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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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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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The story of The Heart is a simple, linear structure.  A car accident renders a young Frenchman, Simon, brain-dead. A medical team proposes harvesting organs, and his parents, after some turmoil, agree. That’s the first half of the book, the provenance of this specific heart. The second half describes its delivery for transplantation. Administrators find recipients, one of them a woman in Paris. Simon’s heart is transported there by plane and sewn into her chest. All this in 24 hours.  
            
The narration is complex, with flashbacks, overlapping times, and literary art that is compelling. There are 28 sections to the story but without numbers or chapter headings, and these are often broken up into half a dozen shorter sections. We have an impression of stroboscopic flashes on the action, with high intensity focus. These create a mosaic that we assemble into dramatic pictures. Even major characters arrive without names, and we soon figure them out.    

Simon.  He’s called the donor, although he had no choice in the matter. At 19 years of age he’s trying to find a path in life.  A Maori tattoo is a symbol for that search. He has a girlfriend, Juliette. He fades away as a character (except in others’ memories) and his heart takes center stage.  

Marianne and Sean, Simon’s parents.  Her emotions, as we would expect, range widely, especially during discussion of whether Simon’s organs can be transplanted. Father Sean has a Polynesian origin and cultural heritage.

Pierre Révol, Thomas Rémige, and Cordélia Owl are respectively the ICU physician, nurse, and the transplant coordinator. These are vividly drawn, with unusual qualities. Skilled professionals, they are the team the supplies the heart.  

Marthe Carrare, Claire Méjan, and Virgilio Breva are a national administrator, the recipient, and a surgeon. Described in memorable language, they are the receiving team.              

The characters’ names give hints of de Kerangal’s range. Since the 1789 Revolution Marianne has been a well-known French national symbol for common people and democracy, but Virgilio Breva is from Italy and Cordélia (recalling King Lear) Owl (as in wise?) has a grandmother from Bristol, England. We learn of personal habits regarding tobacco, peyote, sex, and singing. Medicine is part of a larger world of people of many sorts.              

Even minor characters, such as Simon’s girlfriend Juliette and other medical personnel are touching and memorable.              

These characters animate the story with their passion, mystery, even heroism. While we don’t know the final outcome of the implanted heart, the text shows the professionalism of the medical team, the French national system that evidently works, sensitive care of patients and families, and in the last pages, rituals of affirmation for medical art and for patients.              

There is richness in de Kerangal’s style. At times it is direct, reflecting the thoughts of characters. At times it is ornate, even baroque. She uses many images and metaphors, often with large, epic qualities. A very long sentence about the over-wrought parents describes them as “alone in the world, and exhaustion breaks over them like a tidal wave” (p. 141).  The style uses many similes, often with dramatic and unexpected comparisons. There are references to geology, astronomy, even American TV hospital drama. The style is at times lyric…we might say “operatic.”  One page about Cordélia is very, very funny.         
  
In a different tone, the details of medicine, law, and ethics are carefully presented, and visual imagery puts us in the hospital rooms, the OR, and crowded streets around a soccer game. Throughout it appears that translator Sam Taylor has done an admirable job.               

The text invites us to consider large visions of wholeness. All the major characters seek some comprehensive unity to their lives, and they avoid orthodoxies such as religion, patriotism, and economic gain. Sean has his Polynesian heritage and boat-building passion, which he has shared with Simon. Cordélia, at 25, is an excellent nurse, wise beyond her years in some ways, but is as dazzled by a man as any teenaged girl. Nurse Rémige has his master’s in philosophy, loves the song of rare birds, and is, himself, a serious singer.  

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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.

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Walter Mosley writes in various genres but is probably best known for his mysteries. His 2010 novel, The Last Days of Ptolemy Grey, could be considered another one of his mysteries, but the mystery plot takes a secondary role. Featured more prominently is the struggle the main character, Ptolemy Grey, has with dementia.   

The reader first encounters Ptolemy Grey when he is 91 years old and living alone in an apartment he has inhabited in South Central LA for more than 60 years. Both he and the apartment are in appalling shape. The apartment is cluttered, disorganized, and dysfunctional—as is his aging brain. He knows his mind is failing and seems to him as if it “had fallen in on itself like an old barn left unmended and untended through too many seasons.” (p.153)

Throughout the novel, Mosley presents aspects of dementia and some of its oddities. For example, while Ptolemy is riding on a bus through his town, certain sights trigger clear memories from his childhood 80 years before. At the same time he is unsure where he is going or why. Mosley also shows how people can possibly realize they are slipping into dementia, for example, when Ptolemy stops talking to a friend once “he could see in her eyes he wasn’t making sense.” (p. 122)

Ptolemy’s great-grandnephew Reggie provides him with the assistance he needs to barely maintain his lonely existence in squalid conditions. When Reggie dies, a new person comes into his life. Robyn, a 17-year-old orphan living with Ptolemy’s grandniece, begins to straighten out his apartment and then his mind.    

