Winter Book Discussion, a Summary

Our 2018 Winter Book discussion will take place next Monday November 26th!  Come enjoy a lovely (warm and filling) lasagna with veggie options including gnocchi with white sauce with Cesar salad!

Our selection was a long one this quarter, so please join us even if you haven’t had time to finish– a plot summary is included below!

“The story is told by the protagonist, Marion Stone. He and his conjoined twin Shiva are born at Mission Hospital (called “Missing” in accordance with the local pronunciation), Addis Ababa, in September 1954. Their mother, Sister Mary Joseph Praise, an Indian Carmelite nun, dies during childbirth. Their father, Thomas Stone, the English surgeon of Missing, abandons them and disappears. Orphaned at birth, the pair grow up in the household of two physicians of Missing, both from Madras, the obstetrician Kalpana Hemlatha (Hema) and Abhi Ghosh, who fall in love while caring for the infants. Hema names them Marion (after J. Marion Sims) and Shiva (after the Hindu deity). Ghosh teaches himself surgery to replace Stone. The tissue link between the twins has been separated at birth and the two grow up together being very close initially. Both are exposed to the changing political environment in Ethiopia. There is an unsuccessful rebellion by Haile Selassie’s bodyguard, General Mebratu. Ghosh is imprisoned, then released, in the aftermath of the coup, due to his friendship with Mebratu. Through their parents, both boys are exposed to medicine and taught at the hospital. Over time, though, individual differences begin to become pronounced. When entering puberty their relationship to Genet, the daughter of Rosina, a domestic help, finally tears them apart. Marion is in love with Genet and intends to marry her, but it is Shiva who, interested in sexual pursuits, deflowers her. Marion feels betrayed. Rosina forces Genet to submit to female genital mutilation and commits suicide shortly thereafter. Genet will later join the Eritrean liberation movement. While Marion goes to medical school, his brother stays at Missing. Focused on the repair of birth-related fistulas, he takes up his surgical training with Hema eschewing a formal medical education. On his death bed, Ghosh has three wishes for Marion – to get the best medical education, to find Stone, and to forgive his brother.

When Genet and her comrades hijack an Ethiopian Airlines airplane in 1979, Marion is on a list of her connections. To avoid arrest he flees the country overnight to Kenya. He goes to New York City where he finds a position at Our Lady of Perpetual Succour, a hospital in the Bronx. There, he enters a surgical residency. One day, assisting his senior in a complicated trauma operation, an unknown surgeon enters looking them over the shoulder. It is Thomas Stone, by now a well-renowned liver surgeon from Boston. Marion’s encounter with his biological father redirects his life leading to a painful reconciliation and reunion with his estranged brother.” (1)

 

  1. Wikipedia. (2018, March 03). Cutting for Stone. Retrieved from https://en.wikipedia.org/wiki/Cutting_for_Stone

 

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Parenthood and Emergency Medicine

Hema’s transition into motherhood, her revelations on a crashing plane and in a hopeless OR really spoke to an ongoing discussion in medicine regarding parenthood and career balance. This practice of pushing aside, or putting off parenthood, ‘just till I start my career,’ or ‘ after I finish my training,’ etc is something I’m sure is not unique to medicine.  Interestingly that tension was exemplified by a series of articles published in Emergency Medicine News not too long ago in mid 2017.

The first commentary was printed in July 2017 describing the balance between treating patients and being present for family medical emergencies.  Dr. Sandra Scott Simmons describes her experience:

The conflict between our core values as parents and as EPs creates significant cognitive dissonance. Receiving a text with a photo of an ankle looking like Cole’s looked that night would make most people drop everything to be with him in the ED, but I still showed up to work. I’ve never felt so much inner turmoil during a shift. Parenting may be first on our priority list, but our careers don’t always allow us to realize that ideal. Physicians valiantly do what it takes to meet the high expectations placed upon us, but we’re far from invincible. The cognitive dissonance produced by choices we are forced to make will ultimately affect all of us and our families.” (1)

In a letter to the editor, Dr. Geoffrey Martin offers his response on this long debated balance:

Certainly many families feel the pain of mothers trying to fulfill both roles with equal expertise while suffering terrible “mommy guilt” when significant events occur in their families’ lives. In the end, it’s a choice. Those natural mothering tendencies don’t have to disappear when you become a physician, but you can plan a little differently so that you can experience the richness and fulfillment of both. While you can’t reasonably expect everything simultaneously, with planning and pragmatism you can have both, in their season at their time.

