Playing the Ponies and Other Medical Mysteries Solved, by Dr. Stuart Mushlin

This novel brought to mind one of my favorite documentaries years ago called The Poisoner’s Handbook, which recounted Dr. Alexander Gettler’s attempts to resolve public health crises in the early-mid 1900’s. That documentary cemented my interest in science and the detective work that was often associated with it. This novel was a more doctor-patient focused narrative, but approached cases in the same detective style, and with a real honesty as well. This was evident from the title, and that’s what drew me to it.

Dr. Mushlin’s account was different from those I had seen previously. He writes in a conversational style, and clearly has a very mature and positive spin on the profession. Too often in recent history, I’ve seen the difficulties of medicine, but now Mushlin has reminded me that while long hours and occasionally unruly patients require extensive “bracing”, medicine is something that is incredibly beautiful at the same time. Getting to be a part of a person’s life, knowing their family, maybe being like another member of that family is something that can’t be taken away and is simply the most beautiful human emotion. Mushlin recalls an event where one of his patients, post-operation and treatment, invites him to his son’s law school graduation. Many other patients are either friends of Mushlin or hospital employees, offering incredible perspectives. Mushlin gives the luxury of explaining in detail the important takeaways, such as the chronically understated value of nurses, and the value of humility and how to act when you are wrong in any particular situation. For example, Mushlin recounts these tests called CPC’s (which I can’t find on YouTube, but seem exceedingly cool) where a doctor is given a case, 10 days to prepare, and then present his/her thought process to a group while a pathologist has the real answer. These are often like puzzles, and even experienced doctors can get them wrong. What is intriguing is that past history is considered, and extensive inferences are made to reconcile the diagnosis and symptoms.

In the world I live in today, creativity is stifled more often than not. The most creative people are the most bullied, either on the playground or in the media, or even in academia, and this creativity is stifled. Dr. Mushlin’s example of a thought process does not shy away from creativity, especially since it is also a low-stake situation. This is definitely what I aspire towards, because I want to have creative freedom (within strictly rational bounds of course).

But I digress.

The day I started reading this book (yesterday), I stopped to go on a walk with my highly temperamental mother. My mother is as close to a perfectionist as one can get. As she vented to me (about me), I realized I had two options (thank you Dr. Mushlin). I could either get angry (which I deemed a sign of immaturity) or I could approach things calmly and practice some empathy. Generally, I have much more patience towards other people, but a temper is something I still have to fix. I attempted this empathetic approach, listened to my mother, and tried to find the root cause of her grievance. In doing so, I was able to diffuse the situation, and this helped me grow as a person. Will I still lose my cool? For sure. But am I confident that this is something that will be corrected, or at least decrease, with time? Yes.

 

1984, by George Orwell

This is perhaps the most terrifying book I’ve read in a long time, in that the level of destitution and hopelessness is nearly unparalleled in its scale, rivaling that of only The Narrow Road to the Deep North, by Richard Flanagan. Even writing this passage out is strangely scary, as a major theme of the work is censorship, and the prevention of free thought. It is easy to contrast this dystopian society with that of Brave New World. As a start, sexuality is prohibited in this work, whereas BNW encourages promiscuity to prevent insurrection. In 1984, a continuous war and a police force that stops free thought are what stifle “radicals”, while genetic engineering and threats of banishment are used in BNW. BNW’s World Controller parallel’s O’Brien in 1984, in that they are highly intelligent individuals who see the “qualms”, and yet persist for the “greater good”. Indeed, the prominent feature of the thought police is the ability to conceal themselves among the ordinary folk, and therefore their understanding of natural human curiosities and tendencies to rebel must be up-to-par in order for them to be successful. The world controller, Mustapha Mond, is much kinder and generous to heretics than O’Brien, and conformity is achieved by sensory control. In 1984, however, conformity is not innate to the system, and no such “conditioning” occurs. Therefore, a torturing system and confinement is used to break spirits. BNW has a dystopia that harkens to The Matrix, whereas the dystopia in 1984 is FAR more sinister, and is often drawn in comparison with the Soviets. Both societies have a primary society that the character is entrenched in, and an other world that calls and is “uncivilized” or distinct from the primary society. The amount of modern day cinematic parallels is vast. Right off the bat, I can think of The Truman Show as an example of a unique form of censorship, and in the film Divergent, the concept of confronting a mortal fear is similar to Room 101 in this book.

