Showing 11 - 20 of 245 annotations tagged with the keyword "Medical Education"

Tithonus

Tennyson, Alfred

Last Updated: Jul-28-2016
Annotated by:
Clark, Mark

Primary Category: Literature / Poetry

Genre: Poetry

Summary:

Tithonus” is a dramatic monologue that imagines the once handsome, magnificent Trojan prince to be well-advanced in an unfortunate state brought about by negligent gods and his own lack of foresight.  Exultant over the blessings of his youth, he’d asked Aurora, goddess of the dawn, for eternal life, and she had obtained Zeus’s permission to grant the request.  But Tithonus had failed to ask for eternal youth with his immortality—and neither Aurora nor Zeus had managed to recognize that this feature of the request might be important—so that Tithonus spends eternity growing increasingly decrepit.  In Tennyson’s poem, Tithonus addresses Aurora, hoping he might persuade her to reassign him his mortal status and allow him to die.

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The aim of these reflections on uncertainty in medicine is not to discredit evidence-based medicine or to incite suspicion of the careful and caring processes by which most clinicians arrive at the advice they give.  Rather it is to change conversations among practitioners and between them and their patients in such a way as to raise everyone’s tolerance for the inevitable ambiguities and uncertainties we live with.  If the public were more aware of the basic rules of mathematical probabilities, how statisticians understand the term “significance,” and of how much changes when one new variable is taken into account—when a new medication with multiple possible side-effects is added to the mix, for instance—they might, Hatch argues, be less inclined to insist on specific predictions.  He goes on to suggest that there is something to be gained from the challenge of living without the solid ground of assurances.  When we recognize the need to make decisions with incomplete information (a condition that seems, after all, to be our common lot) we may refocus on the moment we’re in and see its peculiar possibilities. Changing the conversation requires a critical look at medical education which, Hatch observes, “measures a certain type of knowledge essential to medical practice, but it consequently engenders a conception of medicine best described as overly certain . . . .” 

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Annotated by:
Shafer, Audrey

Primary Category: Visual Arts / Painting/Drawing

Genre: Painting

Summary:

Theodor Billroth, one of the most innovative and outstanding surgeons and educators of late 19th century European medicine, is depicted in this painting at the height of fame when he was about 60 years old. Billroth, in full white beard, stands in the center of the canvas, looking away from the patient--an assistant is handing him a surgical instrument. His visage is regal, his bearing composed.Seven white-coated assistants surround the patient, who lays supine with his head elevated. The patient's head is shaved, and according to the artist's notes, the operation is a neurotomy for trigeminal neuralgia--a painful condition of the face. The patient is receiving general anesthesia by open drop method. Billroth favored a mixture of alcohol, chloroform, and ether, anticipating a modern trend to administer multiple agents in anesthesia. Billroth is also using Lister's methods of sterilization and antisepsis. Note that rubber gloves were not yet used in surgery at this time.Light from a large window to the surgeon's right bathes the operating theater with brightness. A full gallery of onlookers includes the artist on the right side of the first row, and the Duke of Bavaria, seated at the opposite end, who came to the operations and lectures for entertainment. Billroth was a celebrated teacher, and thousands came to the Allgemeines Krankenhaus, the General Hospital of the University of Vienna, to observe and study his techniques.

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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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Summary:

Samuel Shem's (Stephen Bergman) The House of God, first published in 1978, has sold over two million copies in over 50 countries (see annotation).  Its 30th anniversary was marked by publication of Return to The House of God: Medical Resident Education 1978-2008, a collection of essays offering historical perspectives of residency education, philosophical perspectives, literary criticism, and women's perspectives, among others. Contributors include such well-known scholars as Kenneth Ludmerer, Howard Brody, and Anne Hudson Jones, as well as physician-writers Perri Klass, Abigal Zuger, Susan Onthank Mates, and Jack Coulehan.  The closing section, "Comments from the House of Shem," includes an essay by psychologist and scholar Janet Surrey (Bergman's wife) and one by "both" Samuel Shem and Stephen Bergman. 

