Summary:

This masterful collection of essays was written by Gawande while he was a general surgery resident. The book consists of fourteen essays divided into three sections: Fallibility, Mystery, and Uncertainty. Although some of the essays fall clearly within the boundaries of the section title (such as "When Doctors Make Mistakes" and "When Good Doctors Go Bad" in the Fallibility section), others cross boundaries or don’t fall as squarely in these general themes ("Nine Thousand Surgeons," an anthropological essay on the cult and culture of a major surgical convention, is also located in the Fallibility section). Nevertheless, the many pleasures of the individual essays, the range of topics explored in depth, and the accuracy of the medicine portrayed are the true strengths of this work.

The book begins Dragnet-style with an Author’s Note: "The stories here are true." (p. 1) And it is this attention to fidelity that makes the essays so compelling. Because even when the truths are hard--the terrible acknowledgment by the medical neophyte about lack of skill and knowledge, the mistakes in judgment at all levels of doctoring, the nature of power relations and their effects on medical pedagogy and on the doctor-patient relationship, the gnawing uncertainties about so many medical decisions--the author confronts the issues head on with refreshing rigor, grace and honesty.

Many of the essays reference scientific and medical research (historical and current) as part of the exploration of the topic. This information is imbedded within the essay, hence avoiding a dry recitation of statistical evidence. Typically, the reader’s interest in an essay is immediately piqued by a story about a particular patient. For example, the story of an airway emergency in a trauma patient, her oxygen saturation decreasing by the second as Gawande and the emergency room attending struggle to secure an airway, surgical or otherwise, sets the scene for "When Doctors Make Mistakes."

This leads to a meditation on not only the culture of the Morbidity and Mortality Conference, with its strange mix of third-person case narrative and personal acceptance of responsibility by the attending physician (see Bosk, Charles, Forgive and Remember: Managing Medical Failure, U. Chicago Press, 1981 for an in depth analysis of this culture), but also a positive examination of the leadership role that anesthesiologists have played in improving patient safety via research, simulator training and systems improvement.

Gawande’s journalistic verve takes him beyond the confines of his own hospital and training to interview patients and physicians on topics as diverse as incapacitating blushing ("Crimson Tide"), chronic pain ("The Pain Perplex"), malpractice and incompetence ("When Good Doctors Go Bad") and herniorraphy ("The Computer and the Hernia Factory"). In addition, he visits his own post-operative patients at home ("The Man Who Couldn’t Stop Eating" and "The Case of the Red Leg") which gives a longer view of postoperative recovery and a broader exposure to patients’ perspectives.

Some of the most telling moments come with the introduction of his children’s medical problems into the text. These range from the relatively straightforward (a broken arm, but a chance to comment on detection of child abuse in the emergency room) to the downright parental nightmare scary (severe congenital cardiac defect in their oldest child and a life-threatening respiratory infection in their prematurely born youngest).

These last two experiences are introduced to provide an angle on issues of choice. Choice of a fully trained, attending physician rather than a fellow to provide follow-up cardiac care for their oldest, and the choice to opt out of the decision-making process for whether to intubate the trachea of the youngest and hence leave the medical decisions up to the care team.

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Author and Oxford don, C. S. Lewis (Anthony Hopkins), lives a sheltered life as a bachelor, sharing a house with his brother. In 1952 he meets an American woman, Mrs. Joy Gresham (Debra Winger). They become friends when Joy moves to England with her young son, Douglas, divorcing her alcoholic husband; when Joy is in danger of losing her visa, Lewis agrees to marry her so that she can become a British citizen.

The marriage appears to be purely a technicality. This is in part because of Lewis’s emotional frigidity with people, which is contrasted with the profundity and energy of his engagement with books and ideas. Joy eventually confronts him about this, and at about the same time she is diagnosed with advanced cancer.

The prospect of her death disrupts Lewis’s ideas about God, suffering, and human relationships, prompting a crisis that leads him to recognize his love for her. Their legal marriage is consecrated in her hospital room and, after radiation treatment puts her in remission, Joy and her son move in with Lewis. After a few months, she dies. Lewis is left with a new knowledge of the real paradoxes of love, connection, loss, and suffering.

