Category: Medicine

Being Mortal

Cover image for Being Mortal by Atul Gawandeby Atul Gawande

ISBN 978-0-8050-9515-9

“Death, of course, is not a failure. Death is normal. Death may be the enemy, but it is also the natural order of things.”

In 1945, most Americans died at home. By the 1980s that number was down to 17%. Today it is trending back upwards as more people pursue options that allow them to live out their final days in the comfort of their own homes. Doctor and writer Atul Gawande explores how dying became medicalized in the intervening years, as science offered new innovations for beating back disease in the 20th century. Encompassing both the elderly and the terminally ill, Gawande examines how end of life care falls short of providing patients with the best possible quality of life in their final days, instead focusing on what else can be tried to fix the unfixable, and beat back the inevitable. From nursing homes to cancer wards to assisted living facilities to hospice care, Gawande reveals the shortcomings of the institutions we have created for the dying, and asks how we can be better prepared to face the question of mortality with clear eyes and compassion.

Atul Gawande’s previous books Better and The Checklist Manifesto both make it amply clear that he takes continuous professional improvement extremely seriously. In Being Mortal, he examines how society and the medical system can improve the treatment and care of elderly and terminally ill patients. Using the case of his wife’s grandmother, he shows how North American nursing homes commonly fall short, by focusing on safety rather than quality of life. Turning to his own grandfather in India, he shows some of the comparative advantages of multi-generational in-home care, but also highlights the inter-generational conflicts and tensions that can arise from this living situation. In the end, he concludes that both models fall short of providing the elderly with the level of control they need to have over their lives in order to be happy.

Gawande is wary of over-idealizing care provided by children in their homes for their elderly parents. In addition to his own grandfather, he uses the case of Shelley and her father Lou to show the stresses and tensions that this can result in. However, many people feel that this model is the ideal, and it is commonly argued that the decline of children caring for their parents indicates a lack of respect for elders in North American culture that comes from the veneration of youth. But Gawande has a slightly different take. He argues that what is being venerated is not youth, but the independent self, and both nursing homes and living with one’s children degrade that independence which is so central to the North American identity. But this way of thinking offers up a question that has been insufficiently answered: “if independence is what we live for, what do we do when it can no longer be sustained?”

Gawande talks about patients, both his own and those he meets in the course of his research, talking with geratiatricians and hospice care workers. He also draws on examples from his own life. Early in the book, he discusses the situation of his wife’s grandmother, Alice Hobson, who lived independently for many years, but eventually began having falls that made it too dangerous for her to continue living alone. She ultimately ending up in a nursing home she despised. Later, after he has explored the nuances of geriatric and hospice care, Gawande approaches the case of his own father, who was discovered to have a slow-growing tumour in his spine when he was in his seventies. His father’s case shows Gawande putting his new skills to use, but equally demonstrates that life is complicated and unpredictable, and that even with this knowledge, the end of life will not necessarily be ideal. Gawande is offering hope and help, not a magical solution that will make every difficult situation easy.

Being Mortal is a book that is important for young and old alike. For those facing choices about where and how they will live in their last years, Gawande offers food for thought about the different options available. Younger readers will be better prepared to navigate these conversations with their parents. And of course, anyone of any age can find themselves faced with an unexpected illness that catapults them into facing their own mortality sooner than they might have wished or planned. Readers will emerge with a better understanding of the warning signs of decline that can severely limit independence, the factors that most affect satisfaction with elder and hospice care for the patients, and questions to use in discussions with doctors and loved ones.

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You might also like When Breath Becomes Air by Paul Kalanithi

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Black Man in a White Coat

Cover image for Black Man in a White Coat by Damon Tweedyby Damon Tweedy

ISBN 978-1-250-10504-2

“When I started medical school and learned about the adverse health outcomes that afflicted black people, I had assumed these disparities were chiefly due to genetics. To be sure, there are diseases like sickle-cell anemia, lupus, and sarcoidosis, which appear to preferentially target black patients at a biological level. But what had become abundantly clear to me during my years in medical school and as a doctor, however, were the many ways that social and economic factors influence health, and, more than anything else, account for the sickness and suffering that I have seen.”

The son of a working class African-American family from Maryland, in 1996 Damon Tweedy accepted a scholarship to Duke University Medical School. As he began learning about various diseases and conditions, he was soon bombarded by a familiar refrain: “more common in blacks than in whites.” Tweedy initially assumed these problems were genetic vulnerabilities, but his experiences soon led him to realize that social and economic factors were, in most cases, much more significant, and in turn these factors play out “along racial lines.” Initially intent on avoiding drawing any attention to his race, Tweedy instead becomes interested in reducing these disparities.

Tweedy divides his books into three parts, proceeding chronologically, first from his medical training at Duke, onto his internship, and then into his practice as a psychiatrist. Each stage presents new challenges. As a student, one of his professors mistakes him for a maintenance worker come to change the lights in the lecture hall, then tries to pretend that the error never occurred. In medical school, Tweedy must balance the well-being of his black patients against the problems that might be caused if he confronts his superiors. He is relieved, in one case, when the supervising doctor is the one to challenge a white nurse who asserts that a nineteen-year-old black woman who suffered a placental abruption after smoking crack cocaine should be sterilized. Later, in his own practice, he confronts new challenges, such as treating a biracial woman who is afraid of black men because of how her black father treated her white mother.

