Summary:

The future of healthcare in the US has long been a subject of debate, with how to pay for it overshadowing other aspects of the topic. In publishing this work, the author, Dr. Ezekiel Emanuel, makes clear: “This book is about [the] transformation in the delivery of care in the United States” needed to ensure that “all Americans receive consistently higher-quality and lower-cost care.” (p. 15)   Paying for health care is not ignored, and indeed how health care payment methods figure in health care delivery is taken into account.  

Emanuel builds the book around 12 particular transformational practices as developed and applied in the several different health care organizations he studied. They included “small physician offices and large multispecialty group practices, accountable care organizations, large managed-care organizations, and even for-profit companies.” He admits to finding these organizations in “a careful, if somewhat haphazard, way” through a combination of serendipitous visits to some of these organizations, attendance at presentations showcasing some of them, and personal recommendations received. (p. 15) Emanuel identifies these 12 transformational practices through “carefully observing and ascribing significance when various groups and organizations in many different geographic locations, are independently reporting similar things.” (p. 16)  

The 12 transformational practices are covered across three chapters in the middle of the book. The first describes the practices that involve the way physician offices are structured and operate (e.g., scheduling patients, measuring physician performance, standardizing care, coordinating care), the second describes the practices that affect provider interactions with patients (e.g., shared decision making, site of service considerations), and the third, the practices that expand the scope of care beyond traditional boundaries (e.g., behavioral health, palliative care). Emanuel provides considerable detail on what these transformational practices entail and on the results they produce. These chapters are preceded by a separate chapter on recent changes in health care stimulating transformations, and a chapter on essential elements required for transformation: catalyzing crisis; leadership; culture, governance, and physician engagement; data; physician management alignment; and financial risk.

Emanuel recognizes that: “No organization can institute all 12 transformational practices all at once. No organization has the management capacity to do that.” (p. 197) Thus, he devotes a chapter on how organizations can adopt the transformational practices that are best suited to them. He aggregates the practices into three tiers and ranks them by prioritization. He carves out a separate chapter on “virtual medicine”—a collection of technologies and methods that enable a range of patient care activities (e.g., diagnosing, treating, monitoring) between different locations. Emanuel covers virtual medicine separately because his view is counter to the conventional wisdom espoused by “the medical techno-utopians,” as he calls them (p. 166) He allows that it can augment health care organization performance but itself is not a transformational practice because “healthcare is fundamentally social.” (p. 175) So as not to leave patients wondering how they could benefit from these practices, he devotes another chapter for them on how to find a doctor.

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Summary:

Brockmeier constructed this novel as six individual stories. No overriding plot carries across all the stories, and none of the individual stories has much of a plot either. But, each is tangentially related to the subsequent story through a journal comprising love notes written daily by a husband to his wife that passes from one story to the next.  

I love the ball you curl into when you wake up in the morning but don’t want to get out from under the covers. I love the last question you ask me before bedtime. I love the way you alphabetize the CDs, but arrange the books by height. I love you in your blue winter coat that looks like upholstery fabric. I love the scent of your hair just after you’ve taken a shower… (p. 16)  

The stories share characters, but only insofar as they are involved in the transfer of the journal.  

Also connecting the stories is a phenomenon in which visible light is produced from the location of the body where there is pain, injury, or disease, and in one case an inanimate object—the journal. It just started to happen.  

The Illumination: who had coined the term, which pundit or editorial writer, no one knew, but soon enough—within hours, it seemed—that was what people were calling it. The same thing was happening all over the world. In hospitals and prison yards, nursing home and battered women’s shelters, wherever the sick and injured were found, a light could be seen flowing from their bodies. Their wounds were filled with it, brimming. (p. 138)  

The Illumination is part of every story, but never the main subject. It’s noticed, it’s discussed, it’s contemplated, and eventually accommodated as part of daily existence:  “everyone began to accept that pain now came coupled together with light.” (p. 139) The Illumination is always there, was always there, and will always be there because “there is no such thing as photonic degradation, that light was effectively immortal, or at least as immortal as the universe itself.” (p. 256)

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Summary:

The title of this book, “An American Sickness,” refers to the author’s view that the costs people who require health care must bear in the U.S. causes its own sickness. The author, Elisabeth Rosenthal, is a physician-turned-journalist so her use of a medical metaphor to explain the harms health care costs are causing people comes naturally to her. The sickness metaphor forms the structure for the entire book, and in particular the way a physician approaches a patient with a health problem to diagnose and treat. Thus, the introduction to the book is the “chief complaint,” Part I is the “history of present illness and review of systems,” and Part II is “diagnosis and treatment.”  