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This book's title is from a Goethe poem, "The Holy Longing," translated from German in its entirety by Robert Bly: "And so long as you haven't experienced / this: to die and so to grow, / you are only a troubled guest / on the dark earth." Ten intensely personal essays tell of the suffering and everyday presence of pain of a severely disabled writer who has advancing multiple sclerosis, and of how, "in a very real sense, and entirely without design, death has become [her] life's work." (p. 13)

Beginning with her father's sudden death when she was a child, the essays describe her aging mother's expected death and the family's decision to take her off life support; her caretaker husband's diagnosis of metastatic cancer with uncertain prognosis; her own attempted suicide; death of friends, pets, including her beloved dog; and a young pen-pal executed on death row. If that weren't enough, a coda, her foster son's murder and again the decision to remove life-support, provides "[t]he end. For now." (p. 191)

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An anthology of poetry and prose by doctors, nurses, patients, and other authors, A Life in Medicine is divided into four sections: "Physicians Must Be Altruistic"; "Physicians Must Be Knowledgeable"; "Physicians Must Be Skillful"; and "Physicians Must Be Dutiful." Each section begins with the Association of American Medical Colleges' (AAMC) definition of the physician trait examined in that section, and short "explications" precede each individual poem and prose piece, linking them to the section's overall theme.

The anthology has a preface outlining the editors' goals and Robert Coles's introduction, "The Moral Education of Medical Students." These organizational touches make the anthology a classroom-ready text for medical students. The anthology's poems and prose--many of which are stunning--were taken from previously published works and exclude many well-known and often-used pieces. But those selections are readily available elsewhere, and the editors do readers a greater service by introducing many lesser-known, but equally important, poems and essays.

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Abba Kovner wrote these poems during and after his hospitalization at Sloan Kettering for throat cancer. His exile into the world of illness begins as he enters the hospital. "He fell asleep under strange skies" (p. 7) and in the hospital "the silence astounds on all / its many floors."(p. 11) [Throughout the book, Kovner refers to himself in the 3rd person.] He tries to pray: "Is there a prayer for one who prays like him / seething . . . " (p. 15) He decries "the infuriating confidence of the doctors." (p. 21) He celebrates the beauty and magnificence of New York. But then the bad news arrives: "When they told him they were going to cut away his vocal cords / entirely it was merely / a confirmation of what he already knew."(p. 31)

To the brisk, young hospital staff, he is just another patient, nothing but an "ancient shard”: "They could not imagine that this was a man / who had fought the world."(p. 36) Only Norma, the Puerto Rican night nurse, connects with him at a different, more human level. "He blushes / when Norma says: What a lovely / head of hair you have, sir!" (p. 88) As he prepares for the laryngectomy, images from the past invade his consciousness--Christmas Eve, 1941; the Vilna ghetto, where "the lice / got under your skin" (p. 68); and "a shoemaker, his name forgotten" (p. 74). The Holy Guests--the souls of Abraham, Isaac, Jacob, Joseph, Moses, Aaron, and David--also visit the sick room.

After the surgery, the conspiracy of optimism brings him along, carries him forward: "What a healthy recovery, / they said. And patted him on the shoulder / with admiration: You’re doing fine. Wow!" (p. 85) But this is at best a voiceless recovery: "From the wreckage of his voice / there arose a bubble / a tiny bubble . . . " (p. 101) Eventually, the patient leaves the hospital, leaves New York, and arrives home: "Fearful from the moment of arrival: he / watches the landing that cannot / be avoided, into / the arms / of people who love him . . . " (p. 111) He settles into a routine, lives his life as if there is nothing new, but ends at "An Ending, Unfinished" (p. 126), back at Sloan Kettering. "Where now? He asked himself . . . " What next?

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This is a rich and diverse anthology of poetry and of prose extracts, both fictional and non-fictional, about becoming a parent. It is organized into three chronological sections: "First Stirrings," about becoming and being pregnant (or of having a pregnant partner: the father’s perspective is refreshingly well-represented throughout), "The Welcoming," about labor and birth, and bringing home the newborn, and "Now That I am Forever With Child," about being the parent of an infant.

