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Summary:This book describes San Francisco’s Laguna Honda Hospital, where Victoria Sweet worked as a doctor for 20 years. In the tradition of the Hôtel-Dieu in Paris (literally “God’s Hotel”), Laguna Honda cares for the sickest and poorest patients, many staying there indefinitely because there is no alternative for them. Sweet learns from her long experience at Laguna Honda that “Slow Medicine” has benefits, that a holistic or unified view of patients works best, and that the reductionism and specialization of modern medicine has limitations and costs. During these years Sweet becomes fascinated by the medieval abbess Hildegard of Bingen and earns a Ph.D. focusing on medieval medicine. At the same time (and increasingly) various forces—economic, legal, political, bureaucratic—cause many changes at Laguna Honda, mostly contrary to Sweet’s vision of medicine.
Part history, part memoir, part social criticism, the book is informative, entertaining, and important for its discussion of the care of our least-well-off citizens and for its perspectives on modern, Western medicine.
There are three intertwining strands to this engaging book: Sweet’s medical evolution as a physician, the changes in Laguna Honda, and her investigations of Hildegard of Bingen and other spiritual matters.
Sweet joins up with Laguna Honda initially for only two months, but she finds the hospital and her work there so fascinating that she stays for 20 years. As an almshouse, Laguna Honda takes care of indigent patients, most with complicated medical conditions, including mental illness and dependencies on alcohol and/or drugs. Many of these cases come from the County Hospital with continuing (but not carefully reviewed) drug treatments. Every 15 or 20 pages, Sweet describes the dilemmas of a particular patient, and her medical (and personal) attention to that patient. The cases are vivid and instructive.
Clearly Laguna Honda is a major figure on the book; we can even consider it (or “her”) a beloved character and a teacher to the young Dr. Sweet, who learns three principles from her work there: hospitality, community, and charity.
Because Laguna Honda is old-fashioned in many ways, Sweet reads her own X-rays, goes the to lab to see results, and spends large amounts of time with each patient. Laguna Honda has an aviary, a farm with barnyard, and a solarium; such features help to heal the whole person. While respectful of modern medicine, Sweet slowly learns that a careful review of a patient through Slow Medicine is more accurate and more cost-efficient than standard, reductionist, high-tech medicine. She comes to respect approaches from “premodern” medicine, including that of Hippocrates and Hildegard.
The second strand is the evolution of Laguna Honda itself. Sweet describes a variety of pressures: the recommendations of consulting firms, rulings from the Department of Justice, a lawsuit, financial difficulties (including fiscal mismanagement), administrators focused on a narrow concept of efficiency, a utilization review board, forms and more forms, and a pervasive sense that modern (including Evidence Based Medicine) is always good. All these and more create a “relentless pressure squeezing the hospital’s Old Medicine into the New Health Care” (p. 322). Sweet demonstrates that her Slow Medicine can actually save money in the long run. Confident that her way is better, she proposes an “ecomedicine unit” that she would match against the modern, “efficient” units in a two-year experiment. (For more information on her concept of ecomedicine proposal, see http://www.victoriasweet.com/.)
As the hospital is “modernized,” many important features of the old place are gone and many “new and improved” aspects don’t work. Somehow there are no rooms for physicians in the new building while there is plenty of space for administrators and managers. A sophisticated computer system doesn’t work. Sweet doesn’t say “I told you so” directly, but we get the picture.
The third strand is Sweet’s investigations of spirituality and pilgrimage. She is fascinated by Hildegard’s notions of the healing power of nature, the ability of the body to heal itself, and wholeness as an aim for a person and for a community. Sweet attends a Swiss conference on Hildegard. She hikes the pilgrimage route from France to Santiago de Compostela in four installments and considers notions of pilgrimage. She feels called to pursue her ecomedicine project and to write this book.
By the end of the book, both Sweet and Laguna Honda have changed and are now headed in different directions.
Summary:The year is 1990; a lump in the groin which Harvey had ignored has enlarged and his wife convinces him to have it checked out. It turns out to be a lymphoma and thus begins the yearlong chronicle. Intertwined with the couple's struggle with diagnosis and treatment is their decision to buy a home, and Joyce's work with an international group of teenagers who have survived war. However, the bulk of this unconventional work depicts in a stark and straightforward way the energy necessary to survive not just cancer, but cancer treatment.
Fat Louise, with an eating disorder since she was nine, would diet in public and sneak candy and peanut butter sandwiches in private. Her parents pitied her and were embarrassed by her. Her college roommate caught her at the secret eating and offered to help her get control of her eating. The diet and exercise ritual, combined with smoking, brought her weight down 60 pounds and made her beautiful and eligible to be married. Her parents were proud. She got married. But often she felt "no one knew her"--that she really wasn't this slim 120 pound beauty.
Then during her pregnancy she lost the discipline and ate compulsively and secretly. After the baby was born she continued to eat--her husband disapproved and didn't want to touch her, her mother scolded. The marriage, based on appearances, started to fall apart; she looked forward to being alone with her child and able to eat anything she wanted without other people judging her.
