Destiny of the Republic

The Book of the Week is “Destiny of the Republic” by Candice Millard, published in 2011.

In 1880, James A. Garfield was a humble soul. He, like Abraham Lincoln, did not traverse the country making speeches because stumping was “considered undignified for a presidential candidate.”

Garfield actually did not want to become the 20th president of the United States, but he was elected anyway. He was inaugurated in 1881, in March– the month in which presidents took the oath of office until 1933– when transportation to Washington, D.C. had been sufficiently improved.

At the time, the Secret Service sought to eliminate counterfeit money, not provide security for the president. He had no bodyguards. It was thought there was no way to prevent a determined public from harming him. So he did not worry about assassination.

On orders from God, a deranged man named Charles Guiteau shot Garfield in a train station. While Garfield lay on the extremely unsanitary floor, a doctor “inserted an unsterilized finger into the wound in his back, causing a small hemorrhage…” and a big infection.

If the president had been shot only fifteen years later, he would have been X-rayed and would have undergone antiseptic surgery. However, at the time, the American medical community was still resistant to accepting Lister’s theories on antisepsis, and instead exhibited arrogant, distrustful behavior.

Read the book to learn the destiny of the United States at this fateful turn of events.

All Creatures Great and Small

The Book of the Week is “All Creatures Great and Small” by James Herriot, published in 1993. This is a lighthearted account of Herriot’s training as an aspiring rural veterinarian in 1930’s England. A crotchety yet experienced character showed him the ropes. The author gradually developed confidence in curing the afflictions of pigs, cows, horses, etc. The job was suitable for neither the squeamish nor faint of heart.

Healing Hearts

The Book of the Week is “Healing Hearts” by Kathy E. Magliato, M.D., published in 2010. This is a personal account detailing one woman’s experiences trying to balance her medical training and career, with her family life.

She details various issues, including but not limited to: the long, rigorous road to becoming a full-fledged doctor in her specialty; the discrimination she faces in a male-dominated field; the job emergencies that cut into quality time with her family; and the healthcare crisis in the United States.

Magliato and her husband have a combined 43 years of education and training in medicine. She, in cardiac surgery; he, in liver transplants. She describes the hardships she faces when passionately attempting to save lives. She must ignore her own physical needs while standing for, say, fifteen hours in a row to help provide patients with a replacement heart, or veins or valves. She needs to hold particular medical instruments in place for many minutes without flinching, lest she harm the patient.

Magliato predicts a collapse of the American health care system. The reason is simply that health insurance companies do not pay what hospitals bill them; rather, they pay what they feel like paying. An insurance company might be billed $385,000 for heart surgery hospitalization, but it might pay the hospital only $54,000.

“…a hospital is ecstatic whenever it collects more than 10% of the bill. How can hospitals not only survive but be able to deliver state of the art care when their price is not met? They can only increase their quantity until the hospital is full. They can only cut their costs until the delivery of quality health care is jeopardized.”

Against Medical Advice

The Book of the Week is “Against Medical Advice” by James Patterson and Hal Friedman, published in 2008. This book discusses the struggle of a teenage boy (Friedman’s son) with various psychological disorders; obsessive-compulsive disorder and Tourette’s syndrome among them.

Cory tried to live a normal life, but by his teen years, he had fallen woefully behind socially and educationally. He had friends, but they were misfits like himself. At one point, he tried checking into an institution but found his life was not improving. However, the law required him to stay there a certain number of days, unless his parents signed a document stating he was refusing to accept the judgement of professionals about his treatment.

A last-ditch effort saw Cory enter an extremely radical program– a survival camp, of sorts– in which kids were forced to cooperate with each other in a harsh environment, or literally face death.

Read the book to learn how Cory fared.

Coronary

The Book of the Week is “Coronary, A True Story of Medicine Gone Awry” by Stephen Klaidman, published in 2007. This book recounts what happens when people are afflicted by certain aspects of human nature:  greed, power-hunger and fear. It is a sensational story, the kind even tabloids could not fabricate.