If you’re planning to tilt your lance at a windmill, maybe take on the lie that women should be everything all the time to everyone. Be a mom, be a wife, be a doctor, but each in its season. Don’t expect to do them all simultaneously with expert ability and no pain. It’s in very few women’s nature, and there’s almost always pain.” (2)

And again, Drs. Tintinalli, Kass and Wolfe Respond to ‘Parenthood and Medicine, Each in its Season’ in Emergency Physicians Monthly.  Tintinalli’s commentary concludes:

Does a Dad feel any different than a Mom in a situation like this? No way. The seasons change with age – your age, your children’s ages, your parents ages – but the tender feelings never go away.

Dr. Geoff Martin seems like a fine guy (based on a video on vitals.com). He seems proud to be an emergency physician. He gives food for thought when he writes “you can plan a little differently so that you can experience the richness and fulfillment [of both].” But change the words “women” or “moms” to “men” or “dads,” and you get the same angst. 

We all make choices. When we realize the pressures and choices become unbearable, time to re-calibrate. Emergency medicine provides us with a world of professional choices:  full-time, part-time, hardly-any-time, high-intensity, low-intensity. We are lucky. We are doctors. We are parents, sons, daughters, friends. We do the very best we can.” (3)

What has been your experience?  How do your priorities, family or otherwise, balance your sense of responsibility to your career?  Does it take a crashing plane and a medical disaster, like in the story of Hema to take a fresh perspective on the debate?

  1. Simons, S. S. (2017). ER Goddess. Emergency Medicine News,39(9), 6. doi:10.1097/01.eem.0000524788.36561.5f
  2. Martin, G. (2017). Letter to the Editor: Parenthood and Medicine, Each in Its Season. Emergency Medicine News,39(8), 21. doi:10.1097/01.eem.0000522233.73773.41
  3. Tintinalli, J. (2017, August 22). Drs. Tintinalli, Kass and Wolfe Respond to ‘Parenthood and Medicine, Each in its Season’. Retrieved from http://epmonthly.com/article/three-women-respond-parenthood-medicine-season/; Emergency Physician Monthly

How do we ask for help in Medicine?

There are so many deeply emotional and tragic moments as the birth of the twins and the struggle between heartbreak and medicine for several of the doctors at Mission.  Stone is frozen, outside of his medical knowledge and paralyzed by his innate connection to the person that is now on his table.  But how often do we, as medical practitioners find ourself in high stakes situations when asking for help seems like the right albeit impossible choice.

Edna Shenvi is a surgery resident recalls in blog Kevin MD:

“Have a plan,” said one attending, “If you don’t know, just guess.” And another, in a teaching session, “Just guess, even if you’re wrong.”

From a chief resident during an awkward pause when a junior was put on the spot: “Just guess; it’s OK.” When someone dares to ask a senior about the next step planned for a patient, the response often is “You tell me” or “What do you think?” In other words: If you don’t know — guess.” (1)

She begs the question, what are we teaching, what are we expecting of our colleagues when we ask coworkers (typically junior colleagues) to guess at the risk of not having an answer. She goes on,

Of course the intention has merit. But for being the behaviors we are inculcated with during our formative years, I think there are dangerous consequences. We now hear that medical errors are the third leading cause of death, it takes decades for evidence-based practices to be implemented, there are huge health care quality disparities within our country and pressure for performance is contributing to physician burnout and suicide. Is any of this really a shock?” (1)

When we “grow up” as residents and enter the “real world” of independent practice and a question arises, are we going to guess? Are we forever supposed ‘fake it till we make it?’ What can we do as teachers and evidence-based practitioners to avoid blind guessing and know when to ask for help and where to look for it?

  1. Shenvi, E., & Kevin MD.com. (2017, November 28). Medicine isn’t a guessing game. Always ask for help. Retrieved November 11, 2018, from https://www.kevinmd.com/blog/2017/12/medicine-isnt-guessing-game-always-ask-help.html

ANNOUNCEMENT!

Our Winter Edition discussion of Cutting for Stone will be held on Monday, November 26st at 6p at Casa de McElhinny, see your email for additional details.

Feature Book: Atlas of Men

From our own Dr. David Sklar, check out his new novel fresh off the press last week and right out of conference: Atlas of Men

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Amazon books gives us a brief description: “Files from a secret research project show up on Dr. Robert Thames’s doorstep, forcing him to think about something he’s been avoiding – the degrading “study” at Danvers Academy, especially the naked photos of each student, including himself, taken at his prep school. He tracks down four close friends from school, and together they uncover the terrible truth of what was buried by the faculty, the school, and the boys themselves.”

 

Check it out and support a local author and fellow EP!

Another Book, with a Twist

You may have seen advertisements for the new NBC Show New Amsterdam, and while Grays Anatomy I can argue with a quote from its signature scene:

“You do know the whole system’s rigged, don’t you?,” says Dr. Reynolds, who does not want anyone to see just how much he really cares. “They ‘re not going to let you come in here and just – help people.”

