"The Woman Who Decided to Die", by Ronald Munson

Perhaps I feel partial to this book because Prof. Munson's introduction to medical practice came the same way mine did: through the lens of clinical ethics. Munson is not a physician, but a bioethicist. His book, "The Woman Who Decided to Die," features 10 vignettes of striking, yet representative ethical predicaments that he has encountered over his career. Munson is a gifted writer, and this book benefits from his succinct, rich, and approachable form of narrative.

The format of the chapters is straightforward: in each, he tells the story of a patient he has worked with. Then, he devotes a couple of pages to the ethical issues inherent to the case, and how doctors approach these issues clinically. For example, a convicted murderer is admitted to the ICU with a failing heart. Prof. Munson is called in for an emergency consultation to determine whether the patient should be put on the transplant list. Should a murderer get a heart before someone innocent?

Perhaps surprisingly for a book about ethics, the book vividly portrays the patient's stories, through the help of lengthy interviews with the patients. Munson also conveys very well the art of medicine. Through his writing we witness the thought process going through the minds of doctors, and the delicate and careful ways that they elicit information from their patients and provide guidance. The book discusses complex issues in medicine in a way that non-scientists can understand, which is rare.

Prof. Munson has written an excellent book. I heartily recommend it as an introduction to clinical medicine and bioethics.

Book recommendations

I like reading books about medicine, and I have found some of them particularly gripping and enlightening. You might enjoy them too. All of these books were written for a general audience.

Practice of medicine
-"Complications," by Atul Gawande
-"Incidental Findings," by Danielle Ofri
-"Better," by Atul Gawande

Cancer
"The Emperor of All Maladies," by Siddartha Mukherjee

Neurology
"The Man Who Mistook His Wife for a Hat," by Oliver Sacks

Medical ethics
-"The Woman Who Decided to Die," by Ronald Munson

Medicine in literature
-"The Plague," by Albert Camus

Big Pharma
-"White Coat, Black Hat," by Carl Elliott
-"The Truth about the Drug Companies," by Marcia Angell

Medical errors
-"Internal Bleeding," by Robert Wachter and Kaveh Shojania

Infectious disease
-"The Great Influenza," by John Barry
-"The Coming Plague," by Laurie Garrett
-"The Hot Zone," by Richard Preston
-"House on Fire: The Fight to Eradicate Smallpox," by William Foege

Endocrinology
-"Why Zebras Don't Get Ulcers," by Robert Sapolsky

Medicine during wartime
-"Long Walk Through War," by Klaus Huebner

Emergency medicine
-"The Blood of Strangers," by Frank Huyler

'Incidental Findings', by Danielle Ofri

In this collection of essays, Dr. Danielle Ofri muses on transitions: of maturing into an attending physician, of becoming a caretaker to her patients, of becoming a mother, and of becoming a patient.  

Ofri's interactions with her patients evoke powerful memories from her past. While working a brief stint as an internal medicine physician at a Catholic medical center, one of her patients has an unwanted pregnancy and wants an abortion. Ofri is forbidden from referring her to an abortion center, but feels conflicted. Ofri reveals to the reader her experience of undergoing an abortion as a frightened seventeen-year-old. Ofri decides that helping her patient is more important than following clinic policy. She refers her patient to an abortion clinic and helps the patient through an emotional trying time.

In another story, Ofri describes a bright 20-year-old patient who has no medical problems but lacks the ambition to go to college. Ofri encourages him to pursue higher education. They set up follow-up appointments, in which Ofri tutors him on his SAT.

The stories cut at the heart of the issues clinicians face. With the tremendous demands on clinicans' time, how can we still take care of the emotional needs of our patients? How can a doctor overcome his hospital's impersonal rules? How much should we reveal about ourselves to patients? How much can we trust what our patients say? Ofri parses these issues in an insightful and personal way. The "incidental findings" of the book's title are the unexpected life lessons Ofri gets from practicing medicine.

In these essays, Ofri is finding her voice as a writer. She experiments with different writing styles, and a few of the chapters are clunky as a result. Still, the richness of Ofri's perspective made reading this book worthwhile. I enthusiastically recommend this little book.
-----
Note: I also reviewed Dr. Ofri's "Medicine in Translation" last month. I enjoyed them both, yet "Incidental Findings" seems the stronger of the two.