1984’s Soviet theme is prominent, and was something I picked up on fairly early. However, Part 3’s torture truly ingrained in me the horror of that society. I remember in high school orchestra, we played Dmitri Shostakovich’s String Quartet #8, which was composed during the Soviet era and brought Shostakovich immense scrutiny. The nuances in the piece could be drawn back to Shostakovich’s fear of being exposed, much like Winston Smith is terrified of being exposed. In some movements, harsh “doorknocks” can be heard, which are meant to imply the secret police has found Shostakovich. Shostakovich’s recurring motifs are powerful and breathtaking, and show up in his other pieces (my favorite instance is that of Shostakovich’s Cello Concerto). His music is drenched in emotion, and you can really truly feel the pain that he felt when playing this piece, both physically at those portions with what he demands, and emotionally, with the despair that the music is conveying. This book lent that piece infinitely more meaning to me, and it already had established a place in my heart. To think that such a world could exist where people aren’t free is exceedingly terrifying, and I feel blessed for having the life that I do.

Another interesting point that I noted as I read this book was the concept of social class and the caste system. There is an argument made for inequality, that equal societies are too unstable and therefore inequality is needed to survive. Even if this is not actively worked for, this is an equilibrium that must always remain in place. The book also brings up the idea that mechanization and education are what give the chance for a truly equal society to exist, but less of a convincing argument exists here. The point that inequality may be an equilibrium is perplexing. Am I, as a future (hopefully) physician, a part of that equilibrium? Is my practicing on patients affecting that equilibrium one way or another? Is the medical doctrine of viewing a patient as an ill human, regardless of social class or other factors, a “control” of some kind to ensure that equilibrium shifts resulting from treatment is a matter of random chance, with no bias (i.e. I shouldn’t be concerned with the social class of my patients when it isn’t of utmost importance, because otherwise the effect on the population of each social class is magnified)? Is th

e world ready for equal societies, and if not, is my desire to help people in poorer conditions meaningless? I drive forward with this ambition because of human empathy. Because I do care for people who don’t get the same chance. What this book has done, however, is made me consider not only whether or not it’s fruitful to help the poor, but also whether I should do this through medicine directly, or some other manner.

I plan on serving the underprivileged with conviction as a consequence of reading this book and its description of the proletarians. However, I might consider building a school, as opposed to a clinic. This is far into the future, and nobody is more conscious of that fact that I am. However, this book has further shaped my worldview, and why I wish to help people. It is as John the Savage mentioned in BNW: people deserve the right to be unhappy, and live the life that they choose. If my practice gives people more time to exercise the right to be free, then that seems perfectly fair to me, and aligns with my worldview already that people should live for happiness.

When Breath Becomes Air, by Paul Kalanithi

This book was actually a recommendation from a friend over a year ago, and I had always been interested in the perspective that was offered (Paul was a doctor and a patient). Essentially, the biography is of a neurosurgical resident nearing graduation, who is then stricken by terminal late-stage lung cancer. As the roles were cruelly switched, it was evident how unusual the transition would be. One passage states that Dr. Kalanithi was given the same room for his diagnosis that he once prescribed treatments for and explained surgeries and complications in. I took away many lessons from these heartbreaking passages.

I related a lot of Dr. Kalanithi’s childhood, with the drive to read and learn, and ultimately grow. The ambition and the strength of his youth resonated with me. Which made this a tough read. A really tough read.

Man, this book was tough to read.

  1. Doctors are not immune to the maladies that plague patients. It’s always a question at the back of everyone’s mind. Why don’t doctors get sick? Well, they do. They’re people too.
  2. The choice to have a child as death is approaching is a difficult decision, but Dr. Kalanithi says that until he is dead, he is still living. That was sound rationale for having a child for them, and sound for me.
  3. This career isn’t what half my peers are anticipating. It’s too grueling to be a “job”. Indeed, the obstacles to being a doctor are not there to deter you; they’re necessary. You really really have to be committed. I still am.
  4. Perhaps the most poignant lesson: a doctor’s job shouldn’t just be about extending life, but making life worth living and having discussions about that. Dr. Kalanithi calls himself an Ambassador for Death.
  5. Have a life outside of medicine, or it will consume you, as it did Kalanithi’s friend.