The chief complaint is: “hugely expensive medical care that doesn’t reliably deliver quality results.” (p. 4) This complaint is also relatively acute given that the financial toxicity health care causes has become so extreme over just the 25-year period starting in the early 1990s. This was the time it took in Rosenthal’s view for American medicine to transform from a “caring endeavor to the most profitable industry in the United States.” (p. 4)  

The source of this complaint cannot be located in one segment of society or in one part of health care in the U.S. It’s diffuse. Therefore, Rosenthal exams several components of American health care to isolate specific causes for the financial toxicity people are experiencing—her review of systems. She exams 11 particular components, with each one comprising a separate chapter as follows: insurance; hospitals; physicians; pharmaceuticals; medical devices; testing and ancillary services; contractors; research; conglomerates; health care as businesses; and the Affordable Care Act.  

Part II on diagnosis and treatment takes the form of a how-to book, as the book’s subtitle announces. Rosenthal is speaking to health care consumers—i.e., all of us—and commanding our attention: “The American healthcare system is rigged against you. It’s a crapshoot and from day to day, no one knows if it will work well to address a particular ailment.” (p. 241) After a chapter on the consequences of being complacent with our personal health care utilization and costs, Rosenthal provides advice in subsequent chapters on these topics: doctor’s bills; hospital bills; insurance costs; drug and medical device costs; bills for tests and ancillary services; and managing all this in a digital age.  

The book is replete with case studies. The writing is geared toward health care consumers who have no expertise in any aspect of health care—it is Rosenthal the health care journalist writing, not Rosenthal the physician and health policy expert. 

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In this book, Ivan Illich offers a harsh critique of health care as provided in western industrialized societies during the 1970s. However, he did not write this book as a health care expert. He was trained as a medieval historian and philosopher, and taught the history of friendship and the history of the art of suffering. Indeed, he admitted:  “I do not care about health.” (p. i) And yet, he could have written the same critique 40 years later.  

What brought Illich’s attention to health care was his broader interest in how modern responses to societal level challenges become counterproductive and even harmful:

The threat which current medicine represents to the health of populations is analogous to the threat which the volume and intensity of traffic represent to mobility, the threat which education and the media represent to learning, and the threat which urbanization represents to competence in homemaking. (p. 7)

Illich’s general thesis is that health care can work against the healing people seek from it, that health care can be as pathogenic as disease, and that health care can expropriate health. Health care is a nemesis to its subjects, he asserted, because it is “a social organization that set out to improve and equalize the opportunity for each man to cope in autonomy and ended by destroying it.” (p. 275)  

Illich builds his argument around the concept of iatrogenesis, which he differentiates into three categories: 1) clinical iatrogenesis, 2) social iatrogenesis, and 3) cultural iatrogenesis, each of which is given a separate section in the book.

Clinical iatrogenesis is the harm done to people as the result of actions taken to restore health or prevent illness, such as an adverse drug event, a hospital-acquired infection, or perforated bowel from a screening colonoscopy. Illich characterizes clinical iatrogenesis as it is understood and used in biomedical circles, but he brings a particular poignancy to it when he refers to “remedies, physicians, or hospitals [as] the pathogens, or ‘sickening’ agents” at work. (p. 27)  

With social iatrogenesis, Illich is referring to the harm societal arrangements for health care can inflict on people it’s meant to help. These arrangements comprise hospitals, physicians, health care product industries, insurers, and government agencies. The net effect of their actions is to standardize health care, and in Illich’s view, standardizing health care amounts to the “medicalization of life.” The more life is medicalized, the more people are forced to operate under the influence of organized health care, “when all suffering is ‘hospitalized’ and homes become inhospitable to birth, sickness, and death; when the language in which people could experience their bodies is turned into bureaucratic gobbledegook; or when suffering, mourning, and healing outside the patient role are labeled a form of deviance.”
(p. 41)  Harm results to people whose ideas of what constitutes illness and whose preferences in the management of their illnesses do not match up with standardized health care. They could be harmed by treatments they don’t think they need, such as drugs to blunt grief, or in the ways they do not prefer, such as in a hospital. Thus, in social iatrogenesis, the social arrangements of health care are the pathogens.  

