Writing

Book Review When Breath Becomes Air

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When Breath Becomes Air

by Paul Kalanithi

Forward by Abraham Verghese

ISBN 9780812988405 Random House, New York 228 pp

This author takes the reader with him through the terrible transition between his very ambitious and successful early life to his death as a 36 year old man– who gets lung cancer in the last years of his neurosurgery residency at Stanford. He had originally wanted to be a writer, but chose medicine instead. Yet he is still also a writer. As physician readers and reviewers, george meyer and I walked his walk not wanting to put the book down until the last word. Though Paul was unable to actually finish his book, he takes the reader to the point where he loses the ability to go on. His wife, Lucy, an internist whom he first met in medical school, provides closure in a touching epilogue.

The story begins at the ending…in the prologue. The author, previously treated for cancer, has recovered enough to nearly complete his 6th and last year of neurosurgery residency, when he develops extreme exhaustion and ominous symptoms. He pulls up and views his own CT scan with

‘lungs matted,… spine deformed, a lobe of the liver obliterated.’

Part I, 100 pages, could be of most interest to the non medically savvy reader. It tells of Paul’s life, from childhood through his years in medical school. Most interesting is that even while young he is concerned about life and death. That interest is sharpened later by patient care and by the death of his best friend. His writing is filled with pithy literary quotes, reflecting his extensive reading as a child and young man; and perhaps, great intimacy with his browser.

His portrayal of medical school and his experiences with patient care will be familiar territory to most physicians, and informative to others. He nicely portrays many of the challenges and contradictions medical students deal with as they progress through their training. Paul talks about the difficulty all of us (most of us) had with our cadavers and of the depersonalization we may develop so we are not too emotionally involved with the bodies we dissect. He describes the struggle of first-year residents who are fighting just to keep their heads above water. He worries that he was on “the way to becoming Tolstoy’s stereotype of a doctor”, dealing with the demands of residency, then practice, filled with the taste and smell of life and death while dealing with the ‘drama’ of the hospital, and administrators. It seems, though, that Paul develops a sense of who he is and what he stands for sooner than many of us do. He professes great sensitivity to patients and their families in the most trying of circumstances. He gets involved…intimately and actively, with patients, something often considered bad form or dangerous.

Part II, titled Cease Not Til Death, will likely be most meaningful to physicians, our friends, families, and other medical professionals. It is headed by this quote from Montaigne:

..to study philosophy is to Learn to Die”.

Paul, the physician, becomes the patient. He describes his years long struggle, both mentally and physically, fighting his malignancy. During a tenuous remission he is able to complete all the demanding requirements of his neurosurgery residency. He writes of the experience during diagnosis, chemo, recovery, mental rigors, and recurrence. Both he and his wife are high powered high pressure professionals, and the marriage is stressful and long distance; yet the cancer changes that, bringing them more together. Paul’s long drawn out dying also intimately involves his oncologist, who helps him consider and make crucial decisions. All their intertwined lives are changed.

This book– short by comparison with so many that are far less informative– is well worth reading both by medical professionals, and by the general public. The former often look into the eyes of death, and the latter will at some time… It seems likely neither will escape life without that encounter.

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   The Medusa Head

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Since Ancient Greece, western medicine has been associated with snakes,[i] so perhaps Medusa’s snake covered head, which when seen, turns people to stone, or ossifies them, is an apt metaphor for medicine today.

The unstated question for physicians is:

“ If Medicine is sick why don’t you heal it yourselves!’ The answer seems to be:

“Sorry. We can’t. Medicine is not a uniform or coherent profession, but many competing and isolated professions; each has looked at Medusa and become stone.

Rubens_Medusa

Rubens’ Medusa

Government, in the role of a modern Perseus may:

1) Cut off the whole Gorgon head (immediate universal government single pay); or
2) Strangle one or several intertwined serpents at a time.

One toxic serpent is the failure of Primary Care. Even though a majority of physicians plan to enter that specialty at the start of training,far too few do so upon graduation. Their disillusionment is the result of ossified training favoring other specialties, and a realization that there is a mismatch between the demands and the value placed on primary care. To kill that snake we must attract and retain the best and the most idealistic students to primary care; and make their training more attractive, and more rational by:

I          More rapid and practical medical training

II        Inducements to practice Family Medicine

III       Restoration of the Humanities in Medical training

IV     Control of the Political Industrial Medical Cabal that drives outrageous costs

 

 

I    Faster and more practical medical training:

This is not a new idea of course; in the Guild system a young  apprentice learned by ‘see one do one’; the ‘master’ determines when the student was ready. The Hippocratic Oath reflects that guild system, requiring teachers and colleagues to hold professional secrets, and one another, sacred. In the USA today training for primary care is almost as long as many other specialties. It could easily be shortened. In the last century many accelerated physician training programs sprung up, most outside the US. I myself was in a U Minnesota accelerated 7 year college MD program devised in WWII– 3 pre med, 3 medicine, 1 internship.

