Summary:

A group of eight women gather for a joint consultation with Dr. Kailey Madrona who is a devotée and colleague of the research endocrinologist, Dr. Jerilynn Prior, a professor at University of British Columbia in Vancouver. Madrona explains that she has arranged for the unorthodox group encounter because she will be leaving practice to pursue graduate studies in medical history.

Dr. Madrona leads an open-ended discussion on the physiological changes associated with perimenopause. Following the controversial research of Prior, she emphasizes that the symptoms are owing to the unbalanced rise in estrogen levels during perimenopause—a period leading up to the cessation of menstruation and continuing for twelve months after the last flow.

Some women patients are skeptical, because they have been placed on estrogen ‘replacement” medication, or they have read that their symptoms are owing to the waning of estrogen. The doctor describes the results of various trials about supplmentary estrogen, including the 2002 Journal of the American Medical Association report. She invites them to keep detailed diaries of their cycles and symptoms.

One by one the women return for private consultation, physical examination, discussion and another follow up visit. Although they have reached roughly the same physiological moment in life, they are a diverse group with different symptoms and needs. Darlene, an angry nurse, is suspicious and non-compliant. Beverley, an Asian immigrant is still hoping to become pregnant. A lesbian wishes to control her moods and hot flashes. A very hard-working waitress needs to understand her strange lack of energy. A wiry, lean athelete wants to improve her performance and is irritated by the inexplicable alterations in her abilities. Others are plagued by sweats, nausea, or migraines. They all are confused about sex.

Dr. Madrona listens to them carefully, examines them with special attention to their breasts, not their genitalia, and recommends treatment with progesterone for everyone. She also urges weight gain for most and readily volunteers personal information about her own perimenopause. All but the nurse eventually comply and are relieved of their symptoms. At the end of a year they meet for a pot-luck dinner to celebrate their recovered health and thank their doctor. Beverley is pregrant.

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Tracy Kidder met Paul Farmer in 1994 when the former was writing an article about Haiti. They next met again in 1999 but it was only when Kidder expressed an interest in Farmer and his oeuvre that Farmer emailed him back, writing "To see my oeuvre you have to come to Haiti" (17). Kidder did just that, following the peripatetic workaholic Farmer to Peru, Russia, Boston, and wherever Farmer flew, which is anywhere there is poverty and disease, especially infectious disease.

In Mountains Beyond Mountains (MBM), Kidder chronicles Farmer’s childhood, medical school years (almost a correspondence course with Farmer’s frequent trips to Haiti), his founding of Partners in Health (PIH) and the construction of the medical center in Cange, Haiti, where "Partners in Health" becomes Zanmi Lasante in Creole.

The story of Farmer’s crusade for a more rational anti-tuberculosis regimen for resistant TB; his political struggles to wrestle with drug manufacturers to lower the price of these and medicines for HIV; his charismatic establishment of a larger and larger cadre, then foundation of co-workers; the story of Jim Kim, a fellow Harvard infectious disease specialist; Farmer’s marathon house calls on foot in Haiti; endless global trips punctuated by massive email consultations from all over the world; and gift-buying in airports for family, friends and patients--these are fascinating reading. In the end one is as amazed and puzzled by the whirlwind that is Paul Farmer--surely a future Nobel Peace Prize laureate like Mother Teresa--as Tracy Kidder was and grateful to have the opportunity to read about it by such an intelligent writer.

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Cameron, 18, and her sister Allie, 15, have inherited their father’s large nose. Living in Los Angeles, at the epicenter of the entertainment industry, they are familiar with the social currencies of money and beauty. Their mother, a former film actress, auditioning again after years at home, is exceptionally beautiful. Cameron’s “nose job”—the rhinoplastic surgery her parents arranged for her when she entered high school—has changed her life; it is debatable whether altogether for the better. She is now popular and accepted, but also, after a history of rejection and peers’ mockery, fixated on the kinds of beauty that bring social acceptance. Her interest in photography dovetails with this fascination.

At just the time her parents decide to arrange for a similar “nose job” for Allie, who doesn’t want it, and would rather spend the summer at soccer camp, Cameron decides to use her savings, and her new legal freedom as an 18-year-old, to have breast augmentation. Her parents and most of her friends oppose it, her boyfriend most strenuously, who can’t understand why she would take the risks entailed to do something so clearly unnecessary. As the girls learn, their mother has, at the same time, decided to have a face-lift as a return-to-career move.