'Medicine in Translation: Journeys with My Patients', by Danielle Ofri

In "Medicine in Translation: Journeys with My Patients", Dr. Danielle Ofri retells the remarkable stories of about a dozen of her patients. Dr. Ofri is an attending physician at Bellevue Hospital in New York City, the nation's first public hospital. Dr. Ofri's stories are about moving to a new country: her patients are immigrants who are trying to maintain their identity in the American melting pot. One patient was left horribly disfigured by a politically-motivated attack in his home country. Another needs a heart transplant but cannot obtain one because of her undocumented status. They persevere in the face of tremendous obstacles.

Dr. Ofri tries to bridge the cultural and language barriers that separate her from her patients. She decides to become an immigrant of sorts: she relocates her family to Costa Rica for a year as a break from medicine and as a way of acquainting herself with the culture and language of some of her Hispanic patients.

It is a touching little book. Dr. Ofri cares for her patients and cares about them, too. Her writing captures how she learns from her patients and uses their example to better herself.

'Polio: An American Story,' by David Oshinsky

Poliomyelitis was a uniquely frightening disease in America during the 1940s and 1950s. Good sanitation generally diminishes the threat of infectious agents, and the widespread adoption of soap and indoor plumbing during the early 20th century had reduced the prevalence of scourges such as black plague, tuberculosis, and typhoid. Yet polio became more menacing as sanitation improved. Because Americans were not exposed to polio as infants, they did not gain immunity early in life. American children became increasingly susceptible to fierce outbreaks of polio that left some paralyzed. The seeming randomness of where polio struck and the life-long toll on its sufferers' bodies mobilized the public to find a vaccine.

'Polio: An American Story' chronicles American medical research's coming of age as well as its loss of innocence. Oshinsky also recounts the fierce and sometimes ugly rivalry between the researchers who tried to win the race to develop a vaccine. In creating the first successful polio virus, Jonas Salk became the first researcher-celebrity. Salk deviated from scientific tradition by leaking his results to the press before they were published in scientific journals. In the book, Salk appears tragically flawed, a keen and enterprising scientist whose selfish and heterodox actions earn the derision of his colleagues.

Oshinsky profiles the March of Dimes, a charity that pioneered the use of heavy advertising and celebrity power to combat disease. March of Dimes created a national army of volunteers (primarily mothers) who fund-raised to support polio victims and develop a vaccine. The degree of public support was extraordinary: over two-thirds of Americans donated to the March of Dimes.

Lastly, the reader also witnesses the triumph and hubris of the vaccination effort. With the public clamoring to receive Salk's polio vaccine, government oversight was relaxed, the manufacturing was rushed, and a handful of lots proved to be contaminated with live virus. The resulting paralysis of dozens of children greatly damaged the public's trust in medicine and forced federal government to regulate more strictly the practice of medicine.

The book was fascinating for showing the origins of the politicization of science in modern America. I was also struck by how short our collective memories are: just 60 years ago the public was desperate for a polio vaccine, and many parents unhesitatingly signed their children up to be the first to receive the experimental vaccine. When it was announced that the polio vaccine was a success, it triggered a national celebration. Yet today, some see vaccines and scientists as the enemy. The public's ignorance of the lessons of the past threaten to undermine our progress in combating disease. It's so that I am not doomed to repeat history that I enjoy reading books like Oshinsky's about the history of infectious disease.

'County', by David Ansell

What's an idealistic medical student to do? Upon graduating from medical school in the 1970s, David Ansell and three of his classmates from SUNY Syracuse had the wild idea of interning at Cook County hospital in Chicago. County was the hospital for Chicago's poor: shamefully underequipped, understaffed, and overstuffed. Despite its problems (or more accurately, because of them), Ansell stayed on at County for decades, growing into a mature physician as he and his colleagues worked desperately to reverse the shocking health inequities they encountered. While at County, Ansell co-authored a famous study that alerted the medical world to the phenomenon of "patient dumping" (private hospitals transferring uninsured patients to county hospitals, sometimes killing them in the process). The paper led to the passage of EMTALA, which requires all emergency rooms to treat deathly ill patients rather than sending them elsewhere.

