It looked like infectious diseases were conquered

Writing in the heady days of new antibiotics and immunizations, esteemed microbiologists Macfarlane Burnet and David White predicted in 1972 that “the most likely forecast about the future of infectious diseases is that it will be very dull.”¹ They acknowledged that there was always a risk of “some wholly unexpected emergence of a new and dangerous infectious disease, but nothing of the sort has marked the last fifty years.” Epidemics, it seemed, were of interest only to historians.

David S. Jones, History in a Crisis—Lessons for Covid-19, New Eng. J. Med. (April 30, 2020) (quoting Macfarlane Burnet & David O. White, Natural History of Infectious Disease, 4th ed. (Cambridge, UK: Cambridge University Press, 1972)

How many med mal practice plaintiffs win, do you think?

Once malpractice cases go to trial, only about 2 to 5 percent result in verdicts against physicians . . . .

James B. Lieber, Killer Care: How Medical Error Became America's Third Largest Cause of Death, and What Can Be Done About It (New York: OR Books, 2015), Introduction.

Keep learning!

Let me advise you to pursue the same course through life, recollecting that, even as practitioners, you must still be students. Knowledge is endless, and the most experienced person will find that he has still much to learn.

Sir Benjamin Collins Brodie, speech to students at St. George's Hospital, London, in 1850, quoted in Bill Hayes, The Anatomist: A True Story of Gray's Anatomy (New York: Ballantine Books, 2008), ch. 5 (citing The Works of Sir Benjamin Collins Brodie, vol. 1 (London: Longman et al., 1865)).

Americans' haze about medicine

For most of the twentieth century, Americans lived in a Norman Rockwell, Marcus Welby haze about medicine. Doctors were wise and respected. Hospitals were though to be clean, quiet, safe, and well-equipped, well-intentioned charitable organizations. No one expected to be the victim of an error.

James B. Lieber, Killer Care: How Medical Error Became America's Third Largest Cause of Death, and What Can Be Done About It (New York: OR Books, 2015), Introduction.

No getting around it: death is hard

We cannot remove the pain of loss. Death—whether of patients or of loved ones—will always be difficult. We can create reforms, we can institute policy changes, and we can even write books. But our professional fear and aversion to dying is the most difficult—and most fundamentally human—obstacle in changing end-of-life care. Our grief is the price we pay for caring for the terminally ill, and our aversion is the weight that anchors our inertia and denia.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), Epilogue

Not all journals grab the same readers

I always enjoyed stopping by this doctor’s desk because he had a passion for forensics, and the academic journals he collected featured articles like "Heroin Fatality Due to Penile Injection," and "Sudden Death After a Cold Drink." Compared to those titles, "Apoptosis in Nontumorous and Neoplastic Human Pituitaries: Expression of the Bcl-2 Family of Proteins" didn’t stand a chance of holding my attention. Wouldn’t you rather read "Suicide by Pipe Bomb: A Case Report"? I would—and I did.

Judy Melinek, M.D. & T.J. Mitchell, Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner (New York: Scribner: 2014), p. 15.

Live long enough, you'll get creaky joints

She also lacked osteoarthritic lipping, the buildup of jagged ridges of bony material along the edges of vertebrae and other joint surfaces. As we age, we all tend to develop some degree of osteoarthritic lipping; it's sort of the skeleton's version of the mineral deposits that gradually clog a house's water lines. Osteoarthritic lipping is a major contributor to the aching joints that plague the elderly. Whenever I show slides of severe osteoarthritic lipping, someone always asks if there's any way to prevent it. "Of course there is!" I exclaim. "Die young!"

Dr. Bill Bass & Jon Jefferson, Beyond the Body Farm: A Legendary Bone Detective Explores Murders, Mysteries, and the Revolution in Forensic Science (New York: HarperCollins, 2007), p.

