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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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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At the heart of this novel is a simple love story. Dr. Bruno Sachs, a slight, stooped, and somewhat unkempt general practitioner in a French village is dedicated to his work and loved by his patients. Sachs is a solitary, self-effacing man who takes his Hippocratic duties seriously and is especially sensitive to the needs of his patients.

In addition to his private practice, Sachs works part-time at an abortion clinic, where he performs an abortion on a distraught young woman named Pauline Kasser. Soon the doctor and his patient fall in love. She moves in with him and becomes pregnant. An editor by profession, Pauline also encourages and assists Dr. Sachs in completing the book he is writing.

The story has many additional layers and dimensions. The reader views Sachs through the eyes of multiple narrators--his patients, colleagues, friends and acquaintances, all of whom write in the first person and present Bruno Sachs as "you" or "he." Thus, the reader gradually builds up a "connection" (empathy) with Sachs by synthesizing multiple glimpses of his behavior and facets of his character. At the same time, Sachs is trying to find his own voice, his own connection, by becoming a writer. At first he jots down random thoughts, then he keeps a notebook, and eventually he produces a complete manuscript.

The book has innovative structural elements that introduce other layers of meaning. For example, the 112 short chapters are organized into seven sections, corresponding with the components of a complete clinical case history: presentation (as in "chief complaint"), history, clinical examination, further investigations, diagnosis, treatment, and prognosis. Similarly, the narratives delve progressively into Sachs' "illness" and follow the "patient" through his course of "treatment."

Another structural element is the cycle of fertility and gestation. The story takes place from September through June, precisely 40 weeks, a pregnancy of nine months, during which Sachs is re-born.

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Tim Metcalfe is an Australian general practitioner who gave up medical practice to become a full-time poet and writer. A statement on the back cover summarizes the process in relation to this collection of 38 poems: " ’Cut to the Word’ is a moving account of one man’s transition from doctor to poet." He begins with the customary initiation: "We were introduced, respectfully, / to the volunteer dead . . . " (p. 13) He discovers the limitations and uncertainties of his new profession: "In tense moments / I wish my stethoscope / was all they want it to be." (p. 18) And the omnivorous demands of medicine: "I come home from work / and there it is: the family / the oldest crying / at the youngest crying / at her mother’s anger / at her crying . . . " (p. 21)

Metcalfe carries the reader through a series of short, incisive poems describing the doctor’s day-to-day work ("Morning Session, " pp. 47-50), as well as through a number of disturbing poems about the world of mental illness, but the book’s climax--so to speak--arrives with "The Doctor’s Complaint, " in which the physician heals herself "by laying down her stethoscope / and walking right out / of that in-patient clinic." At the end the poet writes, "Like a patient I have learned silence . . . Fine steel scissors in hand, / I cut to the word." (p. 63)

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This historical novel is set in 16th century Venice, where the great anatomist and physician Mateo Colombo has just been charged with heresy and placed under house arrest. The book proceeds in a series of short frames or fragments, presenting Colombo’s story from a wide variety of perspectives, ranging from the perspective of Mona Sofia, the most prestigious whore in Venice, to that of Leonardino, the crow who waits each morning to scavenge an eyeball or piece of flesh from one of the anatomist’s cadavers.

What is Colombo’s heresy? True, he has consistently violated the Papal Bull of Pope Boniface VIII that forbid obtaining cadavers for dissection, but his scholarly eminence and friendship with Pope Paul III have protected him from recrimination. His heresy is far worse than simply ignoring a Papal Bull; in fact, Mateo Colombo has discovered a dangerous new anatomical structure, the clitoris!

Mateo was called to the bedside of an unconscious holy woman named Inés de Torremolinos. In the process of examining her, the physician was amazed to discover "between his patient’s legs a perfectly formed, erect and diminutive penis." (p. 105) He took hold of the strange organ and began massaging it. As he did so, there was an amazing response in his patient: "(Her) breathing became hoarser and then broke into a loud panting . . . Her lifeless features changed into a lascivious grimace . . . " (p. 107) Subsequent research undertaken with Mona Sofia, the resplendent whore, as well as with cadavers, confirmed the significance of Colombo’s discovery.