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When Breath Becomes Air

Kalanithi, Paul

Last Updated: Feb-18-2016
Annotated by:
Shafer, Audrey

Primary Category: Literature / Nonfiction

Genre: Memoir

Summary:

Paul Kalanithi, diagnosed with stage IV metastatic lung cancer when he was a neurosurgery resident at Stanford University, was faced with a decision. Should he truncate his career in neurosurgery in order to become a writer - a career he had always envisioned for himself after completing a couple of decades of neurosurgery practice? Married to Lucy Kalanithi, an internist he had met in medical school, Paul’s career and future had looked bright and promising. But as he entered his final year of a seven-year residency, symptoms of excruciating back pain and significant weight loss began. Garbed in a hospital gown, he examines his own CT scan – this is how we meet Paul at the beginning of the Prologue. He then writes of the relatively brief period of misdiagnosis prior to the CT scan. With the initial negative plain x-rays, he is started on nonsteroidal anti-inflammatory drugs. But breakthrough pain and continued weight loss leads to the CT. Paul the physician understands the death sentence the images portend; Paul the patient is just beginning his journey. The diagnosis and treatment cause him to reassess his decisions about his life, to decide to father a child even though he knows he will never see the child grow up, and ultimately to write a memoir, essentially for his daughter.

Paul had graduated from Stanford with undergraduate and master’s degrees which reflected his dual love of literature and science. He combined these in a second master’s degree from Cambridge University in the history and philosophy of science and medicine before attending Yale for his medical degree. He and his wife return to California for residencies. The book is largely a blend of his dual interests: a deep and abiding love and faith in literature and how words can reveal truths, and a passion for the practice and science of neurosurgery. The rupture of fatal illness into his life interrupts his dogged trajectory towards an academic medical career, and, like all ruptures, confounds expectations and reorients priorities.

The book has five parts: a foreword by physician-writer Abraham Verghese, who notes the stunning prose Paul produced for an initial article in The New York Times and exhorts the reader to “Listen to Paul” (page xix); a brief prologue; two parts by Paul Kalanithi (Part I: In Perfect Health I Begin, and Part II: Cease Not till Death); and a stunning, heart-breaking epilogue by Lucy Kalanithi. In the epilogue, written with as many literary references and allusions as her husband’s writing includes, Lucy provides the reader with a gentle and loving portrait of her husband in his final days, reaffirms his joy in their daughter Cady, and chronicles how she kept her promise to her dying husband to shepherd his manuscript into print.

The bulk of the book is memoir – a childhood in Arizona and an aversion to pursuing a life in medicine due to his hard-working cardiologist-father, experiences at Stanford which eventually led him to reverse his decision to avoid a medical career, the stages of his medical career and caring for patients, and his devastating cancer. Though initially responsive to treatment—and indeed, the treatment enables him to complete his residency and decide to father a child with Lucy—the cancer is, as prognosticated from the diagnosis, fatal.

What makes this memoir so much more than an exercise in memory and a tribute to the herculean effort to write while sapped by cancer and its treatment, are the philosophical turns, the clear love of words and literature, and the poignancy of the writing. He begins reading fiction and nonfiction again: “I was searching for a vocabulary with which to make sense of death, to find a way to begin defining myself and inching forward again. The privilege of direct experience had led me away from literary and academic work, yet now I felt that to understand my own direct experiences, I would have to translate them back into language…I needed words to go forward.” (pp 148-9) Paul’s writing ends with what is arguably some of the most poetic prose ever written. He concludes by speaking directly to his infant daughter: “When you come to one of the many moments in life where you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more but rests, satisfied. In this time, right now, that is an enormous thing.” (p. 199)

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The Death of Cancer

DeVita, Vincent

Last Updated: Feb-04-2016
Annotated by:
McEntyre, Marilyn

Primary Category: Literature / Nonfiction

Genre: Memoir

Summary:

The book offers a detailed account by one of the nation’s leading cancer researchers of developments in chemotherapy over the past several decades, as well as the recent history of surgical and radiation treatments in the “war on cancer”—a term he resisted at first but finally embraced with full understanding of its implications.  The narrative touches on many of the writer’s own struggles over economic, political, and moral implications of what a NYT reviewer described as a “take-no-prisoners” approach to cure.  He also includes stories about disagreements with other researchers that give some insight into the acrimony that is part of high-stakes science.  At the NIH and later as head of the National Cancer Institute, DeVita faced many decisions about distribution of resources, how much to put patients at risk, and whom to include in clinical trials.  He provides his own point of view on those controversies frankly.  Not much mention is made of the causes of cancer, of nutritional or other complementary approaches, or the environmental factors in the spread of cancer. The strong focus on the book is on the development of chemotherapeutic treatments that have succeeded in raising survival rates, though few current statistics are cited.

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Dr. Mütter's Marvels

O'Keefe, Cristin

Last Updated: Jan-25-2016
Annotated by:
Glass, Guy

Primary Category: Literature / Nonfiction — Secondary Category: Literature / Nonfiction

Genre: Biography

Summary:

Those who are familiar with the Mütter Museum of the College of Physicians of Philadelphia, best known for its anatomical oddities, may have wondered about the institution’s namesake.  The author of this book, a poet and native of Philadelphia, endeavors to place Thomas Dent Mütter within the context of 19th-century American medicine.  

