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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

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When I was in medical school, I read Samuel Shem’s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine.  I gained comfort from its gallows humor – and it made me feel connected to my peers during the most stressful time of my training. So when I was invited to review Shem’s “bookend” to House Of God, it was with a sense of eagerness and nostalgia that I accepted the challenge. How had the author’s thinking developed since the launch of his first blockbuster in 1978? I hoped to find a kinder, gentler Shem, perhaps looking back on his career in medicine with a sense of grace and dignity. I wanted the pomp and cruelty of his training to fade away into a kind of “it was all worth it in the end” conclusion. Alas, I was jarred into a very different reality.

The Spirit Of The Place is a gruesome portrayal of American suburban decay, mixed with some unexplained hostility towards non-Jewish Americans and those with conservative values. The hero of the book, Orville Rose, escapes his mundane American life for a two year adventure with Doctors Without Borders in Europe. He soon is ensconced in a carnal relationship with a gold-digging, alternative-medicine practicing, Buddhist, Italian yoga master who later dumps him for a Swiss banker. Orville returns from Italy to his home town of Columbia, New York, to sort out his family affairs after his mother’s death. She has arranged to transfer all of her wealth to him if he agrees to live in his childhood home for a full year and thirteen days – a fate almost worth than death.

Columbia is a horrific place, filled with poverty, violent crime, summer mosquitoes, and winter ice storms. The central medical figure is an aging general practitioner (Bill Starbuck) who regularly prescribes a kind of snake oil for various life-threatening ailments (Starbusol). Orville sees this physician as a kind of avuncular mentor, excusing his gross medical malpractice as simply “old fashioned.” Bill soon asks that Orville take over his practice while he goes on a much needed vacation, which turns out to last over a year. Orville is stuck being the only GP for a town of about seven thousand. He soon becomes overworked and overwhelmed. But that doesn’t stop him from falling in love with a single mom and polio survivor who was secretly asked by his dying mother to mail Orville letters (written in advance) after her demise. These letters are filled with venom and manipulative accusations (paging Dr. Freud).

The plot makes the reader predisposed to feel empathy for the protagonist, but Shem so exposes Orville’s character flaws that he is nearly entirely unlikable. Every tender moment in the book is derailed by some sort of unpleasant comment or thought. Take for example, the death of Dr. Starbuck. Orville is at his bedside in the ICU, explaining how important it is to treat patients with dignity, even when they are unconscious. He gently whispers that it’s ok for Dr. Starbuck “to let go” and provides one last facial shave as the man drifts off into his final breaths. And in the middle of this, what does Orville also think to himself?

“…Bill’s groin, the purple crowned penis that had had its share of adventures in repayment for his tending the whores on Diamond street. ‘Two dollars a housecall, Bill, and you never came away empty-handed.’ He took out his comb and combed Bill’s thin hair, gray lines on a shiny dome.”

And then there’s the awkward sex scene where Orville describes kissing his lover’s limb shriveled from the polio virus. I’ll save that one for your imagination.

The point, we are left to assume, of this depressing exploration of human defects (from the physical to the emotional, and at every level of organization – from the family unit to the city government and even national and international politics) is to promote tolerance and understanding of the human condition. Unfortunately the book is more likely to suck the last breath of optimism and hope out of you. The darkness has consumed the light, and with little to admire in any character portrayed in The Spirit Of The Place, it is difficult to read. In fact, it took me over two months to complete it.

That being said, Shem is an excellent writer. And for those who enjoy wrist-slitting fiction, this may be just the book for you. I was personally quite astonished by Abraham Verghese’s exuberant cover jacket blurb:

“An incredible and heartfelt story… The Spirit Of The Place entertains, satisfies, and affirms; it is beautifully conceived and brilliantly executed.”

Clearly not everyone agrees with my analysis. I’d be curious to know which one of us is crazy – me, Verghese, or Shem?

