Doyle Syndrome

Today, I had the fortune of meeting a patient with Marfan's syndrome.  The disease is officially named after the French physician Antoine Marfan but almost a decade earlier Sir Arthur Conan Doyle had created a villain who was very likely to have the condition in his very first Sherlock Holmes story, A Study in Scarlet.  Doyle, through the voice of Watson, described the character of Jefferson Hope as a tall man in his late thirties who an aortic aneurysm.   These are common features seen in Marfan's syndrome which is now known to be a connective tissue disorder.  As Doyle was a physician, himself, he frequently had very clinical descriptions of characters (probably the most accurate in all of fiction) and it is likely he had made an association between very tall, slender individuals and aortic aneurysms.    

History Lesson

As part of a summer reading assignment for school, I just finished The Immortal Life of Henrietta Lacks by Rebecca Skloot.  If you have not heard, this book is about a woman whose cervical cancer cells were harvested and cultured into an immortal cell line known as HeLa.  As the first human cells that could be cultured indefinitely, Henrietta's cells opened up research avenues to numerous medical discoveries and innovations including the polio vaccine, HIV treatments, and breakthroughs in understanding cancer.  However, the  book itself is only partially a recounting of the scientific advances brought about by Henrietta's cells.  Skloot also reports on her investigations into finding out who exactly Henrietta Lacks was, why her cells were taken without informing her family what they would be used for, and her own personal friendship with the Lacks family today.

Skloot has certainly earned my respect as a science writer.  Her explanations are clear and complete.  I was very grateful be reading what I felt was a very fair and balanced work, presenting multiple perspectives on what had happened surrounding Henrietta Lacks and her cells.  The book informs the readers  on the the bioethical issues but refrains from getting preachy or persuading action.  As a reader, I felt I was allowed to appreciate the history and whatever lessons I can learn from it are up to me.

Oh and of course, because a comic book character was referenced  in the book, I had to show who Hela the Marvel character was:

Hela on the cover of Thor #150, art by the one and only Jack Kirby

In the comics, Hela is the daughter of Loki and goddess of death (Skloot and Henrietta's daughter Deborah found this interesting).

On Being a Medical Detective

The following is a recommendation I just wrote for this book:

Although written for a wide audience, Dr. Lisa Sanders’ Every Patient Tells a Story is a book that medical students will find not only entertaining but highly relevant to their education.  In her book, Dr. Sanders identifies and expands upon the essential elements that lead a doctor to diagnosis including the patient interview and the physical exam, fading arts that I know at least NEOMED has been trying to revive.  Throughout the book are stories from Dr. Sanders’ Diagnosis column in New York Times Magazine as well as some from her own training and practice that show that each element is important but it is the integration of the elements that lead to solving complex cases.  Sanders also shows how vital (almost literally) it is to be cognizant of one’s own thinking process in coming up with differentials and is refreshingly honest about being wrong in medicine.  These messages serve as a great supplement to many core themes of the longitudinal 

course at NEOMED.

Additionally, Every Patient Tells a Story (as well as many other medically-inclined books) will do something that I do not think happens enough in medical education: orient students to where medicine today has come from and where it is going.  As medical students, much of what we do seems to be learning from test to test.  But there is always a point where a medical student wonders, “Why is it important that I learn this?”  What it seems we have little time for is finding out what is out there in the field today and how classroom knowledge is part of that.  What are the issues?  What is being done?  What have people already tried?  Books by physician-writers like Dr. Lisa Sanders, Dr. Atul Gawande, Dr. Jerome Groopman, and many others already seek to answer these questions for the public-at-large in plain language.  A medical student up to his eyes in his studies can experience even more excitement than the average person as he reads these works and finds he understands a process or recognizes a disease from class.

Now, while I do believe every medical student should try to read this book, I hesitate to recommend that Every Patient Tells a Story be made into required reading in the sense that every student in the class must read this book at the same time whether it be during the academic year or over the summer break.  My reasoning is this: forcing students who already feel there is a high volume of studying to be done can make them antagonistic toward the reading and the gain becomes diminished.  In high school, I had an English literature teacher that found required reading to be a necessary evil and wanted to remind us that great reading could be done for pleasure.  One day, he rolled in a cart with copies of Ken Kessey’s One Flew Over the Cuckoo’s Nest and told us that anybody that was interested in reading the book could have a copy.  Another time he did the same thing with J.D. Salinger’s Catcher in the Rye, telling us that Salinger would hate it if he forced us to read this book.  Frequently he would bring in reading list from various sources – the 100 best novels, the 100 best non-fiction, etc.  “These are important books,” he would say.  “Just because we don’t read it in class doesn’t mean you shouldn’t.”  When classes would reconvene after breaks he would ask us if anybody read anything interesting and we would all sit around and talk about what different things were read outside of the curriculum.