Bad news, over and over again

The common thread running through our professional world is disease, and many of our conversations inevitably converge on "bad news." They may begin with an initial diagnosis, but those diseases can become catastrophic or just sputter along in a continuous decline until death. We doctors must be there every step of the way. Bad news thus occurs not just once but over and over again.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), ch.8

Scent of a resident

I learned that exhaustion leaves its own olfactory imprint. The white coats of residents who had been up through the night had an acrid, stale odor—the smell of dirtied polyester, sweat-stained cotton, and human flesh trapped too long away from sunlight and normal circadian rhythms. I could recognize my exhausted colleagues with my eyes closed.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), ch. 8

Sacks learns from patients

I find every patient I see, everywhere, vividly alive, interesting and rewarding; I have never seen a patient who didn't teach me something new, or stir in me new feelings and new trains of thought; and I think that those who are with me in these situations share in, and contribute to this sense of adventure. (I regard all neurology, everything, as a sort of adventure!)

Oliver Sacks, On the Move: A Life (New York: Alfred A. Knopf, 2015) (letter to a medical student who had asked to study with Sacks)

A Note-Taking Prize?

I find the idea of a Note-Taking Prize enormously appealing. Were UCSF to resurrect it, I have no doubt the winner would be Ming, a pharmacy student I've gotten to know over the past couple of months. Her notes make mine look feeble, although, granted, our styles differ greatly. During the minilectures in lab, I simply jot words and phrases onto a small pad that fits into my scrubs shirt pocket while Ming records sentence after sentence on sheets of graph paper in tiny, perfect print. She uses a four-color Bic pen, the kind I have not seen since junior high—red ink for notes on blood vessels, black for nerves, green for muscles, blue for organs—clicking from one to another with barely a glance up.

It was over the topic of note taking, in fact, that Ming and I bonded during one of the first labs. I happened to be standing next to her and saw her in action.

"Those notes are beautiful," I said in all sincerity in a pause between her clicks.

"Oh, these are just rough," she replied, and not out of false modesty. Ming planned to rewrite them once she got home, combining her lecure and lab notes and supplementing them with snippets from the textbook. She would then transfer those to a three-ring binder, color-coded by course subject. Now that's my kind of obsessiveness.

Bill Hayes, The Anatomist: A True Story of Gray's Anatomy (New York: Ballantine Books, 2008), ch. 5. (This passage comes after a discussion of a speech by Sir Benjamin Brodie to medical students in 1850 in which he emphasized the importance of good note-taking and says that he awards a prize each year to the student with the "best series of clinical notes.")

Best treatment in 17th century? Prayer

[O]n Henry's second Sabbath, the infant appeared to slip away. Samuel knew from experience that his best option now was prayer. A seventeenth-century doctor could do little or nothing for a seriously ill newborn. Boston had few physicians, and those few men who had come from England with university degrees in "Physic"—the study of the ancient writings of Hippocrates, Aristotle, and Galen—could offer no effective treatments for most illnesses the Sewalls faced: smallpox, influenza, other viruses, and dysentery. Prevailing treatments included bleedings, purgings, the ingestion of concoctions of lavender and other herbs or oil of amber, and for a sore throat the application of the inside of a crushed swallow's nest. The medical profession in its modern sense did not exist.

Samuel was desperate. He wrote notes to the Reverends Samuel Willard and Joshua Moody . . . asking for public and private prayers. A servant raced to deliver the notes. 

Eve LaPlante, Salem Witch Judge: The Life and Repentance of Samuel Sewall (New York: HarperCollins e-books: 2007), p.  17

Dying can be full of potential

Perhaps all those scientific advancements have given us more than the panoply of treatments and longer life expectancies; they have created an impetus to reappraise how we live. By accepting the reality of dying rather than the misconception, we paradoxically give ourselves the luxury of time. The process of dying can be cast as full of potential rather than as devoid of any final opportunities. There is a chance for real interpersonal reconciliation and emotional expression rather than the hasty symbolic gesture of aggressive treatment.

