When Breath Becomes Air by Paul Kalanithi - A Scrub Notes Book Review

"When Breath Becomes Air" is a memoir written by neurosurgeon Paul Kalanithi. The book is a poignant look at the human spirit in both the pursuit of excellence as well as in coming to terms with its own impermanence.

Kalanithi was a Stanford neurosurgery resident when he found himself becoming fatigued, with worsening pain and decreasing weight. A routine chest x-ray discovered multiple lung masses, which were soon proven to be metastatic lung cancer. The book was borne of Kalanithi's other passion, literature, as well as his unfortunately unique perspective as both a healer and now a patient at a time when he was poised to be at the peak of his talents.

The first half of the book details Kalanithi's upbringing and path into medicine. His first love was literature, which he pursued all the way to a master's degree. However, upon further reflection, he felt a desire to pursue medicine after grappling with the question of the intersection of "biology, morality, literature, and philosophy." Since he had initially pursued literature, Kalanithi took two more years to complete the pre-med requirements and then apply to medical school. Accepted at Stanford, he was a fast rising star in the neurosurgery world, despite grueling 100 hour weeks year after year.

The diagnosis, coming near the end of his training, shatters Paul's identity. After striving for close to a decade to become an attending neurosurgeon, his diagnosis is his undoing. He rapidly transitions from physician to patient, and has to learn to let go, to trust in others to have his best interests at heart. The book shows how he meditates that cancer in particular is pernicious in that it makes one mortality both immediate and yet still remote: no longer a hypothetical, but not an immediate reality. Everyone has an answer to what one would do with their last day, but what about one's last decade?

Kalanithi then details the long road back to completing his training, the successes and failures of his treatment, and how he learned to live and ultimately succumb to his fate on his own terms. He died in 2015, leaving behind his wife Lucy and their newborn daughter.

For me, the last part of the book was the most moving, an epilogue written by Lucy about Paul's last days. She charts the uncertainty of his final hours and how he was resilient even while facing the unknown. His final wish was that they see the book to fruition, in which they clearly succeeded.

The book reads like what one would expect of a memoir of a first-time author, but Kalanithi's first rate intellect shines throughout. Even though he never uses the label, it is clear that Kalanithi was a humanist at heart. He does touch upon his wavering relationship with religion. For a reader who questions both their path in healthcare or wants a glimpse of how even the best laid paths can abound with uncertainty, "When Breath Becomes Air" will not disappoint.

Applying Behavioral Economics to Patient Care

Psychologist Daniel Kahneman, along with his frequent collaborator Amos Tversky, are the fathers of the field of behavioral economics. Kahneman was awarded Nobel Memorial Prize in Economic Sciences in 2002 for his work (Tversky was deceased, and thus not eligible). To bring his work to a broader audience, he published "Thinking, Fast and Slow" in 2011:

The basic premise of the book is that our brains actually function via two systems, which he terms System 1 and System 2. System 1 is instinctive, utilizing heuristics to make decisions quickly. A heuristic is a 'rule of thumb', a device to boil down complex information to a simple choice. In other words, it acts as an approximation, that is usually 'good enough' for the situation at hand. System 2 is calculating and rational; it functions more like a computer, coolly processing inputs and trying to generate the optimal decision as an output.

Kahneman's work points out the biases inherent to both of these systems. His most famous result may be prospect theory, which basically shows that humans do not value incremental changes in probability equally, and that they are susceptible to whether those changes are framed as gains or losses. Another big point that Kahneman makes is that our "selves" really consist of two separate entities: our experiencing selves, and our remembered selves. For example, think about a strenous hike or other physical activity you did. In the moment, your experiencing self may be in agony from the stress and pain; however, your remembering self may view it as a very cherished memory because of the overall payoff.

What does this have to do with medicine? Everything! Both patients and doctors suffer from these biases. While the biases are part of being human, that does not mean we should simply accept making poorer decisions because of them. As a physician, here are some things you can do to mitigate these biases from how you decide.

Gathering A History

When you first meet a patient, you will necessarily have to make an initial assessment. That 'subjective' portion, the S in SOAP note, is the lynch pin for the rest of your encounter. If you have bad information, you will order the wrong exams, make the wrong diagnosis, and implement the wrong plan.

Garbage in, garbage out.

Therefore, getting a precise history is critical. However, to do this, you must combat both your own biases and the patient's. The big one to combat here is recall bias. For example, patients with a history of cancer who present with abdominal are more likely to over-emphasize or recall factors that may suggest a mass as the underlying cause of their pain. Do not disregard this history, but do try to correlate it with objective data, such as a CBC to check for anemia, or imaging.


Ordering Tests

The explosion in objective data one can acquire on a patient has been a major boon to healthcare. However, there is a downside to such tests. This bias is on the provider's side. Whether it is an anchoring/recall bias (the last patient with shortness of breath had a pulmonary embolism, so now every future patient with SOB has a PE) or satisfaction of search (one abnormal test result precluding ordering other relevant tests), these biases can lead to either the under- or over-utilization of appropriate testing modalities.