 

“So let’s help as many as we can before they figure us out,” says Dr. Goodwin. (1)

Maybe its the just the grind of year two of residency, but man does that premise, that perspective, that spunk, feel refreshing. Now I know this is the Copa Book Club and I just introduced you to a new TV show, but have no fear, the show is based on a novel by Dr. Eric Manheimer’s memoir Twelve Patients: Life and Death at Bellevue Hospital .

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“Using the plights of twelve very different patients–from dignitaries at the nearby UN, to supermax prisoners at Riker’s Island, to illegal immigrants, and Wall Street tycoons–Dr. Eric Manheimer “offers far more than remarkable medical dramas: he blends each patient’s personal experiences with their social implications”” (2)

 

So whether you’re prone to cuddle up with a new book or snuggle in for a few episodes on your lap top, take time to appreciate the magic in medicine once again.

  1. Lloyd, R. (2018, September 25). Review: Two looks at hospitals and healthcare come to TV with ‘New Amsterdam’ and ‘The Mayo Clinic: Faith – Hope – Science’. Retrieved October 18, 2018, from http://www.latimes.com/entertainment/tv/la-et-st-new-amsterdam-mayo-clinic-faith-hope-science-review-20180925-story.html
  2.  Amazon. (n.d.). Twelve Patients: Life and Death at Bellevue Hospital. Retrieved October 18, 2018, from https://www.amazon.com/Twelve-Patients-Death-Bellevue-Hospital/dp/1455503878
  3. Blanton, K. (2018, September 25). How ‘New Amsterdam’ Gives Real, Neglected Patients A Platform To Be Heard. Retrieved October 18, 2018, from https://www.bustle.com/p/new-amsterdam-is-based-on-a-true-story-that-gives-neglected-voices-justice-11978881

The pause.

I’ve just started out on our newest read Cutting for Stone and already the theme of mortality is strong on my mind.  As second year residents we get to captain our first codes. I was fortunate to be part of a well-run code run by another resident and after an unsuccessful resuscitation there was a moment of reflection, a pause.  Not only was this colleague skilled in resuscitation but also understood the importance of acknowledging a death and dedicated with a thoughtful debrief. As first years we spend several days learning ACLS, ATLS, PALS, all the advanced life support techniques and algorithms. We learned how to do and to fight death and not once acknowledge the toll an unsuccessful resuscitation can have on healthcare workers involved.

In an NPR article Johnathan Bartels of University of Virginia Medical Center describes adapting “the pause” into his practice:

“So the next time we worked on another person who didn’t make it, I decided to be bold and stop people from leaving,” he says. “I just said, ‘Can we stop just for a moment, to recognize this person in the bed? You know, this person before they came in here was alive — they were interacting with family, they were loved by others, they had a life.’ ”

The team did it. Standing together silently, they stopped — just for a minute.” (1)

The practice of honoring a life is not exclusive to emergency medicine, check out how University of Vermont Medical Center honors their organ donors.

 

  1. Lofton, K. (2015, September 27). Trauma Workers Find Solace In A Pause That Honors Life After A Death. Retrieved October 10, 2018, from https://www.npr.org/sections/health-shots/2015/09/27/443104073/trauma-workers-find-solace-in-a-pause-that-honors-life-after-a-death

Winter Book Selection!

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Self described on his website, “Abraham Verghese, MD, MACP, is Professor and Vice Chair for the Theory and Practice of Medicine at the School of Medicine at Stanford University. He is also a critically acclaimed, best-selling author and a physician with an international reputation for his focus on healing in an era where technology often overwhelms the human side of medicine.” (1)

Our winter book selection comes from an author with dedication to the doctor-patient relationship.  Dr. Vergheses states, “I wanted the reader to see how entering medicine was a passionate quest, a romantic pursuit, a spiritual calling, a privileged yet hazardous undertaking.” (1)

If your interest is not yet piqued, consider this short summary from a NYT review of Cutting for Stone. “The plot of this big, dense book is fairly straightforward. Marion and Shiva Stone are born one dramatic afternoon in 1954 in Addis Ababa, the same day their mother — a nun, Sister Mary Joseph Praise — dies of complications from her hidden pregnancy. The boys are conjoined at the skull, yet separated at birth; they are raised by Dr. Kalpana Hemlatha, a forceful woman ciknown as Hema, and Dr. Abhi Ghosh, both immigrants from Madras and both doctors at the hospital where the boys’ natural parents also worked. Missing Hospital, it’s called: “Missing was really Mission Hospital, a word that on the Ethiopian tongue came out with a hiss so it sounded like ‘Missing.’ ” They grow up amid the political turmoil of Ethiopia (its actual chronology altered slightly by Verghese to suit his fictional purposes), and in 1979 Marion flees, first to Nairobi and finally to New York, where he qualifies as a surgeon. Shiva, too, goes into medicine, specializing in treating vaginal fistula, for which work he is acclaimed in this very newspaper, a sure sign of his renown. Almost supernaturally close as children, the brothers become more and more distant as the novel progresses; they are dramatically reunited at its end — through the mysterious agency of the long-vanished Thomas Stone.” (2)