Both Cameron and her mother go through the surgery—Cameron at the cost of considerable pain in recovery and aware of the long-term risks and costs. Allie, on the other hand, after coming to know an aging actress who was once a beauty, makes an eleventh-hour decision to refuse surgery and with it, the impossible standards of beauty that seem to her to entrap so many like her sister.

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Maren Grainger-Monsen, a filmmaker and emergency medicine physician, chronicles her personal journey towards understanding death and dying as she explores the stories of those near death. The film uses a metaphor of the thread of life, and the three Greek Fates who control life (spinning, measuring and cutting this thread), to interweave Monsen's journey with the lives--and deaths--she encounters.

The film begins with her recollection of two experiences during her emergency medicine training: the first time she is paged to pronounce someone dead and a "crisis point"--resuscitating a patient, brought to the emergency room, who had specifically requested no resuscitation. The remainder of the film focuses on Jim Brigham, a social worker for a hospice program, whom Monsen joins for his home hospice visits and who relates the touching and memorable story of his wife's life and death.

Some of the patients Jim visits are Tex, a man dying of heart failure who had experienced a difficult, scary night; Sean, who has Lou Gehrig's disease and who needs help with paperwork and family concerns; and Anna Marie, who has lymphoma and is taken via ambulance to the hospital for comfort measures. Monsen notes how comfortable Jim is discussing death issues and how compassionate and caring he is with a recent widow in the midst of her "grief work." By contrast, Monsen admits to feelings of helplessness, vulnerability, even terror. She wishes her medical education had not been so devoid of teaching regarding death and dying.

Monsen comments on the wavering line between life and death, and whether the "medical machine" prolongs life or death. She visits a young boy left with severe brain damage following a near-drowning incident and "successful" resuscitation 5 years previously. The boy requires constant care, but his father notes that his son is "doing pretty good."

By the end of the film, Monsen has learned "how to sit with someone . . . while death walks into the room." Death no longer equates with failure. She concludes with her overvoice, "I wonder what it will be like to be a doctor who doesn't see death as the enemy."

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Among the "scenes from everyday life" which constitute so-called "genre" painting in 17th Century Dutch art, the profession of medicine was often lampooned. In Gerritt Dou’s painting, the doctor is depicted as a deceiving charlatan, marketing his products with impressive but unsubstantiated claims about their effectiveness. In Dou’s hometown of Leiden, with the Blauwpoort (Blue Gatehouse) in the background left, the quack has set up shop outside the studio of a painter. [At the Web Gallery of Art on-line site, select "D" from the Artist Index, scroll down for Dou, select "Page 2".)

The artist gazes out of his window, holding the tools of his trade, a pallet and brushes. Directly beside him the quack stands under a Chinese umbrella, with stopper in his hand, and presents the patent medicine in a large glass vial to his audience. On his table is a document with a large and authoritative red seal, indicating his credentials and bolstering his credibility. On one side is a barber- surgeon’s basin, on the other is a monkey.

A crowd has gathered around, including a huntsman with a dead rabbit suspended on his rifle, a man with vegetables in a cart, and a woman with a pancake griddle and batter in a large bowl in the right foreground; she is cleaning and diapering a child. In the right foreground a woman gapes at the doctor and his medicine, unaware that her pocket is being picked. In front of her sprawls a child who holds a bread crust to bait and capture a small bird. In the left foreground is a tall, twisted and dead tree; across from it at the corner of the artist’s studio is a living tree lush with foliage.

While Nicolas Tulp (see Rembrandt’s "The Anatomy Lesson of Nicolaes Tulp") enjoyed a reputation as the "Vesalius of the North," this painting is more typical of the prevailing popular depictions of the doctor, not just in the Netherlands but elsewhere in Europe and equally subject to mockery and suspicion. At this time medical care was provided by local physicians, but also by traveling barber-surgeons whose skills and knowledge were dubious.

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This is a collection of 91 poems on medical topics by medical students, physicians in training, and attending physicians; two are Canadian and the rest American. The poems are organized by six traditional groups of medical training and advancement in the profession: Medical Student, First Year; Medical Student, Second Year, Medical Student, Clinical Years; Intern; Resident; and Attending. There are no sections for pre-meds, retired doctors, or other programs (naturopath, chiropractor).

