One-Minute Book Reviews

March 1, 2011

‘Early Diagnosis Is a Double-Edged Sword’ — Quote of the Day

Filed under: Quotes of the Day — 1minutebookreviewswordpresscom @ 9:29 pm
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Early diagnosis can hurt you, three doctors argue their new Overdiagnosed: Making People Sick in the Pursuit of Health (Beacon Press, 228 pp., $24.95). Too many Americans are being treated for conditions that will never cause symptoms, let alone death, say H. Gilbert Welch, Lisa Schwartz, and Steven Woolshin. Some people contend that no harm can come of the “epidemic of diagnosis”:

“But the truth is that early diagnosis is a double-edged sword. While it has the potential to help some, it always has a hidden danger: overdiagnosis—the detection of abnormalities that are not destined to ever bother us. …

“the conventional wisdom is that more diagnosis—particularly, more early diagnosis—means better medical care. The logic goes something like this: more diagnosis means more treatment, and more treatment means better health. This may be true for some. But there is another side to the story. More diagnosis may make healthy people feel more vulnerable—and, ironically, less healthy. In other words, excessive diagnosis can literally make you feel sick. And more diagnosis leads to excessive treatment—treatment for problems that either aren’t that bothersome or aren’t bothersome at all. Excessive treatment, of course, can really hurt you. Excessive diagnosis may lead to treatment that is worse than the disease.”

You can read the introduction to Overdiagnosed on Scribed.

© 2011 Janice Harayda. All rights reserved.

 

September 20, 2010

Funeral of a Small-Town Doctor / From the Memoir ‘The Good Times Are All Gone Now: Life, Death, and Rebirth in an Idaho Mining Town’

Filed under: Memoirs,Nonfiction — 1minutebookreviewswordpresscom @ 11:47 am
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Julie Whitesel Weston grew up in Kellogg, Idaho, in the 1940s and 1950s, when it was “a wide-open, Wild West town” with brothels and gambling dens that attracted men who worked for the Bunker Hill silver mine. Her father, a doctor, examined the prostitutes twice a month for venereal diseases. He also made middle-of-the-night house calls and received venison and elk steaks from patients, whom he asked, “How’s your body?” After setting up his practice, Glen Whitesel stayed in Kellogg until he died in 1978, and sometimes played the snare drum for Tommy’s Trio at the Sunshine Inn.

Julie Whitesel recalls her childhood in her recent memoir The Good Times Are All Gone Now: Life, Death, and Rebirth in an Idaho Mining Town (University of Oklahoma Press, 2009). In this excerpt, she describes her father’s funeral, attended by friends such as real-estate developer Jim Bening and attorney Bob Robson.

“An honor guard of nurses, each dressed in white starched cap, dress, and stockings, stood like wings on either side of the elaborate coffin at the front of the church. His doctor partners served as pallbearers, along with Jim Bening and Bob Robson, and an extra six of friends, a double ring of hands. Townspeople – miners, wives, businessmen and women, gambling and drinking buddies, Tommy’s Trio, my friends, their parents, teachers, coaches, patients, not-patients — filled the church, spilled out into the parking lot, sang hymns, shed tears. The Episcopal priest, Father McReynolds, who had been one of my father’s gin rummy partners and was shaking with Parkinson’s disease, eulogized him.

“‘How’s your body?’ he began. A low wave of laughter filled the church. ‘No one who knew Doc Whitesel would ever say he was without failings. But I like to think he earned a place in heaven in spite of those failings, common to us all, in one form or another. Glen was our doctor, our friend, and an irreplaceable man in Kellogg, Idaho.’ He faced the casket and added, ‘See you later, alligator.’”

You can learn more about The Good Times Are All Gone Now on the sites for the author and for University of Oklahoma Press.

You can also follow Jan Harayda on Twitter at twitter.com/janiceharayda.

© 2010 Janice Harayda. All rights reserved.
www.janiceharayda.com

October 7, 2009

The Moral Failures of U.S. Health Care – T.R. Reid’s ‘The Healing of America’

A specialist in Tibetan herbal medicine wanted to taste T.R. Reid's urine.

