Showing 1 - 10 of 375 annotations tagged with the keyword "Cross-Cultural Issues"

Summary:

This is an ethnographic work written by a Swedish anthropologist who has lived in Cairo, Egypt for several years curating the cultural tropes that are woven into the lives of her traditional Egyptian subjects. Malmström sets the scene for her work by describing a 1994 incident wherein CNN broadcast live the female genital cutting of a young girl in Egypt. A secret practice made public, Malmström uses this event to springboard her commentary on how female genital cutting is practiced, experienced, and viewed among Egyptians.  

Female genital cutting is defined as the partial or total removal of external female genitalia for non-medical (i.e. cultural) reasons. This is largely a practice carried out in Africa and some parts of the Middle East. Egypt has one of the highest global rates of female genital cutting, and the cutting usually occurs at the age of 9 years. Many reasons are cited for the cutting, and in Egypt it is done to decrease a woman’s sex drive as well as to fit the standards of beauty (i.e. labia minora are considered unattractive). It had usually been performed by a traditional practitioner, but more recently, this human rights violation has been medicalized in Egypt and is often performed by doctors in an operating room using anesthesia. Even though Egyptian law and Muslim as well as Coptic Christian clerics have issued bans on female genital cutting, the practice continues in secrecy.  

Malmström starts her book by saying that female genital cutting may actually be carried out in large part as Egyptian political protest against the West. She uses excerpts from interviews with women of different generations, social strata, and degree of devotion to Islam to describe their different experiences and opinions on topics that center around womanhood and the many components of womanhood in Egypt.  

While the title suggests that Malmström will tackle female genital cutting  head-on throughout this piece, she actually takes a more circuitous route. She spends several chapters describing other woman-centric issues to familiarize the reader with Egyptian culture. For instance, Malmström describes how sexuality is expected to be expressed at different points in life: in girlhood, adolescence, and after marriage. She focuses on how Egyptian women are expected to straddle many expectations regarding sexuality depending on the context: sexually receptive to the husband only, for instance, but not so much so that the husband struggles to satisfy her.
  One of the most telling quotes regarding the meaning of womanhood is,

“A woman should always be soft towards a man...She should never accuse her husband of anything or argue with him. A woman should be strong and never show her true feelings. A woman must be beautiful. A woman will win through beauty, softness, and through cooking....A woman should not show her sadness because of him [her husband], since she turns ugly, loses her health and eventually, her husband. She should be even softer towards him and give him everything in life” (p. 169).  

Malmström delves into the centrality of cooking, pain, and endurance of suffering in the lives of traditional women and how these items, as well as being “cut” are seen as necessary to the satisfactory construction of Egyptian female identity. This exploration of many parts of womanhood in Egypt allows the reader to attempt to engage in a nuanced understanding of female genital cutting in the context of a broader, textured Egyptian culture. 

View full annotation

Annotated by:
Teagarden, J. Russell

Primary Category: Performing Arts / Film, TV, Video

Genre: TV Program

Summary:

The Knick was inspired by the Knickerbocker Hospital, founded in Harlem in 1862 to serve the poor. In this 20-part TV series spread out over two seasons, the fictional Knick is somewhere in the lower half of Manhattan around 1900. The time covered during the series is not marked in any distinct way. The characters don’t age much, and although fashion and customs remain static during the series, the scope and significance of advancements that come into play were actually adopted over a longer time than the episodes cover.   

The series builds on some known history. The central character, the chief surgeon Dr. John Thackery, is modeled on a famous surgeon of the time, Dr. William Halsted, in both his surgical adventurism and in his drug addictions. The character Dr. Algernon Edwards, who is an African-American, Harvard-educated, and European-trained surgeon, is based in part on Dr. Louis T. Wright, who became the first African-American surgeon at Harlem Hospital during the first half of the 20th century.  

Storylines of human drama and folly run through the series. Among them are medical cases both ordinary and bizarre, heroic successes and catastrophic failures, loves won and lost, gilded lives and wretched existences, honor and corruption, racism and more racism. Within and around these storylines are the scientific, medical, and industrial advances of the period, as well as the social contexts that form fin de si
ècle hospital care and medical research in New York City.
 