The editors have done a good job of picking well crafted and evocative poems. A dozen have been previously published. For the most part, the poems are short, easily fitting on one page. Almost all are in free verse, although there is one group of haiku, one prose poem, and an impressive sequence of ten Shakespearean sonnets “Breughel at Bellevue” by Anna Reisman.

Many poems treat dramatic moments in training: the anatomy lab, first gynecological exams, physician-patient relationships, especially when a patient is gravely ill or dying. Several poems in the first three sections comment on the differences between the normal social world and the intense medical world of the hospital. Throughout there are references to the pressures of high-tech, unfeeling medicine. Indeed Jack Coulehan sounds this theme in his introduction; he writes that "steadiness and tenderness" are both needed in medical practice.

 

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Dr. Pauline Chen is a transplant surgeon and hence highly trained in the surgical care of desperately ill patients. She found, however, that although she had intensive and first rate training, time and again the message she received from her mentors and peers encouraged a distance from frank discussions about dying with patients who were clearly dying. Dr. Chen successfully suppressed her urges to reflect on the meaning of illness and death. Years into her training, she finally witnessed an attending surgeon stay with a patient and the patient's wife until the patient passed away. The widow sent a thank you note to Dr. Chen for allowing a "dignified and peaceful death." (p. 101) Chen notes that observing her attending stand with the patient during death changed her profoundly: "...from that moment on, I would believe that I could do something more than cure. This narrative, then, is my acknowledgment to him." (p. 101)

Final Exam chronicles Chen's journey from medical student to attending surgeon and examines her experiences with death and serious illness - of patients, family members, friends. The memoir contains three parts: Principles, Practice, and Reappraisal - each with three chapters. The book is chronologically arranged, beginning with anatomy dissection at the start of medical school and ending with Chen as an attending arranging for hospice, thus honoring a patient's desire to die at home rather than in hospital. Chen skillfully weaves her stories around commentary on the social, cultural and philosophical issues surrounding death and the medical response to death. An introduction and epilogue bookend the text and 46 pages of extensive notes and bibliography complete the book.

Although Chen claims to have slowly and painfully awakened to the fact that patient needs extend well beyond good technical care, in fact one sees Chen emerge as a caring physician even from her initial patient contacts in medical school. Chen speaks more to her role as an Asian-American than to being a woman in a male-dominated field, but she clearly has what it takes to succeed in this extremely competitive field, including a good dose of compulsiveness and an incredible work ethic.

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The authors analyze developments in the scientific article in Europe from the seventeenth century to the present. They devote a chapter to "style and presentation" in each century, and a separate chapter to "argument" more specifically in each century, in French, German, and English examples. They find a remarkable similarity of style already evident in seventeenth-century examples, demonstrating that scientific authors were already addressing an international audience. Seventeenth-century articles show an "impression of objectivity" and "a movement toward a more impersonal style" (47), although the English examples were somewhat more personal, less quantitative, and less interested in explanation than were the French examples, and the prose overall is hardly what we would currently expect from a scientific article.

Although the eighteenth-century examples should, perhaps, be considered part of a larger period that included the seventeenth century, Gross et al do track a movement from impersonal to personal style, nominal to verbal style, and minimal presentation to more elaborate presentation during this period. Also, the French examples continue to approximate more closely to twentieth-century norms of scientific style, reflecting their more professionalized community. Overall, the authors characterize much of the eighteenth century as a period of "consolidation and altered emphasis," with "relative stability" of style (116), although the last quarter of the eighteenth century showed a sharp rise in standardization and standards for accuracy and precision.

Gross et al note that nineteenth-century prose still addresses amateurs as well as professionals, and they comment on its persistent difference from "the highly compressed, neutral, monotonal prose" of late-twentieth-century science(137). However, the English and German examples do become more professional in their use of impersonal style, and examples demonstrate a consolidation toward a more "homogeneous communicative style" (138). They also note that the nineteenth century exhibits a "master presentation system approaching maturity," with "title and author credits, headings, equations segregated from text, visuals provided with legends, and citations standardized as to format and position," as well as standardized introductions and conclusions (138).