As Robyn gets Ptolemy’s apartment more organized and functional, Ptolemy’s mind starts to get more organized and functional as well, but only a bit more. Unsatisfied with his progress, Robyn takes Ptolemy to a physician who has an experimental drug for dementia. Ptolemy is told that if he takes the drug he will regain his mental acuity but probably not live more than a few weeks, or months, at best. Without hesitation he takes the drug—“I wanna make it so I could think good for just a couple a mont’s, Doc” (p. 126)—and rapidly regains many memories and mental capacities. During the time he has with his newfound mental agility, Ptolemy is able to make good on a commitment from his childhood and to solve the mystery of Reggie’s death. While the experimental drug enables Ptolemy to wrap up his business, it also produces a rather violent end to his life.

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Perhaps no topic in the history of medicine has been explored as much as the lobotomy.  Psychiatrists, historians and journalists have weighed in on this controversial topic, and the procedure has been featured in a number of Hollywood films.

Yet there is nothing like a narrative of a specific lobotomy patient to draw us into the subject anew.  And that is why Kate Clifford Larson’s new book, Rosemary: The Forgotten Kennedy Daughter, is so compelling—even if we already know the sad outcome of Rosemary Kennedy’s life.

Originally devised in 1935 by the Portuguese neurologist Egas Moniz, the lobotomy involved drilling holes in the skull and using a blade to sever nerve fibers running from the frontal lobes to the rest of the brain.  Moniz believed that psychiatric symptoms were caused by longstanding faulty nerve connections.  Severing them, and allowing new connections to form, he postulated, would help treat patients with intractable mental illness, such as schizophrenia and its paranoid delusions.

America’s chief proponent of lobotomy was Washington, D.C. neurologist Walter J. Freeman who, working with neurosurgeon James W. Watts, reported in 1937 that 13 of 20 patients undergoing the operation had improved.  Freeman would later devise his own procedure, the transorbital lobotomy, in which he actually used a mallet to pound an ice pick through the patient’s eye socket into the brain, then moved the pick around blindly to cut the nerve fibers.

Among the first histories of lobotomy was psychologist Elliot S. Valenstein’s  Great and Desperate Cures (1986), which strongly criticized Freeman and his contemporaries as overzealous physicians who did far more harm than good, creating docile and apathetic individuals no longer capable of caring for themselves.  Physician-historian Joel Braslow’s Mental Ills and Bodily Cures (1997) argued convincingly that a main motivation for the popularity of lobotomies—roughly 40,000 would be performed in the United States by the 1960s—was to enable staff members to maintain order in crowded, understaffed institutions.   In Last Resort (1998), historian Jack D. Pressman made the provocative claim that lobotomy represented the best science of the day and that, at least in some cases, it allowed patients to return home with fewer psychiatric symptoms.

Rosemary Kennedy was born in 1918, the third of what would eventually be nine children of Joseph and Rose Kennedy.  Joe was a successful businessman and investor who later entered politics, first as chairman of the Securities and Exchange Commission from 1932 to 1935 and then as U.S. Ambassador to Britain from 1938 to 1940.  At an early age, it was clear that Rosemary was not as mentally sharp as her two older brothers, Joe Jr. and John.  Larson hypothesizes that Rosemary’s “intellectual disability” occurred at birth, when a nurse forcibly kept her in her mother’s womb—perhaps without adequate oxygenation—while waiting for the doctor to arrive.

It was Rosemary’s blessing and curse to be born into the high-powered and prominent Kennedy family.  Her parents left no stone unturned in trying to help their daughter, sending her to special schools and programs around the world.  But they simply could not tolerate her lack of improvement.  Rosemary was a terrible speller and writer, socially awkward and at times unruly.  Joe Sr., in particular, worried about the negative ramifications to his sons’ possible political careers if word got out about their “retarded” sister.