Before the social movements and transformations produced standardized health care, people of various cultures coped and adjusted in their own ways to the suffering they experienced. Illich’s cultural iatrogenesis occurs when societies capitulate to “professionally organized medicine [that] has come to function as a domineering moral enterprise that advertise industrial expansion as a war against all suffering.” (p. 127)  Illich is not saying that suffering is good and should be preserved, but rather that societies coming under the control of industrialized health care suffer more and suffer in ways they no longer have the authority or will to manage. Cultural iatrogenesis also manifests when professionally organized medicine supplants community responses to health problems people in that community experience: “The siren of one ambulance can destroy Samaritan attitudes in a whole Chilean town.” (p. 8) He elaborates on how cultural iatrogenesis works against people with examples involving treatment of pain, creating and eliminating diseases, and death and dying. 

Illich’s thoughts on countering the counter productivity of industrial health care take up the last section of the book. He does not propose tearing down organized health care, but rather getting it to where “health is identical with the degree of lived freedom,” because “beyond a certain level of intensity, health care, however equitably distributed, will smother health-as-freedom.” (p. 242)  Illich is beseeching organized health care to leave life less medicalized so as to leave more room for people to decide themselves if their challenges are a matter of health or not, and how they would prefer to manage them when health care may have a role. To this end, he concentrated this section of the book mostly on the political responses required to restore “freedom and rights” people ought to have to manage their health.  

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Suzanne O’Sullivan is a neurologist in the British National Health Service. She has a particular interest in psychosomatic illnesses, and in this book, she covers what she has learned about them. O’Sullivan provides these learnings mostly from clinical experience rather than as findings from empiric studies on psychosomatic illnesses.   

Each chapter is built around one or more case studies that focus on particular psychosomatic illnesses, and include historical perspectives and various theories that might explain why they occur.  

The cases O’Sullivan uses presented themselves as seizures, paralysis, urinary tract troubles, generalized and localized pain, gastrointestinal problems, fatigue, blindness, and dystonia. Patients sometimes came to her with pre-determined diagnoses such as epilepsy, Lyme disease, chronic fatigue syndrome, myalgic encephalomyelitis, and fibromyalgia among others. O’Sullivan is emphatic that psychosomatic illnesses are not just any presentation of illness that cannot be linked to a pathological basis. Psychosomatic illnesses arise from “the subconscious mind [that] reproduces symptoms that make sense to the individual’s understanding of how a disease behaves.” (p. 83) Illness presentations that are feigned or self-inflicted (e.g., Munchausen’s syndrome) are not psychosomatic illnesses in O’Sullivan’s view.  

Each chapter delves into some particular aspect of psychosomatic illness relevant to the case study. These include history (e.g., role of the uterus in hysteria), mechanisms at work (e.g., conversion reactions, dissociation), triggers (e.g., stress, loss, personality traits), factors (e.g., previous illness experiences), illness behavior disorders (e.g., associating illness to benign physical sensations), and the higher incidence seen among females. Though O’Sullivan teases out various characteristics and workings of psychosomatic illnesses, she admits that they remain vexing to clinicians because, “almost any function of the body can be affected in almost any way.” (p. 170)

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The Alice Neel painting, T.B. Harlem, can be seen at the National Museum of Women in Arts in Washington, D.C.

We are looking at a young man who has tuberculosis (TB) and who is at home recovering from a surgical procedure designed to collapse a part of his lung that is infected. He looks sick. His presentation conveys how TB can be called “consumption.” From this picture, however, we can tell that it is not just the subject’s body that is being consumed, but also his spirit and any reservoir of hope.  

The painting appeared on the cover of the June 8, 2005 issue of the Journal of the American Medical Association (JAMA).  In his accompanying essay, William Barclay, a pulmonary specialist, surmises that “thoracoplasty” was the surgical procedure used for this person. The procedure involves the removal of several ribs so that the soft tissue the ribs held up collapses upon the lung and closes it off. Barclay calls thoracoplasty “the most radical form of collapse treatment” at the time. He also notes how Neel captured the anatomical consequences of the procedure: His body forms a graceful sigmoid curve, for a thoracoplasty always resulted in a thoracic scoliosis from the pull of the muscles on the side not operated on, with a compensatory cervical scoliosis in the opposite direction.  