The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care. By T. R. Reid. Penguin, 277 pp., $25.95.

By Janice Harayda

This elegant polemic argues that the American health-care crisis is, above all, a moral one: Alone among well-off democracies, the U.S. has never made a moral choice to guarantee health care for all. Americans have decided that everybody has the right to an education and a legal defense, regardless of the cost or difficulty of providing these, T.R. Reid reminds us. But we’ve never decided that everybody has the right to health care. Because we haven’t, the U.S. is the only country in which medical bills can bankrupt people. It’s the only one in which patients who have paid their health insurance premiums for years can — and do — have their policies canceled while they’re fighting for life from a hospital bed.

Fewer than half of all Americans are satisfied with this state of affairs, according to a 2001 study by researchers at the Harvard School of Public Health. But many critics of the system believe that all the alternatives involve conditions too onerous to accept – long waiting lists, the rationing of care, no choice of doctors, or “socialized medicine.”

T.R. Reid offers a powerful rebuttal to that idea with fascinating and well-written portraits of the health-care systems in five countries that have universal coverage: France, Germany, Japan, the U.K. and Canada. Japan, for example, hardly has “socialized medicine.” Its widely admired approach to health care uses private doctors and hospitals and nonprofit insurers. The system involves no gatekeepers, no rationing, and no waiting lists. It offers high-quality care and ample choice for patients. People split the cost of insurance with their employers or if they are unemployed, with their local government. And the Japanese lead the world in life expectancy (85.5 years for women, 78.7 for men).

Reid also evaluates the health care systems in India, Taiwan, Switzerland and other countries. And he found an ingenious way to dramatize some of their differences after an American orthopedist suggested that he have surgery on an injured shoulder. As he traveled around the world, Reid asked foreign doctors how they would treat the problem. In Nepal, he met a specialist in Tibetan herbal medicine who wanted to taste his urine before making a diagnosis. At an Ayurvedic hospital known as “the Mayo Clinic of traditional Indian medicine,” he submitted three times a day to massages of “warm sesame oil laced with forty-six herbs and medications.” These encounters add color and suspense to The Health of America without taking its focus off the moral imperatives of health care reform.

Reid doesn’t urge Americans to adopt any country’s model or a “public option” of care paid for by the government (although he notes that we have a public option in Medicare, a system that its beneficiaries generally like). But he appears to believe we can’t reform the system if we continue to allow insurers to make a profit on basic health care, something no other first-world country permits: The solution lies in a nonprofit model, whether run by the government or a nonprofit group. Reid has suggested in interviews that if Congress can’t enact the needed changes, Americans may have to reform the system on a state-by-state basis, though he damns the Massachusetts approach with faint praise.

The most admirable aspect of The Healing of America is that – like any skilled polemicist
– Reid has an exceptional ability to keep his eye on the ball. He deals forthrightly with the economic and other realities that health care reform would involve, such as controlling costs and creating an effective delivery system. But Reid never allows such issues to transcend the moral dimension of allowing tens of thousands of people each year to die and countless others to suffer needlessly. His powerful indictment shows why health care reform is ultimately not about politics or economics: It is about fairness, justice, and doing what is right for all Americans.

Best line: No. 1: “All developed countries except the United States have decided that every human has a basic right to health care.” No. 2: “ … foreign health insurance plans exist only to pay people’s medical bills, not to make a profit. The United States is the only nation that lets insurance companies extract a profit from basic health coverage.” No. 3: “The design of any nation’s health care system involves political economic, and medical decisions. But the primary issue for any health care system is a moral one.”

Worst line: “British women tend to have their babies at home; Japanese women, in contrast, almost always give birth in the hospital – and mother and child remain there an average of ten days after delivery.” The National Childbirth Trust says that in the U.K., 2.7 percent of women give birth at home.

Editor: Ann Godoff

Published: September 2009

About the author: Reid is a former foreign correspondent for the Washington Post.