Some of the industrial advances we see adopted by the hospital include electrification, telephone service, and electric-powered ambulances. We see that transitions to these new technologies are not without risks and catastrophes: patients and hospital staff are electrocuted, and when the ambulance batteries died -- a frequent occurrence-- many of the patients they carried died, too.

Medical advances integrated into various episodes include x-rays, electric-powered suction devices, and an inflatable balloon for intrauterine compression to stop bleeding. Thackery is a driven researcher taking on some of the big problems of the day, such as making blood transfusions safe, curing syphilis, and discovering the physiologic mechanisms of drug addiction. We see how he learns at the cost of his patients, or rather his subjects. We also glimpse movements directed at population health. For example, epidemiological methods are applied to find the source of a typhoid outbreak, which drew from the actual case of Mary Mallon (aka, Typhoid Mary). Shown juxtaposed to the advances epidemiology was then promising is the concurrent interest that was rising in eugenics and its broad application to control for unwanted groups. Research ethics and regulations were a long way off.


View full annotation

Summary:

INTRODUCTION            
Writing for all the co-authors, Rita Charon challenges “a reductionist, fragmented medicine that holds little regard for the singular aspects of a person’s life” and protests “social injustice of the global healthcare system” (p.1). She gives a history of narrative medicine, lists its principles, and summarizes the book’s chapters, mentioning that several come as pairs that present theory then practice. The six principles are “intersubjectivity, relationality, personhood and embodiment, action toward justice, close reading (or slow looking), and creativity” (p. 4).
The basic thesis is that healthcare can be improved by narrative medicine because “narrative competence can widen the clinical gaze to include personal and social elements of patients’ lives vital to the tasks of healing” (p. 1). 
This is a dense, theory-laden book from the group at Columbia University. The summaries below touch of some of the major points.   

PART I, INTERSUBJECTIVITY             
Ch. 1, Account of Self: Exploring Relationality Through Literature

Maura Spiegel and Danielle Spencer describe the richness of literature that allows readers to respond creatively. In clinical settings, a caregiver may similarly listen attentively and help co-construct a narrative with the patient. Literature can help us explore “the limits of rationality and positivism” (p. 29) and move from “a model of autonomy to one of relationality” (p. 34). 

Ch. 2, This is What We Do, and These Things Happen:  Literature, Experience, Emotion, and Relationality in the Classroom.

Spiegal and Spencer write that current medical education does a poor job of helping future physicians with their emotions.  Clinicians profit from a more integrated self and will listen better to patients and respond to them.      

PART II, DUALISM, PERSONHOOD, AND EMBODIMENT            
Ch. 3, Dualism and Its Discontents I:  Philosophy, Literature, and Medicine

Craig Irvine and Spencer start with three literary examples that illustrate separation of mind and body. This dualism has pervaded modern medicine, causing losses for patients and caregivers, especially when there are power imbalances between them.  The “clinical attitude” (p. 81) dehumanizes both caregivers and patients.           

Ch. 4, Dualism and Its Discontents II:  Philosophical Tinctures
Irvine and Spencer argue that both phenomenology (appreciative of embodied experience) and narrative hermeneutics (privileging reciprocal exchange of persons) help us move beyond dualism.  Theorists Edmund Pellegrino (also a physician), Richard Zaner, and Fredrik Svenaeus help us understand how caregivers and patients should relate. 

Ch. 5, Deliver Us from Certainty: Training for Narrative Ethics

Craig Irvine and Charon write that various humanistic disciplines “recognize the central role narrative plays in our lives” (p.111). There is, however, “indeterminacy” in stories that “cannot be reduced by analyzable data” (p. 113). Narrative ethics urges us to consider issues of power, access, and marginalization for both the teller and the listener. The authors review recent ethical traditions of principalism, common morality, casuistry, and virtue-based ethics. They believe that narrative ethics, emerging from clinical experience and now allied with feminist and structural justice frameworks, will provide a better approach for many reasons. “Narrative ethics is poised to integrate the literary narrative ethics and the clinical narrative ethics” (p. 125).  