 

In any event, 6 years of college before seeing a patient, and 9 years to complete a basic MD degree, is not necessary; neither is 12 or more post high school years before finishing Family Practice training. For any qualified student, we can provide for an MD degree 7 years after high school graduation: 3 college, med school, 3, internship 1, by:

1. Admitting students to med school who satisfactorily complete essential basic science in pre med: biology, bacteriology, medical anatomy and physiology, psychology, and biostatistics.(Thank god for software!) Students who had to recover from a poor high school experience, or pursued an interest in unrelated fields, might be given precede, in consideration of life lessons learned.

2. Beginning to evaluate and treat patients, under supervision, on the first  day of med school.

3. Requiring that the last year of training be a general rotating internship (all specialties included);

4. Requiring this path be followed for all all medical students

 

II Inducements to Family Practice: We can:

 

 

  1. Offer to, but not require of all beginning med students, a fully subsidized path in Family Practice. This would be by way of a loan, cancelled after:
  2. 3 years Family Practice, in selected places, with tax free stipend equivalent to three times the average FP residency pay.
  3. For another 3 years thereafter, continuing that stipend, but also allowing private practice at the selected site. At any time after the first obligatory 3 year period, a subsidized Family Practice physician could elect to practice elsewhere, or apply for any specialty training.

 

 III    Resuscitation of the Humanities

 

What is subjective is generally foreign to medical training, but is elemental in life; one result is that too many physicians are deficient in the Humanities, and to a degree, dehumanized. Too often we:

Cannot or do not write or read well.

With the exception of medical literature, may not read at all.

Are unfamiliar with much of history, literature, music, and art.

Are too detached from patients and community.

Are ignorant of basic logic, philosophy, debate, and public speaking.

Finish training with little interest outside self interest.

 

While physicians are not alone in being dehumanized in a 21st century world, communication is more critical to medicine than most professions because:
# a deficiency in the humanities greatly reduces one’s ability to put the human condition in perspective;
# it leaves one less able to reject specious reasoning or ad hominem argument;
# it lessens our ability to appreciate the beauty and to hear the voice of every era, including our own;
# it limits our options as healers, listeners, advisors, parents, friends and lovers.

Therefore, I suggest at least four required upper division college humanities courses during the last 18 months of premed:

English literature; English Composition

World History; Philosophy or world Religion.

Suggested but optional: Speech, Music, Spanish

 

Adding these Humanities requirements for entry to medical school can both make graduates better physicians, and make a medical career more attractive and practical for students already well grounded in the humanities. More didactic material like Calculus, Physics, or Physical Chemistry, exists in the e.universe, where acquisition and sorting of material is a given; those skills can be added any time a specific medical career requires it because physicians, we hope, do not stop learning at graduation.

 

III     Controlling the PIMC—Political Industrial Medical Cabal

 

Physicians, politicians, and the average voter,–none altogether ignorant and none altogether innocent–are groomed and seduced by the PIMC. (I use the term Cabal instead of Power because to use Power creates a problematic acronym.) Yet I do mean Power– the power of money, which is best considered an addictive drug. Physicians tend to practice in prescribed ways because the Cabal controls this drug: Money. We see it. We complain. We call for change. We want to be free, but wait for someone else to free us, fearing the pain of withdrawal. In short, we go about business as usual. What could be done?

 

The penultimate power in a democracy –while it survives–is the informed voter who actively participates in intense and intestine public debate. An encouraging fact is that this debate about medicine is now growing more active and informative every day. The most significant contribution that physicians can make is to participate actively, while listening carefully, as well as speaking carefully.

 

A good example of unfettered and construcive physician contribution to the public debate is the series of essays by Robert Pearl as seen here: and here: or at these addresses:

 

http://www.forbes.com/sites/robertpearl/2014/03/13/malcolm-gladwell-tell-people-what-its-really-like-to-be-a-doctor/?utm_source=alertsnewcomment&utm_medium=email&utm_campaign=20140317

 

http://www.forbes.com/sites/robertpearl/2014/04/24/americas-broken-health-care-system-the-role-of-drug-device-manufacturers/?utm_source=followingweekly&utm_m

 

By contrast, the PIMC–the Cabal– exercises its right to plant sophisticated misleading or biased self serving material throughout the media: TV, magazines–both public and professional–, the net, and direct advertising. Physicians must call foul whenever media presentations are mired in self-interest. They must call out clearly, and determinedly, but with a civil tone. Screaming, playing The ‘Doctor’ card, or making demeaning remarks loses any debate.

 

There is a saying that ‘all politics is local’. A local medical society magazine is the members’ soapbox; their Hyde Park and Trafalgar Square. It is often their only ready forum. Physicians, to be effective must join the public debate both independently and within the profession. Essays and posit discussions in the medical society magazine generally reflect opinions of local docs; as such, they are far more interesting and believable,and more genuine, than collective or organizational voices alone. When physicians speak as individuals, even if what is said may be unwise, prove embarrassing, or be off the official text, it is still that individual’s opinion. Physicians must be involved, and Speak up. So must we all!

 

[1] http://www.greekmedicine.net/mythology/asclepius.html

 

 

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