I suppose Shem would say we all are, and that’s the point…

Eat To Save Your Life: Another Half-True Diet Book

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I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However, after being approached by the authors’ PR agency with the promise of a book that contains science-based nutrition information I decided to agree to the review. This is how the book was described to me in an email:

In their provocative new book, Eat to Save Your Life, best-selling authors Dr. Jerre Paquette and Gloria Askew, RRN, sort through the piles of information and misinformation about nutrition to reveal the true connection between food and health. Fed up with the advertising hype and conflicting nutritional advice, the duo provides common sense explanations for consumers everywhere who are looking to make smart nutritional choices.

Unfortunately, I was sold (quite predictably) a bill of goods. And rather than ignore the book and simply not do a review, I figured that maybe a negative review would reduce the number of incoming PR requests for future tomes of pseudoscience. In the end, I’ll probably just become the focus of personal attacks by dedicated proponents of various snake oils.

That being said, I thought it might be somewhat instructive to remind Better Health readers of certain basic “warning signs of pseudoscience” that I accidentally overlooked in agreeing to review the book. For a more complete review of similar “signs” I highly recommend Dr. David Gorski’s 2007 classic, humorous take on predictable arguments and behaviors of alternative medicine proponents (written in the style of comedian Jeff Foxworthy).  As for me, I tend to think of much of the world of integrative medicine as a militant group of bakers eager to add odd, inert and occasionally toxic substances to cake recipes.

And so, without further ado, here is a small sample of what authors Askew and Paquette have added to their half-true diet book recipe:

  • The “one true cause” fallacy: The book opens with an interesting review of vitamin C deficiency, noting that it (apparently) took the British Royal Navy 40 years before they accepted that the treatment for scurvy was citrus extract (rather than flogging). Citing this incident as an example of nutritional deficiency leading to life-threatening illness,  it’s a short ride to the “one true cause” fallacy whereby the authors postulate that there are untold numbers of modern diseases caused by unrecognized nutritional deficiency syndromes. Nutritional deficiency may be the one true cause of most diseases, you see.
  • The appeal to research without references. Countless appeals are made to “mounting evidence” of this and that (arthritis being caused primarily by food-related inflammation for example), either without reference footnotes, or with mentions of sources of dubious credibility (such as the Canadian Association of Naturopathic Doctors).
  • The appeal to supplements in lieu of vaccines. No diet advice would be complete without a gratuitous attack on vaccines, right? The authors suggest that flu vaccines (for example) only provide immunity for 2 months “and only for certain individuals.” Meanwhile, they assert that a combination of Echinaceagarlic, and vitamin C support the immune system to successfully fight of viruses. These claims are simply unproven and multiple studies have already found no benefit (over placebo) of these supplements at preventing and treating the common cold.
  • Over-diagnosis. If you think that the world of medicine is predisposed to seeing disease where there is none, try the alternative medicine world. The authors assert that everything from zits, to rashes, to “brain fog” are potential signs of grave underlying immune compromise – caused by, you guessed it, dietary deficiencies.
  • Over-supplementation. The authors argue that “supplementation is a necessity in our nutrient-robbed world.” However, new evidence doesn’t support supplementation for the general population, though it had beentraditionally felt that multi-vitamins might be valuable. In addition, new studies are finding that food sources are preferable to supplements for daily nutritional requirements (such as calcium) and that anti-oxidants such as vitamin E may do more harm than good.
  • The “organic is more nutritious” argument. Although a recent systematic review of the scientific literature found no support for the notion that organic foods contain more nutrients than those grown with traditional methods, the authors attribute Americans’ supposed vitamin deficiencies to poor soil quality caused by non-organic farming methods.
  • Nutrigenomics and DNA hype. The authors do not take a sufficiently skeptical view of the emerging field of nutrigenomics (whereby certain foods and supplements are recommended to individuals based on their genetic profiles). They even suggest that nutrigenomic testing is so much fun, it’s “almost like being part of a CSI television show.” Who cares if it’s no more accurate than fortune telling?

So what’s the half true part? Well, obesity is certainly a driver of many modern illnesses, and obesity is caused by (in no small part) nutritional choices. The authors cite statistics on the ravages of heart disease, high blood pressure, and diabetes on the U.S. population which are all quite true. (How this supports the “deficiency” argument is somewhat lost on me – because it would seem more logical that a possible excess of nutrients could be the “one true cause” of a lot of these diseases, but I digress).