PART III, IDENTITIES IN PEDAGOGY            
Ch. 6, The Politics of the Pedagogy: Cripping, Queering and Un-homing Health Humanities

Sayantani DasGupta urges attention to issues of power and privilege in classrooms, lest they “replicate the selfsame hierarchical, oppressive power dynamics of traditional medicine” (p. 137). “Cripping” and “queering” provide new perspectives on knowledge, for example the untested binaries of physician/patient, sick/well, elite/marginalized, teacher/student. Drawing on disability studies, health humanities, and queer politics, DasGupta challenges “medicalization” and the “restitution narrative” (p. 141).  

PART IV, CLOSE READING            
Ch. 7, Close Reading: The Signature Method of Narrative Medicine

Charon stresses “the accounts of self that are told and heard in the contexts of healthcare” (p. 157). Close reading, traced from I. A. Richards through reader response theorists, is “a central method” for narrative medicine (p. 164). Close reading enhances attentive listening, and both of these deepen relationality and intersubjectivity, allowing for affiliation between caregiver and patient (pp. 175-76). Such linkages aid healthy bodies and minds, even the world itself (p. 176).             

Ch. 8, A Framework for Teaching Close Reading

Charon describes how she chooses texts and provides prompts for responsive creative writing. She illustrates “the cardinal narrative features—time, space, metaphor, and voice” (p. 182) in literary works by Lucille Clifton, Henry James, Galway Kinnell, and Manual Puig.  

PART V, CREATIVITY            
Ch. 9,  Creativity: What, Why, and Where?

Nellie Hermann writes that “healthcare in particular has a vexed relationship to the notion of creativity,” in part because of issues of control (pp. 211-12); values of “evidence based” and “numbers-driven” medicine are also factors. Narrative medicine, however, “is about reawakening the creativity that lives in all of us” (p. 214).            

Ch. 10, Can Creativity Be Taught?

Hermann reports on techniques used in the College of Physicians and Surgeons at Columbia, including prompts and a Portfolio program. A “Reading Guide” helps clinical faculty (and others) respond to student writing. Responses to writing can nourish the “creative spark.”  

PART VI, QUALITATIVE WAYS OF KNOWING            
Ch. 11, From Fire Escapes to Qualitative Data: Pedagogical Urging, Embodied Research, and Narrative Medicine’s Ear of the Heart

Edgar Rivera Colón suggests that “we are all lay social scientists of one kind or another,” seeing people in action in various contexts. He affirms an “assets-based approach to public health challenges, as opposed to a deficits-based and pathology-replicating paradigm” (p. 259). We are all embodied actors in relationship to power, privilege, and social penalty. Research through interviews and participant observation show “meaning worlds” in tension with “systemic inequality and structural violence” (p. 263). 

Ch. 12, A Narrative Transformation of Health and Healthcare

Charon presents and analyzes a case study of patient Ms. N. as treated by internist Charon. They’ve been working together for decades. Charon writes up her perceptions and shares them with Ms. N. Speaking together, they “became mirrors for one another” (p. 274). Psychiatrist Marcus discusses transference and transitional space in that experience. A caregiver as witness can shift healthcare from “instrumental custodianship to intersubjective contact” (p. 288).            

Ch. 13, Clinical Contributions of Narrative Medicine

Charon describes applications of narrative medicine, all with the aim of improving healthcare. She describes techniques for interviews of patients, writing methods, and ways to improve the effectiveness of healthcare teams, as well as changes in clinical charts and other narrative descriptions of patients.

View full annotation

Primary Category: Literature / Nonfiction

Genre: Memoir

Summary:

The subtitle is accurate enough: “A Memoir of a Family and Culture in Crisis,” although the author J.D. Vance is, in fact, the focal point of view throughout, from his childhood to his success as an adult. Few young people made it out of the hills to enjoy stable and successful lives, but J.D. was one of them, earning a degree at Ohio State University, then a law degree at Yale. While recounting his life, he also describes his relatives and neighbors, and he interprets the many dilemmas of his hillbilly culture. 
 
Vance was born in 1984 and grew up in Jackson, Kentucky, a poor town following the collapse of coal mining. His family was beset with poverty, alcoholism, mental instability, and more. His mother had nine miscarriages and suffered from addictions; she had multiple husbands. The culture around him suffered from domestic violence, drug abuse, hoarding, unemployment, honor defended by fists, knives, or guns, as well as bad financial habits, bad diets, obesity, lack of exercise, sugary drinks, dental problems, and what he calls “emotional poverty.”  There was welfare abuse and, in general “a chaotic life.”  He credits his grandparents, other relatives, various teachers and professors for supporting him, guiding him, and comforting him when he was hurt, angry, and/or confused.
 