Ansell's profile of Cook County hospital makes for compelling reading. He clearly loves the hospital, loves his patients, and hates the unfair health and political system that has failed both. I recommend the book for medical students and for those interested in minority health.

'Internal Bleeding', by Wachter and Shojania

Medicine is complex, and slip-ups inevitably occur. "Internal Bleeding," a book by two prominent internists, details some of the harrowing mix-ups that have occurred at their hospitals and ask, why do medical errors occur so often and how can we do better? Medical errors are one of the leading causes of death (the Institute of Medicine approximates the figure at 100,000 per year in the U.S.), but it is so commonplace and hidden that it escapes the public's imagination.

The stories in the book are frightening and instructive. A child is given what would have been a life-saving transplant, except that the blood type of the donor had not been checked against the patient. A patient undergoes the heart procedure another patient with a similar-sounding name was supposed to receive. At a major academic center, an elevator is shut down for maintenance, preventing the transfer of a critically-ill patient from the wards to the ICU. For each of these, the authors study the root causes--what was the accident chain that allowed this to occur, and where could it have been broken and the error prevented?

The authors' perspective is refreshing. Even the best-trained, most competent physicians commit errors. And even when a doctor commits an error, they don't necessary deserve blame and censure. More useful is to try to see how modifying the health-care delivery system could have avoided the error. The authors suggest we follow the model of aviation accident investigators of plane crashes, who look to see how modifying protocols or changing the plane can prevent a future crash.

I recommend the book to medical students, those interested in the issue of medical errors, and those interested in health-care delivery systems.

'Smallpox: The Death of a Disease', by D.A. Henderson

D.A. Henderson led the WHO office that coordinated the global smallpox eradication effort. His 2009 book focuses on the bureaucratic and diplomatic challenges that he and his shoestring staff had to overcome to combat the disease. He gives of an overview of how eradication unfolded in each of the endemic countries, including Bangladesh, which was torn by civil war, and Ethiopia, which had poor infrastructure and a substantial population of nomads. Despite seemingly insurmountable challenges, even the poorest countries accomplished this extraordinary public health feat. Young health care professionals bounding with creativity and ingenuity ultimately prevailed. Henderson also discusses the evolving debate over whether to destroy the remaining stockpiles of smallpox, as well as the threat of a bioterrorism attack involving smallpox. Henderson's work propelled him to a distinguished career as dean of the Johns Hopkins School of Public Health and as a senior White House administrator.

"Smallpox: The Death of a Disease" is a more academic and bird's-eye view of smallpox eradication than is William Foege's "House on Fire: The Fight to Eradicate Smallpox" (which I reviewed earlier). I would recommend first reading "House on Fire." If you find that book particularly stimulating, you will likely enjoy Henderson's book, as I did.

'House on Fire: The Fight to Eradicate Smallpox', by William Foege

William Foege, a physician who went on to become Director of the Centers for Disease Control, recently wrote memoirs of his experiences leading the smallpox eradication efforts in Nigeria and India. Foege pioneered the successful "surveillance and containment" eradication strategy, which let health teams avoid vaccinating the entire population. Instead, dedicated search teams located infections, and containment teams vaccinated those cities that were sites of outbreaks. Using this method, smallpox was eradicated worldwide in the 1970's. Interestingly, eradication saved the U.S. a substantial amount of money--what it spent on smallpox eradication was only a fraction of what it spent each year on domestic vaccination and on verifying that travelers to the U.S. were immune. It's important to note the debt owed to many countries, including the U.S.S.R., which first championed global eradication and donated a tremendous amount of vaccine.

Given how deadly, disfiguring, and persistent smallpox was worldwide, its eradication is perhaps the proudest accomplishment of global public health. Foege's account illustrates how this monumental effort succeeded only because of scrupulous planning, careful research, a shared vision among health workers, and several strokes of good luck. He writes of his experiences in Nigeria, where civil war broke out, and in India, the leaders of which were largely skeptical of eradication.

I found the book fascinating, insightful, and brief. I strongly recommend it to those interested in public health, health systems management, and infectious disease.