Each section contains a cross-section of views, from, for instance, Elizabeth Spires’s languid letter to the fetus inside her to Rosemary Bray’s candid account of her ambivalence about being pregnant; from Julianna Baggott’s thoughts on the Madonna and child, and A. S. (Antonia Susan) Byatt ’s rather frightening description of giving birth in a British hospital in the 1960s, to Hunt Hawkins’s sad poem about holding his dying newborn daughter; and from Jesse Green’s memoir as a gay parent adopting a son to Kate Daniels’s prayer for her children.

The anthology ends with the powerful poem by Audre Lorde that gives its title to the book’s last section. Lorde encapsulates the astonishing change of focus and identity at the heart of becoming a parent.

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A patient expresses his anger and frustration with the physicians who are treating him. A recovering alcoholic, he feels particularly sensitive to what he perceives as the doctors' self-righteousness, and imagines how he would get even with them.

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Lance Armstrong, (currently) four time Tour de France cycling champion, is a survivor of metastatic testicular cancer. This book is largely the story of how his life changed from the moment of his diagnosis (October 2, 1996) onwards. He had been a world class cyclist prior to cancer, but his experience with cancer gave him profound insight not only into his life as a cyclist and competitor, but into life itself.

It is this latter insight which he recognizes as ultimately the most important aspect of his cancer experience. Armstrong notes: "Odd as it sounds, I would rather have the title of cancer survivor than winner of the Tour, because of what it has done for me as a human being, a man, a husband, a son, and a father." (p. 259)

Written in a conversational, straightforward tone, the book chronicles Armstrong's childhood in Texas as the son of a strong, loving, supportive, financially struggling, young mother; his beatings at the hands of a step-father; and his early excellence at endurance athletics. Armstrong became a brash powerhouse cyclist and began to enjoy the material rewards of winning while ignoring the onset of symptoms. At the time of diagnosis, the cancer had spread to his abdomen, lungs and brain.

He documents his search for optimal care, sperm banking, lack of health insurance, surgeries, chemotherapy, self-education and interactions with doctors and nurses. Through it all he acknowledges the tremendous support of his mother and friends, as well as sponsors who stuck with him with no assurance that he would survive, let alone race.

Before he was even through the first year, he decided to start a charitable organization, The Lance Armstrong Foundation, dedicated to cancer research and support of cancer survivors. Through this effort he met his future wife, Kristin Richard (Kik), and her love and support helped him through the dark days of emotional soul-searching post-treatment. The book also details her struggles with successful in vitro fertilization (They currently have a son and twin daughters).

Chapter Nine, The Tour, is an in depth look at the 1999 Tour de France which Armstrong won with the help of his US Postal Service teammates, expert coaching, and his will. This race is brutal, dangerous, and as Armstrong notes, both "a contest of purposeless suffering" and "the most gallant athletic endeavor in the world." (p. 215) He details the maneuvering in the peloton, the strategies, the stages and personalities.

The book concludes with reflections on the birth of his son, the anniversary of his cancer diagnosis, the love of his wife, and his need to ride.

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The story begins with the doctor-narrator unobtrusively observing an older man lying in a hospital bed. The patient is blind and has amputations of both legs. (We are given no medical details that cannot be observed in the room.) The narrator tends to the man's amputation wounds and answers a few simple questions. The man requests a pair of shoes.

Back in the corridor, a nurse tells the doctor that the patient refuses his food, throwing his china plate against the wall of his room. The narrator hears the man and a nurse argue briefly about food and then, by himself, watches as the patient carefully and powerfully throws another dish against the wall. The next day the doctor discovers that the patient has died.

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It is evening; the shades are drawn; the sanitarium is quiet. Inside, the inmates knit and play chess. "The period of the wildest weeping, the fiercest delusion, is over. Inside, everyone has quieted down; even "the manic-depressive girl / is leveling off." There has been a certain amount of improvement. The poet salutes the fortunate ones; for example, the older wife "who has been cured of feeling unwanted" and will soon be home, feeling "as normal and selfish and heartless as anyone else." There is so much to be happy about. Soon the drunks will be cured, and all the cats will be happy. And so, as we leave this scene, "Miss R looks at the mantelpiece, which must mean something." [35 lines]

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