I had previously read that extending life is important, while also making sure that the patient’s desires are heard. There’s a fine balance there that’s quite difficult to achieve, especially if communication is impaired (from damage to critical speech and understanding areas in the brain).

In the first book I had read, it was mentioned that being honest with the patient was ideal, but this book incorporates another layer to that mentality: it talks about subverting the key words that scare people. At one point in my life, to make some money over the summer, I sold CutCo knives (terrible decision), and what stands out to me is the fact that when selling knives, you don’t say “One-thousand, two-hundred twelve dollars”, you just say “twelve-twelve”. Almost casually. This reminded me of that. Instead of using the term “brain cancer”, you just say “a mass found in the head”. In this way, you are being honest with them. In addition, giving broad ranges for survival is important, as it is honest but also lends hope.

Another huge lesson to me was how to face death itself, and how to tell patients about it. Dr. Kalanithi says that most people say that they would confront death with bravado, or extreme sadness. Kalanithi’s way was very honest, and he tried to keep his life very normal. While it is admirable, it is not the way I would approach it. While I would never be so confident as to say that I would beat cancer, I would certainly approach it like a fight, because that’s the only way I know how. I don’t back down, and I won’t in the face of death either. People will all have very individual responses, and my lesson learned from shadowing is that it’s important to treat everyone the same so you don’t let internal biases get in the way. That’s something I will have to consider when dealing with patients, assuming that I even make it to that stage.

(Fun fact: Brave New World was referenced in this book! Heck Yes!)

 

 

Brave New World, by Aldous Huxley

At the behest of one of my high school English teachers, who has become a great friend, I began reading Aldous Huxley’s Brave New World. I was warned that this was going to be a strange book, and it most definitely was. The story followed a “defective” human born into dystopian England, where everything is highly controlled and individuality is crushed for the greater good. True emotions don’t exist, and so this human, named Bernard, finds it increasingly difficult to feel at home in society. Rampant sexual promiscuity and immense conditioning mean that people are almost always satisfied, even if artificially. Eventually, Bernard brings back a “savage” from New Mexico after vacation there, who proceeds to disrupt the order after increasing alienation. This tension culminates in his suicide, as his individuality and his restraints against merging into the crowd of uniformity both break down, breaking him down in the process.

What is interesting is that this shatters the archetypal antagonist role, as the World Controller responsible for this dystopia is revealed to be a sympathetic, yet unyielding personality. He is accepting, even encouraging of science, and believes in God. However, discussion of both of these topics is quashed for the sake of universal contentment, as he believes that these concepts cause passion, which results in instability and the degradation of the orderly society. As the introduction put it, it would introduce entropy into a system with none of it.

Another interesting concept that I’ve been taught to look for in high school is the concept of complexity, where binary opposites are broken down. Here, the savage brought over from New Mexico happens to be the son of a key figurehead in this dystopia, indicating that the lines between “civilization” and “savagery” are not so taut. In addition, this savage, named John, is in quite the dilemma. Although he was physically roughhoused in “savage” New Mexico, retention of his individuality and the ability to access books enabled him to feel comfortable where others wouldn’t expect it. While he was admired (superficially) in London, and his physical being was never compromised (by the people around him, of course), he couldn’t stand the inability to access knowledge, and the deprivation of the right to experience real emotions. In this civilized society, he feels especially out of place, and less than comfortable. This further blurs the lines, and also reinforces a concept I’ve learned from my urban planning course, and my experiences with a resilient grandmother in India: that what Westerners universally believe to be paradise and ideal isn’t necessary or desirable for other parts of the world.