In the 1990’s and single-digit 2000’s, there was a cardiac surgeon, one Dr. Moon, who exhibited the first two aspects in spades– instilling dire panic in impressionable patients, telling them that their clogged arteries could kill them at any second, and therefore, they had to be scheduled for triple or quadruple bypass surgery within the week. Those patients underwent the rigorous, dangerous, and worst of all– in the vast majority of cases– unnecessary procedure, taking weeks to recover, getting saddled with medical bills. Dr. Moon loved the control he had over people, and enjoyed a lavish lifestyle. His reputation was sterling, due to word-of-mouth and great public relations (people truly believed he saved their lives). The hospital where he committed his medical malpractice was one owned by the then-disreputable holding company, National Medical Enterprises (which later changed its name to Tenet Healthcare).

Wait, there’s more! There were other greedy parties involved in the story. Three people saw what was really happening, and found a way to capitalize on the situation. They brought a Qui Tam lawsuit against the doctor and his accomplices. This means they accused him of bilking Medicaid and Medicare out of big bucks by billing the federal government for unnecessary surgeries. They were expecting to reap a large reward for reporting the errant doctor.

Read the book to learn the sordid details and outcome of this extreme saga.

Weekends At Bellvue

The Book of the Week is “Weekends at Bellvue” by Julie Holland, published in 2009. This is a personal account of a psychiatrist who, for nine years, managed weekend admissions to Bellvue, the New York City mental hospital.

Prior to Bellvue, Dr. Holland did her residency at Mount Sinai Hospital in 1992. On her first day, she was put in charge of a patient who believed he was God. Later, she joked to her mother, “…I am starting my medical career at the very top… I am God’s doctor!”

She describes the office politics at Bellvue, why she admitted or released all kinds of patients, including criminals, crime victims, the homeless, addicts, malingerers and people truly in need of help. Colorful vignettes are alternated with details of her personal life. She discusses the growth of her personal relationships– with a close colleague, and with her own psychiatrist, with her eventual life partner, and children. She also relates her fears of being the victim of retaliation by a former employee, and dangerous patients.

There were some extreme stories. At the occurrence of the World Trade Center disaster, a manic Iowa man rode a bus all the way to Ground Zero to help with the recovery effort. There, he was somehow able to get inside and operate a backhoe. He told Dr. Holland, “They need my help.”

Dr. Holland realized she was frustrated that she was able to help patients only temporarily. Bellvue is a revolving door of sorts. Some patients return again and again, because they lack a support system to lift them permanently out of their bad situations, such as addiction, homelessness, or their going off their medication. If Dr. Holland judged that their situations warranted admission to Bellvue, they might get detoxed or restarted on their medication, and/or a comfortable place to sleep in the short term, but once released, would return to the same situation again.

In the end, Dr. Holland left Bellvue because she felt she could be of more assistance to patients in private practice in that she could establish a one-on-one long-term treatment program with them.

The Seeing Glass

The Book of the Week is “The Seeing Glass” by Jacquelin Gorman, published in 1998. This is the personal account of a woman who was diagnosed with multiple sclerosis. The major symptom she experienced was blindness. This generated an amusing anecdote.

When Gorman was admitted to a hospital in New York City for which she served as an attorney, she found the legalese in the documents she was required to sign, familiar (her husband read them aloud to her). She was the one who had written that legalese, irony of ironies.

Gorman also discusses her family members; most memorable among them, her uncle Ogden Nash, and autistic brother.

The Emperor of All Maladies

The Book of the Week is “The Emperor of All Maladies, A Biography of Cancer” by Siddharta Mukherjee, published in 2010. Through this tome, the author, an attending cancer physician, researcher and assistant professor of medicine, discusses the history of cancer– how it came to be named, treated and researched through the centuries, and how it develops on the cellular level. He also talks about how cancer statistics can be manipulated to give people the impression that the illness is more common than it really is (to scare people into getting tested and treated), or– that treatment (including drugs and surgery) is more effective than it really is.