They find that the combination of an increasing "passion for factual precision" and systematization produces more careful theorizing generally in science during this period, even as individual sciences specialize and diverge (158). Increased attention is given to the process by which facts are linked to theory, and to the role of evidence, governed by an "overriding need for explicitness" (160).

Twentieth-century examples include shorter sentences with more information packed into each by way of "complex noun phrases with multiple modifications in the subject position, noun strings, abbreviations, mathematical expressions, and citations" (186). The scientific article is now generally marked by high incidence of passive voice and low incidence of personal reference, along with a "master finding system" made up of "headings, graphic legends, numbered citations, numbered equations, and so on" (186). They argue that the current state of the scientific article reflects an evolutionary process whereby "current practices are a consequence of the selective survival of practices that were, persistently, better adapted to the changing environments of the various scientific disciplines over time" (212).

 

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In 1921, the twenty-four year-old Scottish medical graduate, Andrew Manson, takes up an assistant’s position in a small Welsh mining town. He is idealistic, but he quickly learns that his training is inadequate and that his hemiplegic employer will never return to practice. Manson must do all the work for a pittance and bad food. He befriends another assistant, the surgeon Phillip Denny, whose fatal flaw is devotion to drink. Together they solve the town’s problem with typhoid by blowing up the sewer.

Manson’s escape comes in a new job in a larger town and marriage to the equally idealistic Christine. She encourages him to continue his studies and to conduct research on the relationship between dust inhalation and tuberculosis. The results include higher degrees and international recognition, but they also bring about the wrath of the town’s antivivisectionists. To add to the gloom, Christine looses a much wanted pregnancy and the ability to have children.

The Mansons leave Wales for London, where Manson hopes to extend his research within a government agency. Quickly disillusioned by bureaucracy, he is lured into society practice and slowly abandons his ideals in exchange for prestige and wealth. Christine is increasingly unhappy, but his response is annoyance with her and an affair with a married woman. When one of his new associates botches an elective operation on a trusting patient, he realizes the colleague is nothing more than a society abortionist and that he and his new friends are little better.

He decides to sell his practice and renews contact with Denny to establish a group consulting practice "on scientific principles" in a carefully chosen Midland town. He also helps the tubercular daughter of an old friend to an unorthodox (but effective) pneumothorax in a clinic run by Stillman, an American who does not have an MD. Just as he and Christine have rediscovered joy in each other and their future together, she is killed in a freak accident. Only days later in the depths of grief, he is brought before the General Medical Council on charges of unprofessional conduct laid by his former associates. He acquits himself brilliantly and leaves with his old friend Denny for work in the Midlands.

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A collection of short stories loosely connected to each other by centering on the experiences of four people from their first encounters during medical school and continuing into young middle age.

The first and third stories “Getting into Medical School, Part I” and “Part II,” are about study partners, Fitzgerald and Ming, who have trouble admitting their love for each other until she is accepted to medical school and he is not. Ming teaches Fitzgerald how to prepare successfully by passing along learning tips her physician-cousin provided her in exchange for sex. In the second story, Ming meets fellow students Sri and Chen and drifts away from Fitzgerald. In the third, he wrestles with feelings of rejection and misery as he realizes she has opted for a relationship with the more culturally “appropriate” Chen; however, her study tips pay off in more than one way when he meets Ming’s unsavory cousin at his medical school interview.

Later stories describe clinical encounters with specific cases, one of the most memorable being “Winston,” about Sri’s relationship with a paranoid person; the tale is told alternatively from the doctor’s perspective and the patient’s. in “Afterwards,” Sri must explain to a man’s wife and son, how he died suddenly at a strange hairstylist salon; the news disturbs the family who discover that the supposedly impotent diabetic had been a regular at a sex shop.

Fitzgerald and Chen become emergency physicians. Less settled, Fitzgerald tries several settings, including working for an air ambulance company. His problem with alcohol emerges from deep disaffection and brooding resentment over Ming’s callous rejection years earlier and her subsequent marriage to Chen. The problem begins to threaten his judgement and seriously compromises his health when he falls ill.

In the ironically titled “Contact Tracing” both Fitzgerald and Chen contract SARS (the latter from the former) during the (real) 2003 Toronto epidemic. They are isolated in adjoining rooms separated by glass and phone each other for support and discussion. They reminisce about Sri who has died of cancer and muse on the relevance of do-not-resuscitate orders. The outcome is both humorous and surprising.

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