It is this opportunity, then, and not necessarily the hope of cure, that is the final gift of the medical revolution of the last century.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), ch. 7

Predicting death

We have no reliable way of ascertaining when someone will die. Even with the best medical predictors—physician assessments and statistics—there is often a huge gap between perceived dying and the actual imminence of death.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), ch. 7

Doctors watch people

Doctors—like writers, artists, and spies—are professional people-watchers. More specifically, a doctor's work relies on the ability to discern, among thousands of biological cues, the underlying pathology. It is a skill that is part art, part science; and the more we can see, and sense, and sort, the better our care.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), ch. 6

Surgeon torn between human emotions and professional duties

I want to cry for those in whose bellies I find disseminated tumors, but cannot for fear of being unable to see clearly enough to sew them closed. I want to sit and linger with my patients, but know that such inefficiency would never work in the clinical world. I want to be able to soothe my patients' suffering without the burden of knowing the inexorable future course of their diseases.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), ch. 6

Deconstructing patients

We dismantle people as art experts deconstruct paintings. Instead of seeing families gathered by the lake of a park or the stars in the sky, we see the purple and pink dots, the gray shading, and the yellow highlights.

Eventually we apply these skills not just to diagnosing but also to interpreting everything in our clinical world. Deconstruction becomes our professional tool of understanding, and we rely on it to absorb increasingly complicated clinical problems. A patient in multisystem organ failure, when reduced to bodily systems—neurologic, pulmonary, cardiac, and so on—becomes manageable for even the most junior of residents. . . .

In the course of my training, I actually came to enjoy this deconstructing. It was mentally satisfying, like taking a box of jumbled puzzle pieces, organizing the, then arranging them into a perfect picture. The only problem was that I could not stop doing it. I did it almost constantly at work and then would find myself still doing it during my time off. I saw people in the grocery store or at restaurants, and my eyes would fixate on the loping gait, the barrel chest, or the finely wrinkled skin. Stroke, emphysema, big-time smoker, I would think. It was strangely thrilling, the way having X-ray vision might be.

Then one day my Aunt Grace, my mother's younger sister, asked me for some medical advice. . . .

. . .

The skill that had once simplified my life now left me very much alone, and the profession that had once promised the power of cure now made me utterly helpless.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), ch. 6
 

M and M as death ritual

Our fingers, no matter how nimble and graceful, are always tangled up with the fate of our patients, and when one of those patients dies, it is impossible to divest ourselves of that sense of responsibility. We torment ourselves with the what-ifs. Perhaps, if we had put that stitch in just a little differently or removed that cancer a little higher up or worked a little longer, then maybe our patient's course might have been different.

. . . M and M requires a public accounting of loss and, in so requires a public accounting of loss and, in so doing, reconstructs the death into an event that affirms a core value of our professional identity: the need to be infallible in a highly variable world. In this way, M and M is like death rituals in other cultures; it seeks to transform death's loss into an affirmative experience.

. . .

By defining death only as the result of errors, we erase the face of our patients and insert our own fiercely optimistic version of immortality.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), pp. 118-19.

A surgeon starts to write

Soon after that procurement [of organs from a young woman], I began to write stories. Not much, for when faced with a decision between eating and sleeping for the first time in seventy-two hours or writing, the primal needs won out every time. But when I finished my training a year later, fortified with the relatively regular meals and sleep of an attending surgeon, I began to write with some consistency. To my surprise, the writing seemed to pour out from a locked-up data bank within, oftentimes in unmitigated, logorrheic, and exhausting bursts. And the fictional stories I thought I was creating were almost always thinly veiled narratives about my patients, many of whom had passed away sometime in the last decade.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), ch. 9

The down side of more humane resident hours

While residents these days do spend less time in the hospital than those who trained even a decade ago, the change has had some unpredictable repercussions. The increased "free time" has left residents with less time to form bonds with their patients. The pressure now is to squeeze as much experience as possible into the time limitations, usually at the expense of patient relationships. The transient physician-patient relationships of residency have only become more fleeting.

Pauline W. Chen, Final Exam: A Surgeon's Reflections on Mortality  (New York: Alfred A. Knopf, 2007), ch. 8