Further comments on The Healing of America appeared in the posts “Excuses Aetna, Prudential and Blue Shield Have Used to Deny Claims” and “Going to the Doctor in Japan — Please Don’t Tip the Proctologist.”

Listen to a podcast of T.R. Reid talking about The Healing of America.

© 2009 Janice Harayda. All rights reserved.
www.janiceharayda.com and www.twitter.com/janiceharayda

January 28, 2009

2009 Caldecott Honor Book ‘A River of Words’ Introduces the Poet William Carlos Williams, Whose First Book Sold Four Copies

William Carlos Williams broke with the traditions of Longfellow and others.

A River of Words: The Story of William Carlos Williams. By Jen Bryant. Illustrated by Melissa Sweet. Eerdmans Books for Young Readers, 32 pp., $17. Ages 7 and up.

By Janice Harayda

Melissa Sweet says in a note at the end of this book that her “Brownie troupe” once visited the Metropolitan Museum of Art. That gaffe is, alas, all too typical of this runner-up for the title of “the most distinguished American picture book for children.”

Jen Bryant has written a lively but unexceptional introduction to the life of William Carlos Williams (1883—1963), who combined practicing medicine in a New Jersey suburb with writing experimental verse that broke with the classical traditions of 19th-century lions like Henry Wadsworth Longfellow. A River of Words is the rare book for its age group that shows a man — not a woman — balancing multiple roles.

Williams’s best-known book of poetry, the multivolume Paterson, is often called collage of that city. And Sweet tries hard to apply the artistic counterpart of that technique. Working with mixed media, she combines watercolors and items from Williams’s world: a map, a report card, sheet music, pages from an anatomy book, the stationery from his medical office.

The poet Sara London wrote diplomatically in the New York Times Book Review that Sweet’s pictures are “playfully distracting – the eye hops sparrowlike from leaf to leaf, uncertain where to settle.” At times the images are so frenetic, they’re confusing. On one spread, the left-hand page shows Williams sitting at his desk writing poetry as a boy. The right-hand page shows in childlike handwriting the first lines of his poem “Pastoral”: “The little sparrows / hop ingenuously / about the pavement / quarreling.” The juxtaposition suggests that Williams wrote the poem as a child when, in fact, he wrote it in early adulthood.

Some people have criticized the American Library Association for not honoring enough poetry, and they have a point. The ALA has snubbed prize-worthy books like Behold the Bold Umbrellaphant, which combines wonderful pictures by Carin Berger with some of the best recent work by Jack Prelutsky, the popular children’s poet.

But giving a 2009 Honor Book citation to A River of Words was doing the right thing — showing respect for poetry — for the wrong reason. A River of Words deserves a place in many libraries and bookstores for its spirited and in some ways successful portrait of what it takes to succeed as a poet. That is different from deserving a place on the medal stand.

Best line/picture: A chronology of Williams’s life at the end of the book includes this event for 1909: “His first verse collection Poems is printed and published by a friend. It sells only four copies.” The line is incorrectly punctuated – Poems should be set off by commas – but it offers a healthy jolt of shock therapy to would-be poets.

Worst line/picture: From the illustrator’s note at the end: “Living in northern New Jersey (not too far from where Williams grew up in Rutherford), my Brownie troupe took a field trip to the Metropolitan Museum of Art in New York City.”

Furthermore: A River of Words won a 2009 Caldecott Honor citation. The book has the full text of Williams’s most famous poem, “The Red Wheelbarrow”, and five others: “The Woodthrush,” “The Great Figure,” “Metric Figure,” “This Is Just to Say”, and “Pastoral.” It has excerpts from “Complaint,” “The Descent of Winter” and “Part X, Pictures from Brueghel.” All of the poems appear on the endpapers.

About the authors: Jen Bryant lives in Glenmoore, Pennsylvania. Melissa Sweet lives in Rockport, Maine.

Janice Harayda is an award-winning critic who has been the book editor of the Plain Dealer and a vice-president of the National Book Critics Circle www.bookcritics.org.