In ancient times, cancer was rare because lifespans were short. Several other diseases (tuberculosis, dropsy, cholera, smallpox, leprosy, plague or pneumonia) killed people before cancer would. More prevalent cancer testing has also made cancer a more common culprit in the cause of death, rather than, say, the labels, “abcess” or “infection.”

In modern times, specific factors, (like smoking and changes in public hygiene and diet) have increased the incidence of some kinds of cancer, and reduced the incidence of others.

The author points out the difficulties in determining whether detecting cancer early, helps save lives. Some cancers are quick-killing and others are slow-growing. If someone is diagnosed with an early stage of quick-killing cancer. whose treatment is rigorous and unsuccessful, is that a better situation than one in which someone has the quick-killing kind without knowing it, but goes about blissfully living his life, and dies quickly once he is diagnosed? Perhaps the former person lived six months longer, but given his lack of enjoyment of life after diagnosis, he might as well have died sooner.

The  author also writes regarding testing, “Using survival as an end point for a screening test is flawed because early detection pushes the clock of diagnosis backward.” Say we have the hypothetical scenario of cancer patients A and B. They both developed the exact same kind of quick-killing cancer at the same time. Say patient A’s illness was diagnosed in 1985 and she died in 1990. Patient B’s illness was diagnosed in 1989 and she died in 1990. But since doctors diagnosed A’s cancer earlier, it seems, falsely, that she lived longer and that the screening test was beneficial.

In 1976, a highly regarded mammography study was done on 42,000 women in Malmo, Sweden. The results showed that a significant number of women 55 years and older benefited from breast cancer screening– the lives of one fifth of them were presumably saved than otherwise. “In younger women, in contrast, screening with mammography showed no detectable benefit.” Many additional studies thereafter reinforced this conclusion by 2002: “In aggregate, over the course of fifteen years, mammography had resulted in 20-30 percent reductions in breast cancer mortality for women aged fifty-five to seventy. But for women below fifty-five, the benefit was barely discernible.”

Mukherjee also describes a moral issue that can arise when it comes to the testing of cancer drugs. A company was reluctant to spend hundreds of millions of dollars to do further testing on what appeared to be a promising new drug for a rare kind of leukemia that might (or might not) benefit only thousands of people. Thousands is considered a small number, compared to millions of individuals whom a drug might help in the long run. The company could spend the same amount of money helping millions. Patients for whom all other treatments had failed, aggressively pushed to be included in the drug trial, arguing it could save their lives. The company did eventually agree to test the drug, but on a small scale. The drug was wildly successful in its first decade for those few who were treated with it. However, a few years later, cancer cells had become resistant to the drug. A next-generation drug had to be developed to continue to keep those patients alive.

The author tries to explain why, even with all the resources currently poured into research for a cancer cure and improving treatment, many cases are still fatal even in industrialized countries. Nevertheless, he points out– there are pitifully few resources being thrown into prevention. I suspect it is just not as lucrative as research and treatment.

Time on Fire

The Book of the Week is “Time On Fire” by Evan Handler, published in 1997. The author, a Broadway actor, tells his readers how he survived a five-year bout with myelogenous leukemia in the early 1990’s. His condition necessitated various extreme treatments from which, at that time, fewer than half of patients emerged alive. He details them, good and bad, he received from various medical facilities, whose names he mentions. One action he took, among others, was to get a private hospital room so as to minimize his stress level. One should spare no expense when one is fighting for one’s life. This intense survival story was inspiring, rather than depressing.

The Tennis Partner

The Book of the Week is “The Tennis Partner” by Abraham Verghese, published in 1999.  This is the autobiographical account of the relationship between a medical professor (the author) and an intern at a teaching hospital in the United States.  The two play tennis against each other.  At the time, they are each going through traumatic personal problems; the professor, the aftermath of a failed marriage that produced two sons, and the intern, a struggle to beat drug addiction.  Verghese deftly describes these in engaging detail, throws in his perception of the playing styles of various professional tennis players, and recounts some interesting medical cases.