There are real nutritional deficiencies that cause medical problems, such as iron-deficiency anemia, neural tube defects related to folic acid deficiency, vitamin D deficiency and rickets, and osteoporosis contributed to by low calcium levels. These conditions underscore the importance of healthy eating habits, but do not support the idea that the entire population is deficient in these nutrients. In fact, a large population study analyzed by the CDC, suggests that most Americans are not deficient in any major nutrient even with their current sub-optimal and obesogenic eating habits.

In general, fair-minded individuals will find Eat To Save Your Life to be yet another example of a half-true, hysteria-peddling, micro-nutrient-obsessed diet advice book. Ironically, the book’s title itself states the opposite of what we really need to be doing to reduce obesity-related diseases: stop eating (so much) to save our lives.

This book may be purchased (against my medical advice) at Amazon.com.

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This post originally appeared at the Science Based Medicine blog.

Unaccountable: A Book About The Underbelly Of Hospital Care

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I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety, the potential contribution of checklists to reducing medical errors, and his upcoming book about the need for more transparency in the healthcare system. Marty was well dressed and soft spoken – sincere, and human. We exchanged business cards and wished each other luck in changing the healthcare system for the better. We were two doctors tilting at windmills.

Just two months ago my fiancé sent me a “must read” article from the Wall Street Journal. It was Marty’s provocative piece, “How To Stop Hospitals From Killing Us.” The article was an excellent primer for his book, “Unaccountable: What Hospitals Won’t Tell You And How Transparency Can Revolutionize Health Care” which I highly recommend (holiday gifts, anyone?)

Unaccountable is both horrifying and oddly optimistic. Marty describes case after case of medical errors, lapses in judgment, and near misses in the surgical suite. He exposes the cultural foibles of the medical and hospital hierarchy, leaving no dirty stone unturned. Surgical delinquents such as Dr. Hodad (“hands-of-death-and-destruction”) are presented with detached accuracy, along with a clear list of reasons why the system fails to prevent the Hodads of the world from operating.

From the micro (individual physician mistakes) to the macro (trends in hospital safety breakdowns), Marty turns to survey data to make sense of the shortcomings. Interestingly, hospital “culture” (rated by its own employees) is the most predictive of overall hospital safety performance. Detailed record keeping of surgical complication rates correlates strongly with how employees rate their hospital on three simple questions:

1. Would you have your operation at the hospital in which you work?

2. Do you feel comfortable speaking up when you have a safety concern?

3. Does the teamwork here promote doing what’s right for the patient?

Marty’s conclusion that culture is the defining factor in patient safety and satisfaction ratings is both accurate and squishy. It’s difficult to create a reproducible template for a healthy work culture, and yet good culture is the basis for the success of hospitals such as the Mayo Clinic. Individual hospitals, like individual surgeons, have different personalities and temperaments. Raising them to be upstanding citizens involves a combination of good parenting and good luck.

Because I think Marty is absolutely right about culture as the foundation for safe and effective care, I think he’s also overly optimistic about the potential success of strategies to reproduce caring hospital cultures. By his own admission, not even the Mayo Clinic “mother ship” in Rochester, MN, has been able to create the exact level of quality care in its sister hospitals in Scottsdale, AZ, and Jacksonville, FL. So how can we dramatically improve patient care on a national level? Marty suggests that we need to find ways to force hospitals to become more transparent in order to revolutionize healthcare. His ideas include:

1. Mandatory hospital public reporting of patient re-admissions, complication rates, and never events.

2. Adoption of check lists by surgical teams to reduce errors.

3. Installation of video cameras throughout hospital floors and surgical suites so that staff behaviors can be monitored more effectively (e.g. to enforce hand washing or identify surgeons who have high error rates).

4. Accessible and transferable medical records that put patients at the center of their documentation.

While these ideas have merit, I believe they will fall short of achieving our ultimate goals. In my view, a culture of accountability is not the same as a culture of caring. Adopting certain “Big Brother” (cf. #3 above) strategies to pressure staff to behave/perform appropriately is only going to force the Hodads underground. We need staff to genuinely care enough about their patients to gang up on the Hodads and kick them out of the hospital for good. Caring doesn’t happen at a national level, it is personal and local. That’s why individual hospitals must develop their unique cultures for themselves, with progress measured by responses to those staff questions about whether or not they’d want to be cared for at their own institution.