© 2009 Janice Harayda. All rights reserved.
www.janiceharayda.com

September 18, 2008

Maybe You Don’t Need That Colonoscopy or Those Statins — A Noted Doctor Challenges the Medical Establishment – ‘Let My Polyps Go’

Angioplasties and stents are "good ideas that proved bad."

“Dr. Hadler sees no evidence that mild high blood pressure or mildly elevated blood sugar pose much of a risk to longevity — certainly not enough to warrant the aggressive drug treatment often offered for them. The same goes for … the modest elevations in serum cholesterol that, these days, spell a statin drug for life for many healthy people.”

Self-help books that urge you to micromanage every health risk have become disease unto themselves. So it was cheering to see the New York Times giving serious attention to a new book by a noted physician who still believes that less medicine can be more.

Abigail Zuger, an internist and frequent contributor to Times, recently reviewed Worried Sick: A Prescription for Health in an Overtreated America (Univesity of North Carolina Press, 376 pp., $28), by Nortin M. Hadler, “a rheumatologist and professor of medicine at the University of North Carolina who is a longtime debunker of much the establishment holds dear.” Zuger wrote:

“Dr. Hadler may not actually keep a skull on his desk, but he might as well. We are all going to die, he reminds us. Holding every dire illness at bay forever is simply not an option. The real goal is to reach a venerable age — say 85 — more or less intact.”

Zuger adds that Hadler believes the way to achieve that goal is to ignore much of the conventional advice:

“Reviewing the data behind many of the widely endorsed medical truths of our day, he concludes that most come up too short on benefit and too high on risk to justify widespread credence.

“Dr. Hadler sees no evidence that mild high blood pressure or mildly elevated blood sugar pose much of a risk to longevity — certainly not enough to warrant the aggressive drug treatment often offered for them. The same goes for the extra 20 pounds that make you overweight but not obese, and the modest elevations in serum cholesterol that, these days, spell a statin drug for life for many healthy people.

“He deplores the careful attention we pay to the state of our coronary arteries. Angioplasties, stents, coronary artery bypass grafts — all these procedures, he writes, ‘should be consigned to the annals of good ideas that proved bad.’

“As for the screening that purportedly keeps us safe from cancer, mammography and the blood test for prostate cancer are, in his view, blunt cudgels that can harm as much as help. Nor does he want any part of routine colonoscopies: ‘Let my polyps go.’”

Zuger compared Worried Sick with a new guide by Nancy Snyderman, a surgeon and the chief medical editor of NBC News, who — as anyone who has watched her televised reports may know — is ever-ready to parrot the medical establishment’s prescriptive-flavor-of-the-week. And though Zuger doesn’t come down on the side of either approach, her review is lively, open-minded, and worth reading www.nytimes.com/2008/06/24/health/24book.html?ref=science.

To read more about Hadler and Worried Sick, click here uncpress.unc.edu/browse/book_detail?title_id=1545. Hadler’s book and individual chapters from it are available in e-book or downloadable formats through the Caravan Project www.caravanbooks.org/.

© 2008 Janice Harayda. All rights reserved.
www.janiceharayda.com

January 8, 2008

Backscratching in Our Time — Gina Kolata and Jerome Groopman

The latest in a series of posts on authors who praise each other’s work in a way that may have financial benefits for both

 

I usually post these examples of backscratching without comment, but this one is bad on so many levels, I’d like explain why. A pillar of journalistic ethics says that reporters should avoid not just conflicts of interest but the appearance of conflicts. Gina Kolata is a science writer for the New York Times who has used Groopman, a professor at Harvard Medical School and a bestselling author, as a source. As the comments below make clear, she accepted a favor from Groopman — the blurb for Rethinking Thin — that could put money in her pocket if, say, you bought the book based on his recommendation or if a paperback or overseas publisher paid more for the reprint rights because of the quote (and quotes can affect the amount offered). Kolata has compounded the problem by selecting one of Groopman’s essays for Best American Science Writing 2007, a decision that has almost certainly put money in his pocket, given that contributors to anthologies typically receive an up-front fee or a percentage of the royalties or both. She also used on the cover of the paperback edition of her earlier Flu a quote from Groopman that appeared in the Boston Globe, which is owned by the New York Times. It gives me no pleasure to say any of this because I enjoy Kolata’s work for the Times and regard it as far superior to that of her colleague Jane Brody, who writes the Personal Health column. I also admired much about Flu, Rethinking Thin and Groopman’s How Doctors Think www.oneminutebookreivews.wordpress.com/2007/12/28/.