Reading about Rosemary’s first two decades, and knowing that her lobotomy is approaching, is truly heartbreaking.  Writing letters home from her various placements, she was so eager to please.  “I would do anything to make you happy,” she told her father in 1934 at the age of 16.  “I hate to Disppoint [sic] you in anyway.”

When the Kennedys first arrived in England in 1938, Rosemary, her mother Rose and her younger sister Kathleen were presented to the king and queen.  For once, the circumstances tilted in Rosemary’s favor.  The event was smashing.  Photographs show Rosemary, who had become a very attractive young woman, resplendent in a “picture dress of white tulle.”  She felt, she said, like Cinderella.

But when the family returned to the United States in 1940, with war approaching in Europe, the situation was no different than it had always been.  Plus, now in her early twenties, Rosemary’s moodiness and emotional outbursts were becoming more frequent.

Lobotomy had gotten a lot of press in 1941, particularly in a May article in the Saturday Evening Post that highlighted the work of Freeman and Watts.  And while this piece warned about the dangers of the procedure, it mostly praised its ability to make people with mental illness into “useful members of society.”  At some point, Joe Kennedy met with Freeman and decided that Rosemary should undergo the operation.  Larson does not unearth exactly how the decision was reached—or what Rosemary was told.  But it seems to mostly have been Joe’s doing.

The problem, of course, was that lobotomy was not meant for what Rosemary had—essentially a low IQ.  But Joseph Kennedy, in conjunction with her doctors, had convinced himself she had an “agitated depression,” and thus was a candidate.  That Freeman was a zealot for the operation, as is well documented in journalist Jack El-Hai’s The Lobotomist (2005), did not help.  Most tragically, when Rosemary underwent her lobotomy some time in November 1941, something went “horribly awry.”  Patients were kept awake during the procedure and asked to talk or sing to help guide the surgeon’s scalpel.  But in Rosemary’s case, when Watts made his final cut of brain tissue, she became incoherent.  “The operation,” Larson writes, “destroyed a crucial part of Rosemary’s brain and erased years of emotional, physical and intellectual development, leaving her completely incapable of taking care of herself.”

The rest of Rosemary discusses her life after the lobotomy until her death in 2005.  She spent most of these years at a Catholic residential institution in Wisconsin.  Most cruelly, family members rarely visited, trying to render invisible what had happened.  To the Kennedys’ credit, in later years they corrected this error and brought Rosemary for visits to Hyannis Post and other family outposts.  There are only a few photographs in the book from this later era, but they help to humanize the woman who suffered for so long.

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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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Many are familiar with these stories from the author's practice as a midwife among the urban poor in London's East End in the 1950s.  Each piece stands alone as a story about a particular case. Many of them are rich with the drama of emergency interventions, birth in complicated families (most of them poor), home births in squalid conditions, and the efforts of midwives to improve public health services, sanitation, and pre- and post-natal care with limited resources in a city decimated by wartime bombings.  As a gallery of the different types of women in the Anglican religious order that housed the midwives and administered their services, and the different types of women who lived, survived, and even thrived in the most depressing part of London, the book provides a fascinating angle on social and medical history and women's studies.

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Beginning in 1992, Mark Duxbury and Dean McClellan are high-flying salesmen for Johnson and Johnson, Ortho branch – happily promoting the drug Procrit, (or Epogen -- erythropoietin), for anemia. The drug stimulates the bone marrow to produce more red blood cells. Developed by fledging company Amgen, it was licensed to Ortho for specific uses. Their careers take off, and they earn bonuses and stature, peaking in 1993. Soon, however, Duxbury realizes that he is being encouraged to promote the drug for off-label uses and in higher doses that will enhance sales and profits through kickbacks. He soon realizes that the drug is not safe when used in these situations. People are dying because their unnaturally thickened blood results in strokes and heart attacks.

He raises objections with his employer. For voicing concerns he is ostracized and then fired in 1998. Along with the stresses of his work, the financial difficulties and emotional turmoil, Duxbury’s home life is in tatters; his marriage falls apart and he worries about his daughter Sojourner (Sojie). He develops multiple health problems, including sleep apnea and dependency on drugs and alcohol.

Enlisting the help of the famous lawyer Jan Schlictmann (A Civil Action), whistleblower Duxbury launches a qui tam lawsuit in 2002 against his former employer. This is a civil action under the False Claims Act, which can offer cost recovery should the charges prove warranted. The lengthy process is still going. The last ruling issued in August 2009 allowed the case to proceed. But Duxbury soon after died of a heart attack in October 2009 at age 49.

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