A huge part of the repression stems from access to soma, a hallucinogenic drug that sends the users into a perpetual state of satisfaction and bliss. This drug is distributed as currency and used for leisure, and also serves as an antidepressant in low doses. As such, it serves to tame the more aggressive impulses of humans (which already have been suppressed at the embryonic stage), and it largely responsible for the uniformity and low levels of rebelliousness found in society. The drug mimics a modern-day epidemic, such as those with opioids, as addictions build and withdrawal seems to be incredibly difficult. The concept of suppressing a mass with this kind of drug is reminiscent of the introduction of crack and other such drugs into Chicago and other cities, almost as a way of quelling resistance from those communities and ensuring that improving socioeconomic status is halted. In this way, while this book was meant to reflect the society of the 1940’s, it reflects problems that we see today, as Huxley was known to incorporate ideas of the time (such as Ford’s recently established transcontinental factories, and the Mullerian discovery of cancer-inducing X-rays) into his novels for impact. This book was incredibly strange, and did not leave me with a sense of satisfaction. However, it presented a vast set of ideas that have left me much to reflect on, and whether happiness is truly better than overcoming tragedy in places that cannot afford to deal with hardships as of yet.

The Emperor of All Maladies, by Siddhartha Mukherjee

My previous book review talked about medical ethics in a fictional case. It introduced me to the question of whether orthodoxy is something that can be adhered to when it seems to be on the sure path to failure. This book brought up some more of those issues, and while it solidified some of my convictions, it cast others into doubt…

The novel I read was The Emperor of All Maladies, by Siddhartha Mukherjee, and it essentially is boiled down to a brief history of cancer. Cancer has always occupied a very strange place in my life. I never knew my grandfather because of it (more on this later), I lost a cherished great-uncle because of it, and have seen it affect people all around me. Because of the ubiquitous nature of cancer, I relegated it to the status quo, and never paused to think about what happened in the background, or what the history was.

Admittedly, I was skeptical of cancer research prior to reading this book. I knew millions went into research, I volunteered at the James Cancer Hospital, and I never saw a decline in the number of patients, or any definitive proof that this was working. If you’ve seen Interstellar, you can relate to this notion of a false hope. The thought of seeing so many people be so cheerful for Buckeyethon, only to realize that money may sink into ordinary pipet tips, salaries, and nothing of guaranteed significance was a disgusting thought for me.

This book gave me a new perspective on cancer research. I realized that we while we aren’t churning out immediate cures, we are still relatively infantile in this combat. In that way, our progress has been astounding. However, even these basic concepts are double-edged swords. The fact that there is so much yet to learn means that claims that the cure for cancer is near are not only false, but morally wrong. In addition, the progress that I claimed as astounding has come at the cost of thousands of human and animal lives. The book told me how many failed trials occurred, how many people died or had their lives compromised from poor treatments. Galen’s theory of black bile set progress back hundreds of years, while Halsted’s radical mastectomy left women left devoid of breasts and other critical body parts. The concept of multidrug chemotherapy that pushed the body to its limits is especially daunting, as that’s what I realized killed my grandfather.

When I was very young, I never understood what it meant to go to my grandparent’s house. This was because my grandmother refused to leave India, and my grandfather had passed away. I asked my mother what happened, why he wasn’t with us. She told me a lot of dubious information that I may have been able to reconcile with this book.

Essentially, my grandfather was a civil engineer, working on structures and dams. He was exposed to the burning Indian sun for long periods of time, along with poor working conditions at the sites that he had to visit. He also had enemies because of the wealth he acquired, and was once poisoned by a competitor with some unknown substance. Eventually, he was diagnosed with a “blood cancer” that claimed his life quickly. He was administered to one of the best hospitals in India (one of the most Western), yet died because “he was given the wrong drug”.

This concept was the birth of a hatred for India. I was Indian, but throughout my life, had never felt the source of pride that one does with nationality. After all, how could someone claim that India is advanced when it “administers the wrong drug”? This permeated into every aspect of my life, from my interactions with native people (initially with a spiteful tone) along with a rejection of my own culture. I hated every aspect of it. Relatively recently, I forgave the hospital and forgave those who I had wrongfully blamed, but I didn’t realize that they had just committed the crime that was already present in “idealized” Western culture: multidrug chemotherapy, the agents that pushed my once stern grandfather to the limit. The agents that were used at this Westernized hospital as the pinnacle of cancer therapy. The untested multidrug chemotherapy that was proven to be only occasionally helpful, and often hastily administered. This book let me recognize one of the biggest mysteries of my life by informing me of the history, and letting me probe into and realize what actually had happened.