 

Jerome Groopman on Gina Kolata

“Kolata is a seasoned reporter, and knows how to craft a riveting tale … a masterly recounting of medical history.”

Groopman in a review of Kolata’s Flu: The Story of the Great Influenza Pandemic (Touchtone, $15, paperback) in the Boston Globe, Dec. 12. 1999. “A masterly recounting of medical history” appears on the cover of the paperback edition of Flu.

 

“An incisive, thought-provoking examination of a subject that concerns us all. This book will educate and illuminate those seeking solid information about the struggle to lose weight.”

Groopman in a blurb on the cover of Kolata’s new Rethinking Thin: The New Science of Weight Loss — and the Myths and Realities of Dieting (Farrar, Straus & Giroux, $24)

Gina Kolata on Jerome Groopman

“I also liked Jerome Groopman’s New Yorker article, ‘Being There.’ It raises an issue I had never considered, and in an unforgettable way …”

Gina Kolata on why she choose Groopman’s article as one of the best of the year, in her introduction to Best American Science Writing 2007 (HarperPerennial, $14.95, paperback), edited by Kolata and Jesse Cohen.

One-Minute Book Reviews welcomes suggestions about authors should be in “Backscratching in Our Time,” a series in inspired by “Logrolling in Our Time” in the old Spy magazine.

© 200X Janice Harayda. All rights reserved.

www.janiceharayda.com

December 28, 2007

Take One Misdiagnosis and Call Me in the Morning – Jerome Groopman’s ‘How Doctors Think’

A Harvard Medical School professor says that physicians’ faulty logic can kill

How Doctors Think. By Jerome Groopman, M.D. Houghton Mifflin, 291 pp., $26.

By Janice Harayda

It’s flu season, and that’s bad news for you if you have an obscure disease with flu-like symptoms. Your doctors’ diagnoses might reflect a confirmation bias (a tendency to find what they expect to find), an availability error (a decision based on how easily examples come to mind) or other cognitive flaws that Jerome Groopman describes in this engaging bestseller.

Groopman’s thesis is that a doctor’s state of mind strongly affects clinical decision-making. And many of his examples are eye-opening if paradoxically commonsensical. Do doctors’ friends get better care? Not necessarily, Groopman says. A doctor might hesitate to prescribe a necessary but painful test for a friend. Do doctors favor the sickest patients, who may need their care the most? Actually, they prefer healthy ones. One social psychologist found that “the sickest patients are the least liked by doctors, and that very sick people sense this disaffection,” Groopman writes. Apparently many doctors feel they have worked in vain when a disease resists treatment and stop trying to help. How Doctors Think

Much of this is so interesting that you wish this book didn’t reflect biases of its own. One is that it slights mistakes that result from factors other than cognitive flaws, such as fatigue, poor training and inadequate supervision.  “Experts studying misguided care have recently concluded that the majority of errors are due to flaws in physician thinking, not technical mistakes,” writes Groopman, a professor at Harvard Medical School and staff writer for The New Yorker.

But when you go to the end notes of his book to look for the source of that hard-to-believe “majority,” you read: “Although the frequency of misdiagnosis has been studied, few researchers have focused on its relationship to physician cognition.” So who are those “experts” who found that most errors result from doctors’ thinking?  The notes name only one expert who found such a “majority,” a researcher who had studied “serious errors that led to malpractice claims.” But Groopman says that the majority of all errors result from physicians’ thinking, not the majority of errors that lead to malpractice suits. Either his end notes are incomplete or he misrepresents in the book some of the material he cites in the notes.

