into the embryonic form of what we now call an internship and residency. Giants like “The Four Doctors” (to use the title of John Singer Sargent’s famous portrait of William S. Halsted, William Osler, Howard A. Kelly and William H. Welch - but known simply as “The Big Four” at Hopkins) were the godfathers of the American postgraduate medical model which emphasized clinical science, teaching, patient care and research. The rise of acute care teaching hospitals as the venue of postgraduate medical education, and not the medical school or university, is an interesting story and one which Ludmerer tells in great detail over a number of chapters. It is one replete with predictable turf wars, professional turmoil and politics, and societal change in all aspects of the 20th century. This last phenomenon receives its due attention in every chapter but is dissected in meticulous detail in the final chapters dealing with the Libby Zion case, duty hours and the increasing role of the Accreditation Council for Graduate Medical Education (ACGME) in postgraduate medical education.

Beginning in the 1930’s, American medicine grew increasingly specialized and, in the ensuing decades, subspecialized, much to the consternation of pre-WW II general practitioners who, suddenly and for the first time, found themselves in the minority, in numbers and in influence, of their own profession. Concomitant with the phenomenon of specialization was the imprimatur by academic medicine of the structured, sanctioned residency as the sole route to specialty practice with, of course, the birth of associated accrediting agencies. Along with the move, physically, academically and politically, of postgraduate medical education to acute care teaching hospitals, the control of this education moved from medical schools to the profession at large.

Ludmerer deftly describes the “era of abundance”, the salad days of postgraduate medical education in the 1950’s and 1960’s when giants still made rounds on the floors of postgraduate medical venues; funds were plentiful; outside criticism was an as yet unborn bête noir; and social, economic and governmental curbs were only a tiny distant cloud in an otherwise blue sky. Ludmerer is correct in attributing much of medicine’s professional and social hegemony as well as its transient immunity to criticism in this era to the following evident successes of medicine: antibiotics; initial inroads into antineoplastic therapies; startling technological innovations in imaging; a burgeoning spate of life-saving vaccines; and spectacular advances in surgery, especially pediatric, cardiothoracic and transplant. Fatal diseases of the 1930’s and 1940’s were now often cured in days and of historical interest only.

Like all salad days, those of medicine eventually succumbed to new historical forces: foreign medical graduates in the workplace; the ever-growing financial burden of the residency; and economic pressures like Medicare and its associated regulation. There were other factors, too: professional and societal expectations of standardization and quality care; the explosion in subspecialties; the horrid wastefulness of unnecessary diagnostic tests and therapies borne of an earlier undisciplined abundance; the supercession of the intimate primary physician-patient relationship by the fragmented care of specialists and the rising supremacy of technology over personalized histories and careful physical examinations (why percuss the abdomen when you can get a CAT scan?). Dissatisfaction amongst residents is a dominant theme Ludmerer rightly raises early and often: the conflict and tension between education and service, between reasonable work and “scut”, between being a student and a worker (at times, quite a lowly one).

”High throughput” - the much more rapid turnaround time between admission to an hospital and discharge - has radically changed forever the entire nature of postgraduate medical education, and not for the better in the eyes of the author and of this reviewer, who were fellow residents a lifetime ago at Washington University in St. Louis. This decreased length of stay, a result of the remarkable improvements in diagnosis and therapy mentioned above, meant that the working life of providers (attending physicians, residents, physician assistants and nurses) was in high gear from admission to discharge, thereby increasing tension, likelihood for error and, exponentially, the workload for the resident while simultaneously and irrevocably damaging the possibility of a meaningful, careful provider-patient relationship (like a friendship, of which it is a subspecies, such relationships can not be rushed) and decreasing opportunities for learning. Medicare; changing patient populations; societal and professional disgruntlement; the Libby Zion mess and the ensuing cascade of regulations from all sides, but most especially the ACGME - all receive careful and systematic treatment in the final chapters of this monograph.

Ludmerer ends with a chapter listing what he sees as opportunities for achieving (or re-achieving) excellence. Indeed, he has made it the book’s subtitle. They are the following: a plea for the ACGME to revise its 2011 duty-hour regulations; an equally earnest hope that interns and residents will soon realize a more manageable patient load; a related wish for academic medicine to decrease the unfortunate occurrence of economic exploitation of house officers; a suggestion that this annotator shares, i.e., that the process of supervision, improved (but inadequately) with recent ACGME requirements, be further strengthened; and a hope that medical schools will restore teaching to the central place in the institutional value system it used to enjoy. Ludmerer issues a call for the more vigorous promotion of “an agenda of safety and quality in patient care” (page 312) and suggests that the education of residents be expanded to include venues outside in-patient sites. Elsewhere in the book, he also expresses the expectation that the inclusion into clinical teaching of private patients alongside “ward” patients, more feasible with recent improvements in the re-imbursement of medical care, be routine and maximized to the enjoyment and benefit of all concerned.

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