One way to guard against this is to understand treatment algorithms at great length. While there is a tendency to avoid 'algorithmic thinking' in medicine, the notion is often misapplied. One can go beyond algorithms only after they have fully mastered them, and can confidently assess that the current patient does not fit the algorithm. This is a wholly different matter from simply ignoring an algorithm altogether.


Making a Plan

Finally, once all the history and data have been gathered, and an assessment, it is time to come up with a treatment plan. As Kahneman's book title implies, this is a good time to think slowly. Have all the patient's problems been addressed? Does every abnormal lab value have either an explanation or a plan to address it? A good treatment plan will also include some way to assess its own effectiveness, whether that is by scheduling a follow up exam or test, or some other objective measure. A plan without follow up is simply wishful thinking.

Ultimately, the practice of medicine is a human practice, subject to human biases. However, as our understanding of these biases advances, it behooves us to mitigate these biases to the best of our abilities. If we are to do no harm, we must ensure that we unblind ourselves to the harm our biases may cause.

Being Mortal by Atul Gawande - A Scrub Notes Review

As long time readers of this blog (hi MJB!) likely know, Atul Gawande is quite popular around here. The general / endocrine surgeon at Brigham and Women's Hospital is also a well known contributor to The New Yorker and author of four books. His latest book is Being Mortal: Medicine and What Matters in the End.

Like his other books, this work is a mix of his previous pieces for the New Yorker as well as original writing. Gawande tackles an issue oft overlooked in his prior works and within medicine at large: what to do when medicine has no more to offer. The book unfolds by describing what occurs when medicine (and healthcare in general, including non-physician providers / caregivers) try to go beyond their limitations and fit patients to their models of care, instead of trying to shape care around patients. Anecdote by anecdote, Gawande describes patients, friends, and family members and their struggles with the healthcare-industrial complex. The overall tapestry is one of failure: the system did not work for these patients.

And how could it? The healthcare system is a Frankenstein collection of parts that has been optimized to fix simple, close-ended problems. The ear infection, the ruptured appendix, even the small breast cancer - all of these are easily tackled by the healthcare system. Where we stumble is when we attempt to shoehorn patients with complex or chronic problems into this model of one-and-done care. It simply does not work, and can often do as much harm as good.

In Being Mortal, Gawande attempts to show how in certain corners of the country, patients and providers are pushing back. From Oregon to Boston, initiatives have developed that attempt to create better environments for patients to live and to heal, without sacrificing overall outcomes. Surprisingly, in some cases, patients do better with less than with more care.

If one is to quibble with this book, it is that Gawande neglects to provide enough concrete, actionable advice about what to do regarding the issues he raises. For a general audience, he does not spend sufficient time discussing concepts like durable power of attorney, living wills, DNR/DNI orders, or even how to learn more about it. Gawande spends a chapter detailing his own trip down one flight of stairs to the geriatric center beneath his clinic and what he learned, but most of his readers are unlikely to have such easy access to a place like that. Admittedly, that is not the point of the book as it is not meant to be a self-help book about chronic health, geriatric, or end of life issues. Still, for a book that hopes to effect change, an appendix pointing out where one can learn more would have been nice.

Overall, the book is a worthwhile read for anyone who is elderly, is responsible for an elderly person, or cares for an elderly person. In other words, everyone should read this book. It is not a light-hearted read, but it is something better: an important read. While the ultimate outcome cannot be avoided, we can control how we prepare ourselves and each other for it, and in the process, live better, more fulfilling lives.

Other Books By Atul Gawande:

 

Previous Scrub Notes Reviews:

• Atul Gawande: The Man Behind "Complications"
• Atul Gawande and "Better" - A Medical Student's Review
• Does "The Checklist Manifesto" Apply to Medical Students? 

In Stitches: A Book Review

The pun in the title of In Stitches by Anthony Youn, MD is the first big clue to the tone and content of this light-hearted book about the medical and life education of Dr. Youn. The book describes how Dr. Youn grew up in the U.S. as a bit of an outcast but fashioned a career as a plastic surgeon out of his experiences. The book has two main threads essentially running parallel: Tony's development from boy to man, and Dr. Youn's emergence from student to physician. In many ways, the dichotomy is something all medical students struggle with to some degree, given the degree of commitment this profession requires.

The first act of the book focuses on Dr. Youn's upbringing. Born to two hard-working Korean parents growing up in small town Michigan with his brother. His father early on instills in him the importance of dedication and sets a career goal of becoming a physician. His father had grown up in difficult conditions, but through perseverance, had thrived, running a successful OB/GYN practice in the town the family settled in. In many ways, Dr. Youn's recounting of his youth is a realistic retelling of the "American Dream", warts and all. While the net result is success, it does not come without sacrifice and struggle. There is a bit of a lull as Dr. Youn describes his high school and college (mis?)adventures. There was a bit too much of teenage awkwardness for my tastes, without tying back to the other thread of the development of Dr. Youn.