Hillel D. Braude, a physician and a philosopher, has written an important, albeit dense and narrowly circumscribed, study. While “Intuition in Medicine” is the main title, the subtitle, “A Philosophical Defense of Clinical Reasoning” is a more accurate description of the book, which originated as a doctoral dissertation. While some of the prose will appeal only to specialists, there are important and thoughtful analyses of such topics as Evidence-Based Medicine, modern dehumanized medicine, the relation of beneficence and automony, and principalist ethics in general.
Throughout, intuition is narrowly conceived and in the service of clinical reasoning, as it applies to standard, Western physicians and not to other healers (or nurses), and the emphasis is on interventive medicine to cure illness and relieve suffering more than on health promotion.
Braude writes in the introduction that intuition has long been understood to be “a direct perception of things,” but he resists a more precise definition: “Rather than defining and using a single concept of intuition—philosophical, practical, or neuroscientific—this study examines intuition as it occurs at different levels and in different contexts of clinical reasoning” (xviii).
Eight chapters explore these different levels in such topics as moral intuitionism, Aristotle’s phronesis (or practical reason), the rise of statistics (a basis for Evidence-Based Medicine), and C. S. Peirce’s notion of abduction. Braude’s careful analysis traces historical and theoretical developments in analytic philosophy and how these may be applied to clinical reasoning. He uses an impressive range of thinkers: Achenwall, Albert, Allan, Andre, Ashcroft, Aristotle, Bacon, Barrow, Barton, Beauchamp, Bergson, Bernard, Bichat, Black, Bottero, Bourdieu, Brody, Browne—just to take names headed by A or B.
Throughout, Braude puts in dialectic two poles on a spectrum arguing that they both have contributions to make. He believes that between them is an “ethical space,” where discoveries and applications can be made, but he clearly favors all the concepts from the lefthand list for medicine. In tabular form, we can list aspects of the two poles:
Aristotelian practical reasoning Kantian abstraction
Naturalist approaches Nonnaturalist approaches
Primacy of beneficence Primacy of autonomy
Fact and value joined Fact and value separated
Case-based Evidence-Based Medecine
Individual patients Large groups of patients
Narrative experience Statistical correlations
Anthropocentric focus Mechanist, positivist foci
Tacit, organic knowledge (Polanyi) Dualism (Descartes)
Braude believes intuition is a cognitive process but has other dimension, the corporeal and the social. While these provide a grounding, intuition for him is generally rational. He also argues for medical care at the personal, face-to-face level, not through applications of algorithms.
A brief conclusion, “Medical Ethics beyond Ontology” clarifies some of the arguments and sketches some valuable notions from Husserl and Levinas. He writes “intuition . . . does appear to be fundamental for human judgment” because “an intuition faculty” can “extract universals from the particular” (p. 170). Drawing on Husserl, he defines phenomenological intuition as “the primary means through which objects are presented to consciousness.” This affirmation includes the basic human, which is also the focus for medicine. For Levinas (and my summary is much too brief), “interhuman solidarity” is a source for medical care, a form of responsibility that is different from Foucaultian power relationships, ethical rules and priniciples, or “an uncritical acceptance of medical authority” (p. 177).
When Lia Lee's sister slammed the front door to their Merced, California, apartment, Lia experienced her first in several years of increasingly severe seizures. The Lee family knew that the noise had awakened a dab, an evil spirit who stole Lia's soul. They also knew, in the midst of their grief for their infant daughter, that people suffering from "the spirit catches you and you fall down" often grew up to be healers in their Hmong culture.
Not surprisingly, the physicians and other health professionals who worked with Lia and her parents over the next seven-plus years did not share this diagnosis--most of them did not even know about it. Fadiman melds her story of Lia, the Lees, the family's physicians and social workers, and countless other people who enter the Lees' life (usually uninvited and unwelcome) with the long history of the Hmong people, their religion and culture, and their more recent lives as refugees from war in Laos and Cambodia (and the troubled history of their relationship to the U.S. military system).
Summary:Entering a school as the first student with a serious disability (cerebral palsy) after starting his education in a "special" school, Christopher Nolan had to develop careful and clever strategies for developing friendships, allowing others their curiosity, and finding ways to use his considerable gifts against the odds of both the disease and the prejudice it bred. One of his strategies is the inventive, cryptic, poetic, Joycean idiom in which he writes his story. He did, in fact, succeed in a school where he was accepted as a kind of experiment, in an area of Ireland not known for its progressive attitudes. In this narrative he moves back and forth between inner life, family life, and life at school, allowing readers to get to know him as a deeply reflective, adventurously social, and courageous human being, living with his debilitating condition with a degree of consciousness that took full account of the losses as well as finding avenues of expression that allowed him, intellectually, at least, full range of motion. The narrative takes us through his school years where he distinguished himself as a poet and also as a human being for whom life with a disability shaped an extraordinary dexterity with language.