At his hearing before the High Tribunal, Colombo explains his findings, which are far too complex and subtle to summarize (pp. 138-165). The finding of greatest interest, however, is that "there is no reason to believe that there exists in women such a thing as a soul." (p. 151) In fact, Colombo contends he has proven that the "amor veneris" or clitoris performs in women "similar functions to those of the soul in men, " although its nature "is utterly different since it depends entirely on the body." (p. 153)

You’ll have to read the book to discover what the verdict of the High Tribunal of the Holy Office was and Mateo Colombo’s fate.

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Written by a medical historian who is also a physician, The Breast Cancer Wars narrates how breast cancer diagnostic methods and treatments have developed from the early twentieth century. More significantly, the book describes the debates and controversies that permeated this evolution and the ways in which not only clinicians and researchers, but, increasingly, women patients/activists shaped how we view, diagnose, and treat breast cancer today.

Individual chapters explore the influential (and ultimately contested) radical mastectomy procedure of William Halsted, the development of the "war" against breast cancer as a full-blown campaign developed and conducted within the public media and consciousness of the United States as well as within medical practice and research, the intertwined development of feminism and breast cancer activism, the "fall" of the radical mastectomy, and the continuing controversies surrounding mammography and genetic testing as modes of early detection and risk assessment. Lerner draws on a range of primary sources including texts from the archives of the American Cancer Society, the papers of doctors and patients, and advertisements from popular and professional magazines throughout the century.

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A physician is summoned to make a housecall on a family with whom he has had no prior contact. He quickly sizes up the situation: the household is poor but clean; the patient is a female child whose parents are nervously concerned, dependent on, yet distrustful of the doctor. The child's beauty and penetrating stare make an immediate impression on him.

Concerned that diphtheria may be the cause of illness, he uses his customary professional manner to determine whether or not the child has a sore throat. But the child will have none of it and "clawed instinctively for my eyes." The attempt at an examination rapidly escalates into a physical "battle" as the physician, convinced that it is crucial to see the child's throat "and feeling that I must get a diagnosis now or never," becomes ever more enraged and forceful while the girl continues to resist with all her strength, and the parents are in an agony of fear for her health and embarrassment over her behavior.

This is no longer a professional encounter. The doctor admits at the beginning of the struggle to having "fallen in love with the savage brat" and recognizes that he is behaving irrationally. The closing sequence could as easily be depicting a rape as a forced throat examination.

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From the mundane to the profound, from the body as physical preoccupation to the body as sacred, the poet explores in 21 highly personalized lines the significance and symbolism of the human body. Washing your feet without giving it a thought means you are in good health; struggling to do it because of overweight is a reminder of mortality. This (any) physical act "should be ritual . . . memorial, meditative, immortal." It conjures up an image of the Degas ballet dancers washing their feet, and then, remarkably, that " . . . they also seemed to be washing God’s feet."

But the creative power of Degas is yet another reminder of the author’s limitations. He is vulnerable, mortal and not creative enough to gain immortality by producing a masterpiece: "It is sad to be naked and to lack talent."

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A young doctor, recently assigned to a country hospital, is fraught with anxiety, especially over his lack of experience with obstetrical problems. One night the midwives call him; a woman is having a difficult labor. The fetus is presenting in a transverse position. The doctor must reach internally and “turn it around by the foot,” as Anna Nikolaevna, the seasoned midwife, reminds him.

The doctor has never performed this procedure. He buys time by going back to his room to consult the textbook (under the pretext of going for cigarettes). Finally, he can't avoid it any longer. He performs the rotation. It works! Both mother and baby are saved.

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The story begins as an MRI technician assures Baily that "Contrary to popular opinion, . . . this is not a torture device." The test was ordered because her arm suddenly went numb and she suddenly lost most of her vision during algebra class. With no idea what's wrong, Baily speculates about the possibility of a brain tumor, about how disease will change her life, about early death. She is uncomfortable with her mother's cheery reassurances, which consist mostly of simple theories like the possibility that Baily was reacting to missing lunch, but wants them, nonetheless.

Since the pediatric wing is full, she is put in a room with an old woman for observation overnight. The nurse runs her through a series of highly irrelevant questions about her physical health from drug use to dentures. Then her mother is required to leave for the night. In the morning they take her for an EKG before her mother can get there; Baily returns to her room in a state of morbid conviction that she's dying, which is finally overturned when the doctor comes in to explain to her that she had a classic case of severe migraine.

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