Medical ethics are again brought up, but this time in a more deeply personal manner. It seems to always whittle down to “orthodoxy” vs “unorthodoxy”, but now it gets deeper. It deals with large institutions vs small institutions, and, if I am to reference my previous review, big business vs the morally sound few. The novel brings up a few prominent cases where my beliefs were called into question. I had believed that big institutions and regulations were necessary, especially after incidents of fraud, along with horribly conducted and unauthorized trials. But eventually, the Herceptin fiasco with Genentech, and the FDA’s refusal to approve Herceptin for general use because of its “experimental” label, told me that sometimes too much institutional involvement can stall some really important treatment options.

In addition, the focus was brought up by Dr. Mukherjee that the extension of life needs to be considered, as opposed to the elimination of death. The focus on humanity and not numbers was referenced in my first review by Dr. Kubler-Ross, and she mentioned that when people died, they often died unhappily. In the olden days, hospice and comfort were emphasized, and now numbers and artificial measures are more important. This could be because of our innate inability to face the concept of death. This is an important concept, because failing to keep humanity in medicine means that frenzied doctors with supposed cures run rampant, and the fate of my grandfather befalls other people.

I would like to close off with some thoughts about the James again. Dr. Mukherjee mentioned that it’s unlikely that cancer will ever be cured. This is something I had believed as well. When thinking on this concept, and reflecting upon the James, one cannot help but believe that the James and everything it stands for is a massive monument of failure. A monument of humanity’s futile attempt to stave off death, and the countless resources poured in vain. This is quite the depressing thought, and brings to mind the history of cancer research, where false hope was circulated only for everything to come crashing down. Why is the James different?

Dr. Mukherjee explains that we can redefine victory as extending lifetimes to the norm. A cancer patient living as long as a healthy individual would be a way to define victory. In that sense, all that needs to be changed is the rhetoric. Instead of claiming to cure cancer, we must focus on outliving it, tending to it, and using the James to increase length of life. If we do that, I do believe things will turn out all right.

 

The Citadel, by AJ Cronin

Before I begin discussion about this novel, The Citadel, I would like to introduce how I even thought to do this. I was meandering through Snapchat when I stumbled upon The Met Gala. I was fascinated by the outfits people were wearing, and strictly for comedic purposes, I began looking through. Well, the videos showed a picture of a Donatella Versace, and then it dawned on me that these designer brands were family businesses (a little late to realize this obvious concept, but hey, better late than never). I googled Versace, and naturally the rivalry with Giorgio Armani came up. I then read about Armani, and found out that he almost became a doctor because of this book. Indeed, this book is seen as the impetus for the National Health Service in Britain. Already, there are two monumental impacts as a result of this one novel. Armani may never have been a fashion mogul, and Britain’s healthcare would be in total shambles (The NHS is already struggling a bit, but at least it exists). So, I decided to read this book.

The novel follows the tale of Andrew Manson, a fresh-faced doctor from Scotland, who arrives in a Welsh mining town in order to pay off his loans. He initially begins work as an assistant, and earns a meager salary. However, this is good enough for him, and he works diligently and dutifully for the townspeople.

SPOILERS AHEAD, DO NOT READ ON IF YOU INTEND TO READ THIS BOOK

Manson is a fairly hot-blooded individual, and throughout his time in the Welsh town, he begins to question everything he ever learned in medical school, and its applicability. He even uses dynamite to blow up an unhealthy sewer because he’s realized that it is the source of the typhoid epidemic in his town (which is completely illegal, but ends up working).