Like many other hillbillies, J.D. moved some hundred miles north into southern Ohio, where steel companies provided jobs—that is, until they closed, like many other employers in the Rust Belt. There also, hillbillies were left without income and social problems increased. Stores and restaurants closed. Payday lenders and cash-for-gold shops took their place. Drug dealers and users took over empty houses.  

After high school, Vance joined the Marines. He credits the military for teaching him discipline, persistence, and for developing his self-respect. For his success at Yale, he thanks his professors, his girlfriend (later wife), and classmates for helping him understand customs of New England society. One example: he leaves a banquet to call his girlfriend; she instructs him on how to handle the nine pieces of unfamiliar silverware surrounding his plate.  

The last three chapters (11, 12, 13) and the conclusion analyze his experience on more conceptual terms, including the “social capital” prized by the the New England world, social instability of the culture he was raised in, and “adverse childhood experiences” (or ACEs), the psychologists’ phrase for the damaging events children experience in a culture of poverty, violence, and limited futures. He writes that governmental child services have policies that don’t understand the important roles of aunts, uncles, and grandparents in subcultures that rely on extended families.  Indeed, faithful to his mother, he, as an adult, provides specific help to her. 


View full annotation

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.  



View full annotation

Summary:

This monograph is an important contribution—along with the Health Humanities Reader (2014)—to the burgeoning field of health humanities, a new academic field and the presumed replacement for (and expansion of) medical humanities. While the medical humanities included philosophy, literature, religion, and history, health humanities includes many more disciplines, and the creative arts.
This book is dense with theory and abstraction, but it imaginatively and intelligently promotes the notion that health is a larger and more useful concept than disease, which dominates and limits standard medicine. 

Five authors are listed for the book as a whole; none are attributed specifically to any of the eight chapters.
 
The first chapter “Health Humanities” promotes health humanities as an expansion of medical humanities to include more people (including unpaid caregivers and patients), social and national well-being, and the arts, such as dance, music, and visual art. We need to consider wider ranges of meaning, agency, and patients’ varying life stories. Unpaid caregivers have been neglected, even though “the majority of healthcare as it is practiced, is nonmedical” (p. 13). Medicine per se has been too science-based and too disease oriented, but critical theory and the arts can be “enabler[s] of health and well-being” (p. 19) with many applications to hospitals, clinics, homes, and neighborhoods.

“Anthropology and the Study of Culture” describes a wide range of inquiry, both worldwide and throughout human time, including rituals, conceptions of disease, health, death, and impacts for patients. Some cultures believe in spirit possession. The Chinese have worked with qi (life energy) for millennia. Cultural studies look at popular media, spiritual perspectives, also local and subcultural values.
 
“Applied Literature” discusses pathographies, including mental illness (for example, self-harm); it reviews concepts from Rita Charon and describes how reading groups can promote well-being. Literature expands our understanding of humans well beyond the biomedical gaze. Closely related, “Narrative and Applied Linguistics” reviews notions from Osler, Barthes, Bruner, Propp, Frank, and others. Patients want, beyond technical expertise, healthcare personnel who will help them co-create an enabling narrative. New techniques in linguistics include analysis of a corpus of usage, for example, teen language, thereby gaining approaches to young patients who cut themselves.

At 23 pages, the longest chapter is “Performing Arts and the Aesthetics of Health.” It posits that all arts are uniquely human because they are relational, aesthetic, and temporal (with time in a kairos sense, not just chronos). The arts fit into health practices, which also share the same three qualities. The arts promote coherence, agency, communication, expression, and social wellbeing, traits that are described specifically in music, dance, and drama. Similarly, the next chapter “Visual Art and Transformation,” promotes this particular art, whether elitist or popular, as communicative and transformative. The making of art can be healing. 

“Practice Based Evidence: Delivering Humanities into Healthcare” argues against Evidence Based Practice and its limitations. Instead of Randomized Controlled Trials, smaller, more qualitative studies may be more accurate and useful. Practice Based Evidence (and feminist and postmodern approaches) all create wider and deeper notions of validity.