At the very least How Doctors Think leaves a different impression of the causes of mistakes than the chapters on medical errors and problem doctors in Atul Gawande’s Complications, a more cogently argued book by another physician who writes for The New Yorker.  Gawande quotes from a landmark series of papers in the New England Journal of Medicine that reported that one percent of all hospital admissions involved negligence that prolonged the stay or led to death or disability of the patient. A smaller study of the treatment of cardiac arrests found that “27 of 30 clinicians made an error in using the defibrillator – charging it incorrectly or losing too much time figuring out how to work a particular model.”

Groopman is a bit like a coach who blames the problems in baseball on the character flaws of individual players instead of the culture that produced them. He says that doctors “desperately” need patients to “help them think.” If that’s true, it reflects badly on the entire American system of medical education, training and certification, not just on individual physicians. Clearly many doctors need more than “help” thinking logically – they need to learn how to work the defibrillator.

Best line: “When a patient tells me, ‘I still don’t feel good. I’m still having symptoms,’ I have learned to refrain from replying, ‘Nothing is wrong with you.’ The statement ‘Nothing is wrong with you’ is dangerous on two accounts. First, it denies the fallibility of all physicians. Second, it splits the mind from the body. Because sometimes what is wrong is psychological, not physical. This conclusion, of course, should be reached only after a serious and prolonged search for a physical cause of the patient’s complaint.”

Worst line: Groopman says his book is for people who aren’t physicians “because doctors desperately need patients and their families and friends to help them think.”  Isn’t it bad enough that we have all those TV commercials telling us to ask our doctors if we need a certain drug because, basically, they’re too dumb to figure it out on their own? Do we need this kind of smarm from doctors, too? Groopman doesn’t mention that there are 285 doctors for every 100,000 people in the U.S. and, if he’d written his book for doctors, he might make a lot less money.

 

Recommendatiom? A good but one-sided book. If you’re interested in medical errors, consider reading the chapters called “When Doctors Make Mistakes” and “When Good Doctors Go Bad” in Atul Gawande’s Complications: A Surgeon’s Notes on an Imperfect Science (Holt/Metropolitan, 2002) www.gawande.com instead of or in addition to How Doctors Think

Editor: Eamon Dolan

Published: March 2007  www.jeromegroopman.com  and www.houghtonmifflinbooks.com

One-Minute Book Reviews is for people who like to read but dislike hype and review inflation. It is also for people who dislike long-winded weasel reviews that are full of facts and plot summaries but don’t tell you what the critic thought of the book.

© 2007 Janice Harayda. All rights reserved.

www.janiceharayda.com

November 13, 2007

The ‘Tyranny of Positive Thinking’ and Cancer Patients — A Physician-Author Says That It’s Not Always Best to Tell People to ‘Be Optimistic’

Can you give too much encouragement to people who are ill?

By Janice Harayda

Not long ago, I reviewed Betty Rollin’s Here’s the Bright Side and objected to its theme that all human suffering holds “a hidden prize waiting to be found.” I argued that some losses are so sad — the death of a child, say — that urging people to find their “bright side” is cruel.

Later I read some interesting, related comments by Jimmie Holland, chair of Department of Psychiatry and Behavioral Sciences at the Memorial Sloan-Kettering Cancer Center. They appeared in an article Leslie Brody wrote about caring for her husband, who has pancreatic cancer, for the New Jersey daily, The Record, on May 20, 2007.

“Think twice before telling the patient to ‘be positive,’” Brody wrote. She added:

“Dr. Jimmie C. Holland, author of The Human Side of Cancer and a pioneer in the psychological aspects of the illness, has written about the ‘tyranny of positive thinking.’ When people insist patients should ‘be optimistic,’ they imply that those who get sicker may be to blame for not trying hard enough to stay upbeat and conquer the disease.