I believe the same philosophy can be applied in medical education.  The greatest service to medical students would be to inform them of what books are out there and what they are about. Rather than have all students read the book at the same time, I would like to see Dr. Sanders’ book be part of an independent reading assignment where the student may choose a book from a list of several and share his or her thoughts on the work in the small group sessions.  In this way, every student can feel that there was some personal value in the choice he or she made and has unique thoughts to share with a group of people who did not necessarily read the same work.  Fellow group members benefit by getting informed about a book they may not have read.  This, I feel, would truly create a good vehicle for discussion amongst students about many of the themes of the longitudinal course at NEOMED.         

The Hot Zone

Next week I am going to Washington DC so I thought it would be appropriate to post about The Hot Zone.  I read this back in high school before I came up with the idea for The Physician's Library but I definitely believe it belongs on this list of must-read books for anyone interested in medicine, especially infectious diseases.

Normally, I am pretty wary of popular science writers but Preston is really, really good.  He's very thorough and informative, researching his subjects very meticulously.  It's actually hard to believe he isn't a scientist, himself (he actually has a PhD in English so technically he's Dr. Preston).

If you don't know, The Hot Zone is about the Ebola virus, one of the most violently deadly infectious diseases in our world.  The book reads like a suspenseful novel and the scary thing is that Preston has not had to embellish in the slightest.  The book includes a very good history of what we know about the virus and recounts an incident where a strain of Ebola was found in a monkey house in Reston, VA, a city near Washington DC in 1989.  Luckily, Ebola Reston was found to be non-pathogenic to humans.

Atul Gawande

     

 This week I am posting about Atul Gawande.  Like always, I came across Gawande at Borders (a company I will always remain loyal to).  As a general and endocrine surgeon in Brigham and Women’s Hospital in Boston, an associate professor at the Harvard School of Public Health, an associate professor of surgery at Harvard Medical School, contrbutor to The New Yorker, a former Rhodes scholar, and MacArthur fellow, Dr. Atul Gawande's scholarship is highly credible.  

At the same time, I find Gawande very accessible and enjoyable for both physicians and patients.  When I think of Gawande, I think of a very sobering writer, a surprising feat given the topics he sometimes covers including the U.S. healthcare system and medical error.  In some ways, I would guess that Gawande writes like he talks to his patients: he presents the facts and the situation and gives his most educated opinion without being inflammatory.  It is very comforting to find such journalism in our era of pundits and "news" shows.

I was lucky enough to get to hear Dr. Gawande lecture at the Cleveland Clinic a few months ago.  The focus was on the U.S. healthcare system.  I will always remember what he said on the complexity of medicine and how we were all "fooled by penicillin."  Penicillin was not the quick-fix end of infectious disease.  There will be no quick-fix for the healthcare in the United States.       

In his first collection of essays for The New Yorker, Gawande focuses on the humanity of doctors and the degree of uncertainty they must deal with while lives are on the line.  This is some of the best medical writing out there, this book was a National Book Award finalist.  In his second collection of essays, Atul Gawande writes in the same vein of fellow The New Yorker contributor, Jerome Groopman, in the performance of a physician and issues in medical practice at home and abroad.  Gawande’s sincerity and thoughtfulness in the stories he tells and perspectives he gives does not change in his follow-up book.      

The Citadel

I recently finished The Citadel over spring break.  Cronin is a great writer and some day I may read one of his other books.  The comparison to Arrowsmith is warranted as the protagonist, Andrew Manson, is a young, idealistic physician who contends with a culture of corruption and materialism among his peers.

There are some really great moments in this book and as a doctor himself, Cronin is able to add a certain credibility to the medical scenes.  One of my favorite parts is when Manson has a eureaka moment diagnosing a patient, Emrys Hughes.  Hughes has had recent changes in temperament.  In the night, he goes mad and goes after his wife with a knife.  One of Manson's colleagues, Dr. Bramwell, wants to commit Hughes and needs a second opinion to do so.  He calls Manson, who wants to do his own examination and finds a better explanation:

       Emrys Hughes was in bed, and seated beside him - in case restraint should be necessary - were two of his mates from the mine...
      He went over to Emrys, and at first he hardly recognized him.  The change was not gross; it was Emrys true enough, but a blurred and altered Emrys, his features coarsened in some subtle way.  His face seemed swollen, the nostrils thickened, the skin waxy, except for a faint reddish patch that spread across the nose.  His whole appearance was heavy, apathetic.  Andrew spoke to him.  He muttered an unintelligible reply.  Then, clenching his hands, he came out with a tirade of aggressive nonsense, which, added to Bramwell's account, made the case for his removal only too conclusive.
     A silence followed.  Andrew felt that he ought to be convinced.  Yet, inexplicably, he was not satisfied.  Why, why, he kept asking himself, why should Hughes talk like this?  Supposing the manhad gone out of his mind, what was the cause of it all?  He had always been a happy, contented man - no worries, easygoing, amicable.  Why, without apparent reason, had he changed to this?  
     There must be a reason, Manson thought doggedly; symptoms don't just happen of themselves.  Staring at the swollen features before him, puzzling, puzzling for some solution of the conundrum, he instinctively reached out and touched the swollen face, noting subconsciously, as he did so, that the pressure of his finger left no dent in the [edematous] cheek.
     All at once, electrically, a terminal vibrated in his brain.  Why didn't the swelling pit on pressure?  Because - now it was his heart which jumped! - because it was not true [edema], but [myxedema].  He had it, by God, he had it!  No, no , he must not rush.  Firmly, he caught hold of himself.  He must not be a plunger, wildly leaping to conclusions.  He must go cautiously, slowly, be sure!
     Curbing himself, he lifted Emrys' hand.  Yes, the skin was dry and rough, the fingers slightly thickened at the ends.  Temperature - it was subnormal.  Methodically he finished the examination, fighting back each successive wave of elation.  Every sign and every symptom - they fitted superbly as a complex jigsaw puzzle.  The clumsy speech, dry skin, spatulate fingers, the swollen inelastic face, the defective memory, slow mentation, the attacks of irritability culminating in an outburst of homicidal violence.  Oh! the triumph of the completed picture was sublime.

In the beginning...

Dr. Jerome Groopman's How Doctors Think was the first book that started me on my medical reading.  I got it back in high school and read it early in college.  This is a great book for both patients and people in the medical profession.  Groopman, a frequent contributor to The New Yorker and author of several other books, offers a complete and thoughtful metacognitive analysis for doctors without being critical.  He arms patients with the ability to tug at their physician’s thought processes and implores his fellow doctors to become aware of where their thinking goes wrong.  I particularly enjoyed the chapter about the cardiologist from Ohio who was a Sherlock Holmes fan.

The American Fear of Literature

Sinclair Lewis' Nobel Prize speech from 1930.
http://nobelprize.org/nobel_prizes/literature/laureates/1930/lewis-lecture.html

Lewis was the first American to win the Nobel Prize.
"...in America most of us - not readers alone but even writers - are still afraid of any literature which is not a glorification of everything American, a glorification of our faults as well as our virtues."

Secret Origin

Sometime in the middle of my college years, I looked at my collection of books and noticed a few that were related to medicine, the field I had decided to pursue (I a student in a dual-degree BS/MD program).  I decided it would be practical to read these books and find more medically-related fiction and non-fiction if I had any spare time, especially the works of physician writers.  Over time, I had quite a few under my belt and I decided to keep track of these titles for myself and to share with others who might be interested.  It was one of my high school English teacher's that suggested I convert the list into blog form.

  

The idea and name for The Physician’s Library actually comes from Sinclair Lewis’ Arrowsmith.  One of Martin Arrowsmith’s childhood heroes is an inarticulate and shabby but scientifically inclined physician named Doc Vickerson who tells young Martin: “Physician’s library just three books: ‘Gray’s Anatomy’ and Bible and Shakespeare."

Naturally, I hope to have my library be quite a bit larger than Vickerson's.  However, one of the interesting things I found about his list is that only one of the three books is a scientific text.  Although they are important, I believe that scientific texts alone do not make for a full medical education.  After starting medical school, this is a theme I have run into over and over again.  As you will see in many of the books on this list, medical science is a tangent to another aspect of medicine presented (e.g. medical cognition, medical error, social justice, etc.).  Reading these books can prompt a reader to consider these often overlooked aspects.  While there is obvious relevance to physicians and medical students, I hope that non-medical people will find these titles interesting as well.

Since the title of this blog comes from Arrowsmith, I think it makes sense that I list it first on this blog:

Arrowsmith

By Sinclair Lewis

Arrowsmith is probably the first novel to carefully research and accurately depict the culture of science.  The book follows Martin Arrowsmith from his days in medical school to his career as a physician-researcher.  For Martin, scientific truth is a sacred moral and throughout his education and career he struggles to defend this value against commercialists, religious zealots, and the pretensions of society.  One of the most surprisng aspects of the novel is how some things have not really changed in the medical education and practice in the past century.  Lewis was awarded the Pulitzer Prize for Arrowsmith but refused it.

This was actually the first of Lewis' books I have ever read and it has enticed me to read more of his books (I got Arrowsmith and a few others where I get most of my books - at a library booksale) and more about him.  One of my future posts will probably include his Nobel prize speech which criticizes the American literary establishment at the time.

  

As for Dr. Martin Arrowsmith, I found many of his experiences in college/medical school a little too close to home.  I identified much with Arrowsmith, who was intellectually drawn to medicine and frustrated with those who were allured to the prestige and financial stability of medicine. It's amazing how some things never change.    

Probably one of my favorite parts of the novel is the Scientist's Prayer:

"God give me unclouded eyes and freedom from haste. God give me a quiet and relentless anger against all pretense and all pretentious work and all work left slack and unfinished. God give me a restlessness whereby I may neither sleep nor accept praise till my observed results equal my calculated results or in pious glee I discover my error. God give me strength not to trust God!"