“Creative Practice as Mutual Recovery” suggests that caregivers, whether professional or lay, also find healing as they deliver care.

In “Concluding Remarks” we read, again, that  “the majority of health care and the generation of health and well-being is non-medical” (p. 153). Medicine and medical humanities are “too narrow a bandwidth,” but health humanities can support all caregivers, various institutions (including schools), self-care, and complementary medicine.   

View full annotation

Primary Category: Literature / Nonfiction

Genre: Treatise

Summary:

This short but complex book assesses the many, current risks to all life on earth and considers some avenues for repair that may provide hope for the future. E. O. Wilson, a distinguished scientist, describes how all life on earth is inter-related. With a long view to the past and a wide view of the present—from microscopic creatures to humans—Wilson praises our planet’s biodiversity and warns of the dangers that may cause it to collapse; these dangers are human-related. Humans are an apex predator, smarter than all other creatures, but we are also too numerous, using too many resources, and causing various pollutions, including global warming. The health of the world and the health of all its creatures—humans included— are, for better or worse, interlinked forever.   
A Prologue warns that we are playing an “end-game” with the earth. To avoid a point of no return from mass extinctions, Wilson proposes a bold plan of setting aside one-half of the earth in reserve in order to stabilize the survival of humans.  

Part I, “The Problem,” describes the damage to our planet, on a par with the Yucatan asteroid 65 millions years ago, the so-called Fifth Extinction. We live in a narrow biosphere threatened by dying species, invasive species, collapse of interdependency, pollution of air, land, and water, loss of the commons, overhunting, human population growth, and outright habitat destruction (including the many impacts of climate change). He states, “the Sixth Extinction is under way” and “human activity is its driving force” (p. 55).   

Average time for recovery from each of the five previous extinctions is 10 million years. 

Self-centered humans do not understand the vast complexity of nature, including the many species not yet studied. He imagines far-distant geologists observing, “What a terrible time it was for people, and for the rest of life” (p. 9).  

Part II, “The Real Living World,” criticizes some conservationists who see nature in service to humans. Wilson says we are not owners of nature but stewards. He describes the abundant life of the Great Smoky Mountains National Park and a typical seashore as well as the extinction of the Ivory-Billed Woodpecker. Wilson contacted “eighteen of the world’s senior naturalists,” asking for suggestions for the “best reserves” to shelter “plants, animals, and microorganisms” (p. 135). Fifteen pages lovingly describe their recommendations of 33 places around the world. He concludes that “a great deal of Earth’s biodiversity can still be saved!” (p. 136).  

Part III, “The Solution” states, “The only solution to the Sixth Extinction is to increase the area of inviolable natural reserves to half the surface of the Earth or greater” (p. 167). Wilson reviews crises of water and food, and he warns against “self-inflicted disaster” that could wipe out most species by the end of this century. He provides two examples of restoration projects, the long-leaf pine lands in Florida and Gorongosa National Park in Mozambique. He believes the population bulge to ten billion people will be temporary.            

Wilson rejects geo-engineering of the oceans or the atmosphere as well as a proposed use of a passing asteroid. He argues that synthetic biology has promise for improving our brains for moral reasoning and ecological understanding. We need altruism (all working for all) and biophilia (deep love of nature).

View full annotation

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.  

View full annotation

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.

View full annotation

Attending Others

Volck, Brian

Last Updated: Apr-11-2016
Annotated by:
McEntyre, Marilyn

Primary Category: Literature / Nonfiction

Genre: Memoir

Summary:

This memoir of a life in medicine takes the writer from St. Louis to a Navajo reservation to Central America to the east coast and from urban hospitals to ill-equipped rural clinics. It offers a wide range of reflections on encounters with patients that widen and deepen his sense of calling and  understanding of what it means to do healing work.  He learns to listen to tribal elders, to what children communicate without words, to worried parents, and to his own intuition while calling on all the skills he acquired in a rigorous medical education.  Always drawn to writing, Volck takes his writing work (and play) as seriously as his medical practice, and muses on the role of writing in the medical life as he goes along.

View full annotation