A white wound dressing on the left side of the subject’s chest draws our attention because of its brightness and because the subject’s right hand is pointing to it. It’s not covering the surgical incision because that’s on his back. Barclay suggests that the dressing is covering a wound that opened up a track from the skin to the chest lining or to the lung (i.e., a fistula). The dressing takes the shape of a cross, which made the writer of the text accompanying the painting at the museum where it hangs wonder if we are to see the subject as a martyr in the form of Christ.

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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 siècle 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.

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Lee Chandler is approaching middle age and working as a maintenance man for an apartment complex in Quincy, Massachusetts. We get a sense for his days as we watch him shovel snow from the walks, unclog toilets, fix leaks, and argue with tenants. We get a sense for his nights as we watch him at a bar drink himself into a fighting mood and then watch him fight. He returns to his sparse subterranean apartment that he shares with no one to sleep off the beer and the bruises. He’ll do it again the next day.  

Lee takes a call as he’s shoveling snow. His older brother Joe is in the hospital in Manchester. He would not get there before Joe dies. A few days later Lee finds out he’s now guardian to Joe’s teenage son Patrick. This is not a responsibility he knew about or welcomed, and one that anchors him to his hometown of Manchester. He doesn’t want to stay in Manchester. Through a series of flashbacks, we find out that it’s not the struggles that come with taking on the responsibility of a rambunctious teenager that makes him want to leave again, it’s the unspeakable tragedy he experienced there years before. He blames himself for this tragedy, as did his wife Randi, and many of the townspeople.  

Over the next few months, Lee is busy making burial arrangements for his brother, situating his nephew, and looking for work while being reminded regularly of what causes his profound suffering. He also experiences fresh assaults. One in particular is the reemergence of his now ex-wife Randi. She attends Joe’s funeral forcing him to bear the sight of her with a new husband and in the late stage of pregnancy. A little later he encounters her in town with her newborn child in a buggy. She wants to make amends for her contribution to his suffering. Lee’s response to Randi’s entreaties is gracious but lifeless, and explains how he gets through the days. He has no internal resource to muster responses to anything, good or bad. He’s hollowed out. “There’s nothin’ there,” he tells Randi.  

We’re given no reason to expect there will ever be anything there again for the rest of Lee’s life through a conversation he has with Patrick. Lee has arranged for a family friend to adopt Patrick so that he could leave Manchester for a job in Boston. When Patrick pushes him to stay, Lee confesses: “I can’t do it. I can’t beat it. I can’t beat it.”

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Jake Jameson is an architect who came of age in immediate post World War II London. He grew up in “the wilderness” of the English moors and peat bogs far from London. He returns to this wilderness with a wife and an infant son, and to where his mother, a childhood friend, and many memories still live. We read about his successful career, his Jewish mother and her flight from her native Austria, his marriage to Helen and her unexpected death after about 30 years of marriage, his infidelities, his son’s incarceration in a prison he designed, his daughter’s death as a young child, and how eventually the wilderness he lived in moved from the moors to his brain. We don’t learn all of this easily because it comes in one form through Jake’s damaged memory and in another form through the tellings of more reliable witnesses. We are left in our own confused state about certain parts of story until the corrections and clarifications come later in the book. For example, we can go far into the novel thinking that Helen could have died from falling from a cherry tree until we learn near the very end that she died from a stroke, probably.

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As the movie opens, the married artists Einar and Gerda Wegener are working out of their apartment in Copenhagen. The year is around 1908 and they have been married for just a few years. They do not have children as yet, but they have hopes that they would soon.  

Einar is a painter of Scandinavian landscapes and Gerda is a figurative painter. When the model for a painting Gerda is working on fails to appear one day, she asks Einar to take the model’s place. Einar would need to pose with the model’s dress and assume a feminine posture. In posing as a woman, Einar's simmering desire to become a woman comes to a boil.

At first Gerda finds Einar’s interest in posing as a woman an interesting diversion and as a means to have some fun at various social events. But, Einar becomes more and more serious about his interest in transitioning to a woman in more than just wardrobe and affect. As an early step in that direction, he takes on the name Lili Elbe and the pronoun "she."  She gives up painting and becomes Gerda’s primary model. Gerda’s paintings become highly sought after with her new model.  

Lili’s quest to become a woman intensified over the subsequent years and extended to hoping to acquire a uterus so that she could give birth. With Gerda’s help, Lili eventually finds a surgeon in Germany who is willing to perform a series of risky procedures that will make her into a woman. After the operations, Lili was transformed into the woman she wanted to be, but without the availability of anti-rejection drugs and antibiotics, she died in the hospital with Gerda at her side.

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