 

  1. McCarter, J. (n.d.). Abraham Verghese: Biography. Retrieved October 3, 2018, from https://abrahamverghese.com/home/biography/
  2. Wagner, E. (2009, February 06). Book Review | ‘Cutting for Stone,’ by Abraham Verghese. Retrieved October 3, 2018, from https://www.nytimes.com/2009/02/08/books/review/Wagner-t.html

Featured Read

 

I have to say I’m a bit biased given my public health projects around opioid addition and treatment in the ED, but this read comes with special recommendation by former resident Melody Glenn!  Its hard to go through a night shift without seeing the effects of opioid misuse and addiction so if you’re looking for catharsis in this frustrating cycle of addition, consider Dreamland.  Below is a feature from the NY Times regarding Dreamland along with 2 other books which explore the opioid crisis.

 

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DREAMLAND
The True Tale of America’s Opiate Epidemic
By Sam Quinones
384 pp. Bloomsbury Press. (2015)

In this National Book Critics Circle Award-winning book, the investigative journalist Sam Quinones looks at two phenomena — the overprescription of pain medication in the 1990s and the influx of black-tar heroin from Mexico to the United States — to explain how opiate addiction has come to plague hundreds of towns across the country. In the 1990s, many doctors freely prescribed powerful analgesics, including the highly addictive OxyContin, resulting in widespread pain-pill abuse. Black-tar heroin, delivered primarily by Mexican drug dealers from the municipality of Xalisco, was introduced around the same time and became a cheaper alternative with similar effects. Quinones weaves together the roles of a cast of characters, including pharmaceutical executives, narcotics investigators, recovered addicts and the dealers who set up a system that Quinones compares to pizza delivery.

 

Bonus reads:

CLEAN
Overcoming Addiction and Ending America’s Greatest Tragedy
By David Sheff
374 pp. Eamon Dolan/Houghton Mifflin Harcourt. (2013)

MARLENA
By Julie Buntin
274 pp. Henry Holt & Company. (2017)

 

  1. LeÓn, C. D. (2017, July 13). 3 Books Take a Deeper Look at the Opioid Epidemic. Retrieved September 25, 2018, from https://www.nytimes.com/2017/07/13/books/review/newsbook-opioid-epidemic.html

Winter Book Selection

We’re gearing up for our next discussion in late November, comment below with your favorites from this list or your own selections!

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Cutting for Stone- Abraham Verghese
A sweeping, emotionally riveting first novelan enthralling family saga of Africa and America, doctors and patients, exile and home. Marion and Shiva Stone are twin brothers born of a secret union between a beautiful Indian nun and a brash British surgeon at a mission hospital in Addis Ababa. Orphaned by their mother’s death in childbirth and their father’s disappearance, bound together by a preternatural connection and a shared fascination with medicine, the twins come of age as Ethiopia hovers on the brink of revolution.
 

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Being Mortal- Atul Gwande
In Being Mortal, bestselling author Atul Gawande tackles the hardest challenge of his profession: how medicine can not only improve life but also the process of its ending
 

OneFlewOverTheCuckoosNest.jpgOne flew over the Cuckoo’s Nest- Ken Kesey

In this classic novel, Ken Kesey’s hero is Randle Patrick McMurphy, a boisterous, brawling, fun-loving rebel who swaggers into the world of a mental hospital and takes over. A lusty, life-affirming fighter, McMurphy rallies the other patients around him by challenging the dictatorship of Nurse Ratched.

God’s Hotel Recap

This week we will be meeting on Thursday at Casa de McElhinny, see your weekly emails for more details. Below is a quick recap of the God’s Hotel and some of its themes. At any rate, come for the food, stay for the company, see you there!

“God’s Hotel is the beautifully written story of Laguna Honda Hospital in San Francisco, California an “almshouse” (the last of its kind in the country) which provides care for the poor, needy and underprivileged.

As the book unfolds, the reader is shown the hospital through its stages of transformation: how it used to be, and how it has been made to be by new regulations. Medical students and physicians will recognize the injustices of the changing system, as will anyone who has ever been a patient. Dr. Sweet argues (quite convincingly, given that she uses only simple, true anecdotes) that change is not always better, and that something essential has been lost in “modern” medicine.” (1)

http://in-training.org/gods-hotel-reviewing-story-medicine-9672

 

  1. In-Training. (2015, October 16). God’s Hotel: Reviewing the Story of How Medicine Should Be. Retrieved August 27, 2018, from http://in-training.org/gods-hotel-reviewing-story-medicine-9672