The pace picks up as Dr. Youn enters medical school and begins to form the relationships that will in turn make him the physician he is destined to be. There is still a bit of the hijinks of his high school year, but the evolution is apparent in the writing. The book's high point comes when Dr. Youn enters the wards as a third year medical student. The story regarding how he handles his first 'difficult' patient is particularly poignant. The vignette embodies what is meant by empathy in medicine. While cliche, such moments show just how 'actions speak louder than words.' While at times, I wished to have more insight on why Dr. Youn chose medicine initially (other than his father's insistence) and how he developed his passion, it is clear from the writing that Dr. Youn cares deeply about his profession.

Ultimately, In Stitches is a wonderful, light-hearted narrative of one person's transformation from outsider to professional. Even for readers not pursuing medicine, the book offers lots of laughs for anyone who has ever felt different.

Updated 2015-12-25

Does 'The Checklist Manifesto' Apply To Medical Students?

This post is long overdue, but I finally got around to reading Atul Gawande's most recent book The Checklist Manifesto: How to Get Things Right. Longtime readers of Scrub Notes are likely aware that I'm a big fan of Gawande's writing. His first book Complications has practically become required reading for pre-med students. His second effort Better continues along the same vein. However, The Checklist Manifesto is Gawande's first major effort to move beyond merely an anecdotal descriptive text on the trials and tribulations of practicing medicine into the area of shaping policy and medical practice. And, to this reader, he makes a fairly convincing argument, utilizing extended examples from diverse fields such as piloting, building construction, and finance.

Gawande's argument primarily targets his fellow surgeons. However, what can medical students learn from his text? Can the humble checklist help a medical student succeed in learning the necessary knowledge to succeed in medical school? I doubt any serious study has been done in this area, but intuitively, the answer is yes. As Gawande suggests, try a checklist.

But, what does trying a checklist mean for a student? The checklist is meant to address a systemic problem, not an individual one. Gawande targets fellow surgeons because they run the ORs: they have primary responsibility for the patient's well-being as well as for insuring that the OR runs well. A trainee like a medical student typically simply plays their assigned role. However, therein lies the problem.

By simply playing an assigned role, the student learns from their environment in a haphazard way. Some ORs meticulously run through time-outs and other preparatory procedures; others perfunctorily mention them or even avoid them except for the most necessary ones. However, the student's responsibility ultimately is to the patient, not to maintaining a culture of complacency that he or she may find herself in. By creating and running through their own mental checklist prior to any patient encounter or procedure, you can ensure that you and your team avoid making unnecessary mistakes that may cause the patient harm. Even if you feel powerless on a team or service, your personal checklist can help ensure that you are doing your utmost to serve the patient. Although this may not be the 'heroic' side of medicine, as Gawande notes, the effects can be profound in terms of safety and patient care.

Beyond patient safety, taking the time to craft a checklist can help you break down a complex procedure into simple steps. As you are learning and practicing the procedure, focusing on these simple steps will make it easier to learn the procedure and learn to do it the right way in a safe manner. Gawande emphasizes this in his subtitle: How To Get Things Right. And that's what any student wants to do: get things right.

 

Updated 2015-12-20

Atul Gawande and "Better" - A Medical Student's Review

As a med student, and one who had recently completed his surgery rotation, I feel I had a relatively unique perspective while reading this book, as compared to most readers. It was also interesting to read this book and gauge my reactions, relative to how I reacted when reading Gawande's prior book Complications. When I read Gawande's first book, I had not yet started medical school, and had at best, an educated lay person's background. I found the stories there intriguing and confirmed my romantic notions of medicine. This book mirrors my own internal evolution to a certain degree. Less romanticized, more practical, it discusses more of the everyday issues in medicine, ones that I see often as a student out on the wards. People do not wash hands as much as they should, the science of efficiency has not been applied to medicine, and the book takes us all to account for that. While medical technology has become remarkably efficient and high-tech, the actual delivery of medicine leaves much to be desired. Anyway, I digress.

The book reads very much like Complications. Gawande presents 12 separate essays about different aspects of healthcare, from the advances in obstetrics to the lack of investment in studying the provision of care to the doctors who are involved with executing prisoners who have been given the death penalty. Unlike Complications though, Gawande injects more of his own personal opinions after a more dispassionate presentation of each subject. The writing is sparse and clear, making it easy to read. Some of the chapters read almost like a medical Profiles in Courage

However, unlike Complications, this book did not leave me feeling as enthralled. Perhaps I have become jaded by medicine, or perhaps the topics of 'improving' medicine are simply not exciting. I think I liked Complications better simply because it dealt with more esoteric issues. While I agree with Gawande that the topics covered in Better are more important and can potentially affect many more people, the cases covered in Complications are simply more intriguing, such as the woman with necrotizing fascitis, or the reporter who sweat too much.

Overall: 9 out of 10 - a good engaging read that covers many important and relevant topics.

Updated 2015-12-06