I was hooked at this point, because I can relate to Manson. Getting good grades in high school and college did not immediately transfer to job skills. I struggled in the research lab at the beginning, and to be honest, am still finding it difficult to be a good researcher. It’s part of a learning curve, but the feeling of ineptitude is something we share. Manson, however, always make the moral decision, and is a strong advocate for honest medical practices and fairness. This is in stark contrast with other people in the profession, who are either corrupt or outdated, and therefore dangerous. Adhering to his ideals is difficult for Manson as the book continues. Being a good person often means that he makes less money than other people who lie in order to get more medical visits. While that isn’t a concern for me, what did shock me was that Manson’s attempt to expose the system brought him many enemies who tried to dispose him from the profession.

While part of my decision to choose the medical profession stems from financial stability, it is only in the sense that I want a job that is respected, and therefore, constantly in demand. I’ve seen what unemployment has done, even to my immediate family, and the shifting jobs and constant change can cause extraordinary stress that I wish to avoid. I only wish for stability of job, and something that is not easily replaced. The fact that honest practices earn less money isn’t the concern for me, because that’s fine so long as the job is stable. What concerns me is the threat to his employment. Another concern is the fact that unorthodox and illegal treatments (illegal because they are not approved yet, as opposed to having detrimental effect or no merit) results in the doctor being ostracized, even if it works.

The issue of doing something that is legal but won’t work, as opposed to illegality that works is something I still have to tussle with. Without a doubt, this is a case-by-case situation, but this is the eternal question applied to the medical profession: do the ends justify the means? I have yet to come up with an answer, and in the novel (no doubt for literary purposes), Andrew comes out of his court hearing for illegal but effective actions as innocent. However, in today’s society, no such guarantee exists, and therefore I will have to ask practitioners about how they do such things.

This was a highly enjoyable book to kick of the 2018 summer, and I hope to add many more concepts to help shape my view of medicine.

 

My Summer 2018

This summer, I made it a goal to improve myself  as a well-rounded person. As such, I began taking an Edx Online Class in Urban Planning. I’ve learned several interesting bits of information, and a few stood out to me and made me think about what I was doing:

  1. The heterogeneity of slums within the same city. The first step towards global awareness is the realization that others don’t have it as well as you do. My mistake, prior to taking this class, was believing that this was the only necessary realization. I learned from this class that others don’t have it as well as you do in different ways from each other and different from what you anticipated. For example, one of the modules mentioned that two slums in a city, one in the inner city and another near the outside, may respond differently and have different kinds of poverty. In the inner slums, where migrants stay and leave, and where jobs and opportunity are, social networks are weak (because everyone needs to be cut-throat and people are leaving all the time). This amounts to a social poverty. In outer slums, people are even worse off due to distance from jobs and opportunities, but thrive on social connections with each other to maintain an adequate standard of living.
  2. The concept of diversity. When I was writing my essay for Morrill Scholars in during my senior year, I related the ethnic diversity that I experienced growing up where I did. I was surprised when I did not get the Scholarship, because the ethnic diversity in my school had shaped me, and the fact that I couldn’t relay that meant a flaw on my part. I knew there were different kinds of diversity at that time, but I chose to focus on ethnic diversity. I learned from this course that even the simple act of ignoring other kinds of diversity can have far-reaching ramifications. For example, in Toronto, the idea of diversity is lauded and praised. However, this is strictly with regards to “economic-boosting” diversity. There are people who suffer from mental disabilities, or people without homes who can be factored into the diversity argument in terms of socioeconomic diversity, yet because they are seen as a burden to the city, they are often found on the outskirts, away from the mainstream, and are ignored in favor of “ethnic diversity”.
  3. It’s important not to become a victim of the fleeting nature of news stories. There was a time period where Syrian refugees settling in other countries was the focus of the news. However, that isn’t covered as much despite the persistence of the problem. This course introduced as a model the Za’atari camp in Jordan, which formed as a result of the Syrian exodus, yet is now growing into a permanent settlement. Had I been asked prior to this course, but still recently, about how living conditions were in this camp, I would have presumed tents and rations. However, these tents have been converted to cabins over the last few years, and a happier life seems to have been attained beyond mere rations. Referencing the first point, it’s not enough to recognize that the world is complex. It’s essential to dig into the “nitty-gritty” of that complexity, because then you shave off another layer of ignorance.