“Holland says a patient’s mind-set might help him stick to a grueling chemo regimen, but it’s less clear whether attitudes and emotions in themselves can affect tumor growth or the body’s response. Patients — and their families — should feel free to vent depressing and anxious thoughts without being judged.

“Instead of saying ‘Chin up,’ or, ‘You’ll be fine,’ it’s better to say, ‘Hang in there,’ or ‘We’re thinking of you,’ or ‘We’re hoping for the best.’”

Links: To read the original review of Here’s the Bright Side, click here www.oneminutebookreviews.wordpress.com/2007/08/21/. To read about The Human Side of Cancer, click here www.humansideofcancer.com.

© 2007 Janice Harayda. All rights reserved.

www.janiceharayda.com

July 18, 2007

Atul Gawande Tells What You Can REALLY Expect When You’re Expecting

A surgeon looks at the pros and cons of forceps, Cesarean sections, epidural anesthesia, fetal heart monitors and other fixtures of modern delivery rooms

Better: A Surgeon’s Notes on Performance. By Atul Gawande. Holt/Metropolitan, 273 pp., $24.95.

By Janice Harayda

Last year the New York Times published an article on a remarkable medical study that found that – contrary to a near-universal belief – pushing during labor helps neither the mother nor the baby. The study also found that women who were told to push may have more urinary problems after the delivery. One of the doctors who did the survey, published in the American Journal of Obstetrics and Gynecology, said that the research did not mean that women should never push. Instead, he said, they should do “what feels natural to do – and for some women that would be no pushing.”

I had two reactions to this news. First, if I were pregnant, I would ask my obstetrician if he or she planned to tell me to push and, if so, why, given there seems to be no benefit to doing this during every birth. Second, why didn’t we know this news sooner? Why have doctors for so long inflicted the needless agony of pushing on women? I had no idea what the answer to the second question might be until I came across a striking fact in the chapter on childbirth in Atul Gawande’s Better: Most doctors pay lip service to the idea that nothing should be used in medicine unless it has been properly tested and shown to be effective by a respected research center, preferably through a double-blind, randomized trial.

“But in a 1978 ranking of medical specialties according to their use of hard evidence from clinical trials, obstetrics came in last,” Gawande writes. “Obstetricians did few randomized trials, and when they did they largely ignored the results.”

That observation helps to explain why Gawande, a surgeon and writer for The New Yorker, may be our most important medical writer. Unlike many others working in the field, he doesn’t write mainly about the latest developments in medicine. He digs deeper, looking for the “why” behind the “what,” while taking on extraordinarily complex topics. But his writing is rarely harder to understand than in his lines about the 1978 survey of medical specialties. He seems to make a grail not just of accuracy but of clarity.

The chapter on childbirth in Better shows his work at its finest. It deals largely with why so many women have Cesarean deliveries, which account for about 30 percent of American births. Many people explain the statistic by saying that Cesareans are more convenient and lucrative for doctors than vaginal births. Gawande argues persuasively that there is a larger reason for the pattern. And part of it has to do with the virtual disappearance of forceps from delivery rooms.

In the 1960s fewer than 5 percent of deliveries were Cesareans and more than 40 percent involved forceps. And those numbers are related. Gawande makes a strong case that in the hands of experts, forceps are safe (according to some research, safer for mothers than Cesareans). But forceps are hard to learn to use properly – a process that can take two years. And if forceps are used by inexpert doctors, the results can be disastrous. Cesareans are easier to master. And this has led hospitals to phase out forceps and, in many cases, do C-sections instead. To discourage the inexpert from using forceps, Gawande says, “obstetrics had to discourage everyone from using them.” This change has come at a cost. Gawande notes that, as straightforward as Cesarean deliveries can be, they can go wrong. The baby can be lacerated. If the head doesn’t come free quickly, the child can asphyxiate. The mother also faces risks:

“As a surgeon, I have been called in to help repair bowel that was torn and wounds that split open. Bleeding can be severe. Wound infections are common. There are increased risks of blood clots and pneumonia. Even without any complication, the recovery is weeks longer and more painful than with vaginal delivery.”