We learn here that notwithstanding being “medicated” with wine, surgical patients emitted such agonized screams that observers were known to vomit and pass out in their seats. We learn that Philadelphia was a cesspool of infectious disease for which there was no effective treatment.  We learn too of the rivalry (including behavior that would be considered unprofessional today) between the well-established school of medicine at the University of Pennsylvania (Mütter’s alma mater) and upstart Jefferson (whose faculty Mütter would join).  

In an era before the germ theory of disease became widely accepted, there was of course no concept of sterile technique.  To suggest that a surgeon should wash his hands was to imply he was not a gentleman because “all gentlemen were clean” (page 104).  Resistance to anesthesia was based not so much on concerns about potential danger but on the notion, when it came to obstetrics, that pain was a punishment for the sins of Eve.  Doctors could be downright sadistic to their patients, to the point of beating them like livestock.  That there was no concept of surgical aftercare meant that patients would be sent home immediately following an amputation. Victims of grotesque tumors and disfiguring accidents were considered “monsters” who lived lives of unimaginable misery.  

Enter Mütter, whose importation of plastic surgery from Paris to America brought hope to thousands of incurables.  He had an intuitive sense of the role of cleanliness in reducing morbidity and mortality.  He was a passionate advocate for anesthesia when it was seen as little more than a fad.  He abandoned traditional teaching methods that held a professor should be distant and unapproachable, and became beloved by generations of Jefferson students.  
 

In short, Mütter emerges as not just a likeable guy, but the forerunner of a whole new concept of what a good doctor should be, a sort of cross between P.T. Barnum and Mother Teresa.    

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Annotated by:
Kohn, Martin

Primary Category: Literature / Nonfiction

Genre: Essay

Summary:

Brian Dolan has done a great service for the field of medical humanities through his efforts in putting together this volume. Its 19 reprinted articles cover the spectrum of disciplines/fields/methodologies that anchor our work:  history, literature, film, theater, arts, narrative, storytelling, critical (disability) studies, human values, and professionalism. His opening essay, “One Hundred Years of Medical Humanities: A Thematic Overview” very pertinently and extremely ably sets the stage for the remainder of the book. Quite helpfully, authors of “recently published articles,” in this instance from 1987 on, were asked “to reflect on their piece and add introductory comments that would help frame it, or enable them to address issues raised since its original publication” (p.167).  To the reader’s benefit, almost all of those contemporary authors did so.  As cited on the book’s  back cover, the work of some of our field’s most important educators are in this volume, including contributions from Erwin Ackernecht, Gretchen Case, Rita Charon, Jack Coulehan, Thomas Couser, Lester Friedman, Kathryn Montgomery Hunter, Paul Ulhaus Macneill, Guy Micco, Martha Montello, Edmund Pellegrino, Suzanne Poirier, Johanna Shapiro, Abraham Verghese, and Delese Wear. 

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The Physician

Gordon, Noah

Last Updated: Nov-17-2015
Annotated by:
McEntyre, Marilyn

Primary Category: Literature / Fiction

Genre: Novel

Summary:

When nine-year-old Rob Cole, child of poor 11th-century English farmers, loses his mother, he is consigned to the care of a barber-surgeon who takes him around the countryside, teaching him to juggle, sell potions of questionable value, and assist him in basic medical care that ranges from good practical first-aid to useless ritual.  When, eight years later, his mentor dies, Rob takes the wagon, horse, and trappings and embarks on a life-changing journey across Europe to learn real medicine from Avicenna in Persia.  Through a Jewish physician practicing in England, he has learned that Avicenna’s school is the only place to learn real medicine and develop the gift he has come to recognize in himself.  In addition to skill, he discovers in encounters with patients that he has sharp and accurate intuitions about their conditions, but little learning to enable him to heal them.  The journey with a caravan of Jewish merchants involves many trials, including arduous efforts to learn Persian and pass himself off as a Jew, since Christians are treated with hostility in the Muslim lands he is about to enter.  Refused at first at Avicenna’s school, he finally receives help from the Shah and becomes a star student.  His medical education culminates in travel as far as India, and illegal ventures into the body as he dissects the dead under cover of darkness.  Ultimately he marries the daughter of a Scottish merchant he had met but parted with in his outgoing journey, and, fleeing the dangers of war, returns with her and their two sons to the British Isles, where he sets up practice in Scotland.

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