As a scholarship student, Tweedy starts out with an inferiority complex, afraid that people will think he does not deserve to be in medical school. He fears anything that will draw attention to his race, and cringes at every mention of racial medical statistics. This initial fear tempers somewhat, but it leads to his very cautious and measured approach in this book. Tweedy largely skirts around more controversial topics such as the war on drugs and discriminatory policing, both factors which contribute to the shortening of black lives.

Through a more personal lens, Tweedy also examines his own health problems. He discovered his high blood pressure when he and a classmate were practicing taking vital signs in their first year of medical school. A follow-up visit to the doctor also revealed early signs of kidney failure, prompting Tweedy to rethink his diet and exercise routines. This helps him relate very personally to the difficulty patients have making lifestyle changes for the sake of their health. But while he realizes that his own blood pressure and blood sugar are more important health metrics than his weight, since he remains naturally thin throughout, he doesn’t seem to extend this insight to patients, often remarking on their weight. He also fails to stand up for a black patient who wants to try lifestyle changes before going on blood pressure medication, afraid that he will be considered a racial agitator if he challenges the other doctors.

This book felt particularly relevant at the time of reading, as news went viral of a Delta flight attendant refusing to believe that Tamika Cross, a Texas obstetrician and gynecologist, was a doctor. Tweedy’s experience makes it abundantly clear that there are disparities for black doctors and patients alike, and that they play out in subtle ways throughout the medical system, but add up to a large gap in care. What is less clear is the path forward. The Affordable Care Act is acknowledged as something that may help some patients, but not enough. Nor does Tweedy feel that every black patient needs a black doctor; he more than once trips over his own assumptions about black patients, and encounters skepticism of his credentials among both black and white patients. But his stories provide a window for issues that deserve broader consideration.

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Cover image for When Breath Becomes Air by Paul KalanithiYou might also like When Breath Becomes Air by Paul Kalanithi

When Breath Becomes Air

Cover image for When Breath Becomes Air by Paul Kalanithiby Paul Kalanithi

ISBN 978-1-4104-8785-8

“I was less driven by achievement than by trying to understand, in earnest: what makes human life meaningful? I still felt literature provided the best account of the life of the mind, while neuroscience laid down the most elegant rules of the brain.”

After ten years of medical education, Paul Kalanithi was on the verge of completing his training as a neurosurgeon when he became concerned about his own health. At first he blamed the rigours of residency, but a CT scan soon revealed the worst: cancer in the lungs, spine, and liver. Early in his university career, Kalanithi studied literature, dreaming of a career as a writer, but was driven to medicine by questions about mortality and meaning that he felt could not be answered by literature alone. Suddenly, those questions became urgent and personal, and the only time left to write a book and achieve that dream was now.

Kalanithi’s February 2014 New York Times op-ed “How Long Have I Got Left?” was a viral sensation. Two years later, Kalanithi is dead, but his book, When Breath Becomes Air, has been on the New York Times best-seller list for twenty-nine weeks as of this writing. It sits a few spots above Being Mortal, by fellow Indian-American doctor Atul Gawande, which has been on the list for eighty-one weeks. Clearly the theme of mortality has struck a nerve.

When Breath Becomes Air is both short (280 pages) and fast-paced. One moment Kalanithi and his wife are considering whether or not to get pregnant, and a couple pages later, she is three months along. At no point does he arrive at the moment he decided to start writing the book, though his connection to literature is evident and explored. The style, the sense of rushing, is literally characteristic of the state in which Kalanithi was living; the timeline he had expected suddenly sped up and warped beyond recognition. When Breath Becomes Air is, in a sense, unfinished, derailed by Kalanithi’s rapid decline. But that is an essential component of its truth, of the reality that he faced.

Up front, Kalanithi admits that he and his wife were struggling at the time of his diagnosis. The long hours of medical school and residency—his wife is also a doctor—had taken a toll on their connection. But I was moved by the fact that his illness reconnected them. I didn’t get the sense that Lucy stayed out of obligation, but rather that the diagnosis stripped away everything that had gotten between them over the years. To be honest, Lucy Kalanithi’s epilogue was the part of the book that affected me most. This is, perhaps, unfair. She had time; time to reflect, and time to polish, a luxury her husband did not enjoy.

Kalanithi’s concern with seeking the meaning of life is largely philosophical, and occasionally religious. He is able to approach his death theoretically and intellectually, in a manner that can almost seem cold, even as it is also obviously the fire that drove him into medicine in the first place. After getting two degrees in literature, Kalanithi put off his dream of being a writer to pursue the medical side of this question, imagining a literary career could wait until after he was an established neurosurgeon and researcher. He is idealistic, and even romantic, still finding his voice even as he loses it. When Breath Becomes Air is simultaneously reflective and rushed, because while Kalanithi is concerned with big, deep questions, he was left with little time to ponder them.

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Further reflections on life and death: Mortality by Christopher Hitchens