With all of this, Gawande isn’t trying to frighten women away from having Cesareans or bring forceps back to every community hospital. He is instead trying to show the trade-offs that medicine involves. And this is only a small part of what he says in his chapter on childbirth, “The Score,” which also covers such delivery-room fixtures as fetal heart monitors, epidural anesthesia and the labor-inducing drug Pitocin. It is an even smaller part of what he has to say in the 11 chapters of Better that deal with subjects other than childbirth, including advances in military medicine and the need for doctors to wash their hands more often.

Women who are pregnant may reach for books like What to Expect When You’re Expecting and The Girlfriends’ Guide to Pregnancy. And patients who are facing surgery may turn to guides to their illnesses. But both groups could benefit from also reading this fine collection of essays. For some of them, Better may just be better.

Best line: Gawande writes about the Apgar score, which rates a newborn’s health: “In a sense, there is a tyranny to the score. While we rate the newborn child’s health, the mother’s pain and blood loss and length of recovery seem to count for little. We have no score for how the mother does, beyond asking whether she lived or not – no measure to prod us to improve results for her, too. Yet this imbalance, at least, can surely be righted. If the child’s well-being can be measured, why not the mother’s, too?”

Worst line: None.

Editor: Sara Bershtel

Published: April 2007

Furthermore: The New York Times article on pushing during labor, “Rethinking the Big Push During Contractions, appeared on Jan. 3, 2006, page F8. I can’t link directly to it, but here’s a link to a similar reprint in its sister publication, The International Herald Tribune. When you click on the following link, you will reach a page that says “Multiple Choices” and see another link that looks just like it (below the phrase “Available Documents”). You have to click on that one, too, to read the story (which appears below an article on “lazy eye”): www.iht.com/articles/2006/01/04/healthscience/snvital/php/php.

Links: Gawande has posted many of his articles on medicine at www.gawande.com.

© 2007 Janice Harayda. All rights reserved.

www.janiceharayda.com

May 30, 2007

Atul Gawande Takes the Pulse of the Medical Profession

Filed under: Essays and Reviews,Nonfiction — 1minutebookreviewswordpresscom @ 1:18 pm
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True or false: More people go crazy when the moon is full.

If you said “true,” you probably haven’t read Atul Gawande’s Complications: A Surgeon’s Notes on an Imperfect Science (Picador, $14, paperback), a stylish collection of essays by a Boston surgeon and contributor to The New Yorker. Gawande reviewed more than a hundred studies of how lunar phases affect human behavior after his fellow doctors warned him to expect more hospital admissions when the moon was full. He found that researchers had pored over all kinds of evidence – police logs, homicide statistics, emergency room visits and consultations with psychiatrists. The result? There’s no relation at all between craziness and the full moon. Some studies have suggested the opposite – that full moon has a beneficial effect on human behavior.

This is the kind of fascinating material regularly dispensed by Gawande, who also wrote the new Better: A Surgeon’s Notes on Performance (Metropolitan, $24). The essays in Complications deal with subjects from doctors’ mistakes to patients with terrifying diseases like necrotizing fasciitis (known, somewhat misleadingly, “flesh-eating bacteria”). Gawande often takes controversial positions. He challenges the idea – cherished by many doctors – that surgeons need “good hands,” saying the continual practice of surgery matters more. (Doesn’t the quality of the practice matter? What about education? Can practice make you a great surgeon if you went to a medical school or work at a hospital that’s a step away from losing its accreditation?) But part of the appeal of Complications is that Gawande www.gawande.com has the courage to risk saying things other doctors won’t and the rhetorical skill to give his views force. He never hides behind a cardboard shield of medical omniscience. And he deals with a wider and more offbeat range of medical topics than physician-authors like Oliver Sacks and Sherwin Nuland. So you may enjoy Complications even if you couldn’t get through The Man Who Mistook His Wife for a Hat or How We Die.

© 2007 Janice Harayda. All rights reserved.

www.janiceharayda.com

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