Summary:Emily Bauer, mother of two small children, psychotherapist and teacher, social, smart, athletic, and strong-willed, finds, after a curious series of falls and other accidents, that she has ALS, "Lou Gehrig's Disease," a disease that involves slow atrophy of all muscular control, leading to complete paralysis and then death. The disease is relentless, and treatments palliative at best.
Summary:Eric Calhoune is known to his classmates as "Moby" because of the extra weight he has carried since grade school. Though his mother is young and athletic, he has inherited the body type of the father he's never known. Now, in high school, the fat is turning to muscle under the discipline of hard swim team workouts. But that transformation has been slow in coming, since for some time Eric has taken on a private commitment to "stay fat for Sarah Byrnes." Sarah, whose name is a painful pun, was severely burned as a small child not, as we are given to believe early on, because of an accident, but because of a cruel and crazy father who stuck her face and hands into a woodstove in a moment of rage. She has lived with him and his threats for some time; that and her disfiguring scars have made her tough, smart, and self-protective. Eric and she became friends as social outcasts. Well-matched intellectually and in their subversive wit, they write an underground newspaper together. Sarah, however, lands suddenly in the hospital, speaking to no one, making eye contact with no one. Eric faithfully visits her and, per nurses' instructions, keeps up a running one-sided conversation as if she could hear him. As it turns out, she can. She is faking catatonia because the hospital is a safe place, and she has chosen this as an escape route from her father. Eric and a sympathetic coach/teacher go to great lengths to find Sarah's mother-who, it turns out, can't bring herself to be involved in her daughter's life because of her own overwhelming shame. Ultimately the father is apprehended, and Sarah, nearly eighteen, is taken into the coach's home and adopted for what remains of the childhood she bypassed long before. In the course of this main plot, other kids enter the story and in various ways come to terms with serious issues in their own lives, some of which are aired in a "Contemporary American Thought" course where no controversy is taboo.
Jerome Lowenstein is a nephrologist, author, and founder of the Bellevue Literary Press and the Humanistic Aspects of Medicine Education seminar program at the NYU School of Medicine. In this thoughtful and illuminating book of essays he explores the patient/physician relationship in a world where medicine has embraced technology and scientific advances in the laboratory at the risk of neglecting the humanistic underpinnings of the field.
Dr. Lowenstein graduated from medical school at NYU in the late 1950s and spent nearly his entire professional career at NYU Medical Center and Bellevue Hospital. When he was a resident, long before work hour limits were instituted, the house staff gathered in the cafeteria at midnight to dine on the days’ leftovers. This communal meal “provided a fine opportunity to communicate with colleagues directly, rather than by beeper and phone, about many of the days ‘medical leftovers,’ ” (1) sharing information as well as the frustrations and rewards of caring for patients. “The Midnight Meal” poses the challenge of retaining the core of relationships, both between patient and physician and among colleagues in the rapidly changing world of medicine today.
In the essay, “Can You Teach Compassion,” Dr. Lowenstein tells his readers about the student who responded to the question with “I don’t know if you can teach compassion, but you surely can teach the opposite.” (13) The student was referring to how students become “desensitized” during their clinical years to the suffering of their patients, sometimes to the point of using derogatory terms to describe them. Dr. Lowenstein argues that teaching attendings can and should encourage students to learn about their patients. He writes how he once interrupted an intern who began to present a case by stating: “This is the first hospital admission of this thirty-five year old IVDA.” Dr. Lowenstein asks: “Would our thinking or care be different if you began your history by telling us that this is a thirty-five-year-old Marine veteran who has been addicted to drugs since he served with valor, in Vietnam?” (17) Learning about the lives of their patients, Lowenstein emphasizes, does not detract from the clinical picture, but rather enhances it.
Summary:Tora lived happily on a mountain farm in Norway until her beloved mother's death and her own subsequent diagnosis with leprosy, an illness common in early 19th-century Norway and one that drove her mother to suicide. Upon diagnosis (at the age of 13) she is taken to the leprosarium in Bergen, from which very few emerge. Most are left there by families whose fear of the disease leads them to abandon even much-loved children, parents, and spouses. There, despite the misery of living among many who consider themselves the living dead, she finds a friend in Marthe, the chief cook and general caregiver, a woman of almost boundless kindness; and the "Benefactor," a pastor who is remarkably unafraid of the disease from which most flee, and who befriends Tora as she grows into an unpromising early adulthood. Another unlikely friend is a noblewoman who has languished, embittered, behind a closed door with a trunk full of her old gowns and several cherished books, including the Bible, The Divine Comedy, Gulliver's Travels, and a popular Norwegian epic about the adventures of Niels Klim at the center of the earth. She gradually softens toward Tora, who cares for her tenderly as the older woman teaches her to read. Reading becomes not only Tora's consolation, but that of many of her fellow inmates. Near the end of her own short, but surprisingly rich life, Tora's father shows up after years of neglect. Forgiving him, almost against her will, she reaches a new level of acceptance of her own mysterious fate. The book includes a short afterword about the actual leprosarium in which the story is situated and about Gerhard Armauer Hansen who in 1873 discovered the bacillus responsible for leprosy, the first bacterium proved to be the cause of a chronic human disease.