I agree with Marty that hospital data transparency might be the best antiseptic we have to scrub the underbelly of medicine, though the ultimate success of our procedures will always be culture and surgeon-dependent. And that’s something you can’t regulate from Washington.

***

Marty’s book is available for purchase at Amazon.com.

Check out your local hospital safety scores from LeapFrogGroup.

The Thrifty Patient: A Doctor’s Guide To More Affordable Healthcare

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No matter the outcome of the presidential election this year, it’s likely that Americans will be spending more of their money on healthcare going forward. Dr. Davis Liu, a family physician at the Permanente Medical Group in California (and a contributor to this blog), has written a primer on how to get the most bang for your healthcare buck. The Thrifty Patient: Vital Insider Tips For Saving Money And Staying Healthy is a helpful little book for those smart enough to read it.

The first step to becoming a “thrifty patient” is to reduce your need for professional healthcare services. This lesson is perhaps the most important of all: lifestyle choices are the largest controllable determinant of how much healthcare you will consume. Daily exercise, healthy eating, and preventive care services (such as vaccines and screening tests) are the most effective ways to avoid expensive healthcare.

Dr. Liu offers tips for selecting a doctor, questioning the necessity of tests and procedures, choosing less expensive treatments, getting a second opinion, and learning to get the most out of a short doctor visit. He explains why annual check ups may not be necessary, and lists all the preventive health screening tests you’ll need (according to age) to maximize your chance of avoiding many major diseases or their expensive outcomes.

According to Liu, an excellent primary care physician (PCP) can be the best ally in avoiding unnecessary medical costs. Without a PCP’s guidance, 60% of patients select the wrong specialist for their symptoms or concerns. This can trigger a costly cascade of extra testing and referrals. Liu recommends trustworthy websites that can aid in disease management and patient education – suggesting that “Dr. Google” may not be so bad after all, armed with a correct diagnosis from a healthcare professional and links to credible sources of information.

Being thrifty isn’t necessarily “sexy” – but practical tips for avoiding unnecessary and expensive interactions with the healthcare system could add up to some pretty amazing savings (both financially and emotionally). Anyone who takes Dr. Liu’s advice to heart is likely to live longer and better – I just hope that the people who could benefit most from these tips find their way to this book. Perhaps you know someone who needs an early Christmas gift? :lol:

The Thrifty Patient can be purchased here on Amazon.com

True Medical Detective Stories: A Great Little Book

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I just finished reading True Medical Detective Stories, Dr. Clifton Meador’s personal collection of medical mysteries. Dr. Meador is a prolific writer and the former dean of the University of Alabama School of Medicine and professor at Vanderbilt School of Medicine. His 50+ years in the academic arena have exposed him to some delightfully rare and bizarre medical cases, and he shares his top 18 in this pithy little book.

Dr. Meador was inspired by Berton Roueché, a staff writer at The New Yorker, who helped to popularize the medical detective story genre in the 1940′s and beyond. Each vignette is between 3-5 pages in length, making for a very quick and entertaining read. In choosing to review this book I was very tempted to give away details of some of the cases in order to entice you to read it, but I have resisted the urge so as not to spoil the fun.

Broadly speaking, the stories include a rare case of intractable hiccups, a bizarre infection caused by sexually deviant behavior, and several examples of the power of the mind to inflict bodily harm on oneself and others. In each situation, the underlying cause of the symptoms or disease is uncovered through careful listening and analysis. Often, human shame and fear must be managed before the truth can bubble to the surface.

I highly recommend this book to healthcare professionals, skeptics, and anyone interested in a fascinating look at some of the most unusual medical cases described in one book. Perhaps we can all learn to become better listeners, or true “medical detectives,” from Dr. Meador’s stories. You can find his book here at Amazon.com. Enjoy!

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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Click here for a musical take on over-testing.

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Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

Read more »

See all book reviews »

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