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"Being Mortal" by Atul GawandeContinuing in our series of recommended reads, the following is a review of "Being Mortal: Medicine and What Matters in the End" by the acclaimed surgeon and writer, Atul Gawande.

Is this really a "must read?"
Not necessarily.

Cool. So who should read it?
You should read it if you, a loved one, or a patient of yours may one day get old, deteriorate, and/or die.

So...basically, we should all read this book?
Basically.

What is the book about?
It's about the process of growing older, suffering from worsening health, what we do for people dealing with morbidity and mortality, and what we could be doing for them. Gawande makes a compelling case arguing that in taking measures to protect ourselves, to give patients what we think they'd (or we'd, or their families would) want, to avoid what would feel like our, or their, failure, to essentially create some order, certainty, and control where there was little, we are actually doing everyone a disservice, and failing at our aims.

What did reading this book stir up in you?
A number of things. To wit:
  • Watching my grandmother grow old, feeble, and increasingly dependent in front of my eyes, after she lived a life in which she cared for everyone and was fiercely self-reliant. She lost her vision completely, and most of her hearing. She became incontinent, paranoid, would lose herself in time and space, and vacillated between anger toward us for perceived mistreatment and depressed about the same, interspersed with periods of lucidity. She outlived all the loved ones in her life and generation, all of whom maintained use of their faculties until the end. She fractured her hip at one point, and her clavicle at another. She furiously engaged in physical therapy because of her fear of becoming bedridden. In the end, I considered her death to be mercy in light of the years she'd suffered. I worried that my father wouldn't be able to let go when she was in the ICU. However, once he realized that her multi-system failure was part of the process of dying, he said to her doctors that she'd never want to be kept alive artificially. We asked that they do so only long enough for her large extended family to assemble and see her off, which we did.
  • I remember as a first year medical student, in the classes in which we learned about humanism in medicine, being taught by a gerontologist. She warned against the tendency to distance ourselves from patients we feel we cannot cure. She talked about feeling the loss of every patient of hers who's died, about taking time to cry for each.
  • Despite these classes, the tradition in medicine, and in my experience is one of paternalism, and the tendency is to feel that we know and can fix everything. The pressure to deny our limitations is tremendous. The tendency to think a good patient is one who does as we say is significant. The kind of medicine and providers Gawande illustrates are the exception, and not the norm.
  • Oncology and neurosurgery are two specialties on which Gawande focuses in this book because of the incidents of suddenly being confronted with one's mortality that those field provide (and provided to the people in his life). I've worked with exemplars of both extremes that Gawande illustrates. I remember oncologists teaching us that a certain malignancy was incurable by currently known treatments, and in the next breath telling the afflicted patients and their families that those treatments would be very effective. Mind you, they weren't lying. They would focus on the possibility of slowing/stopping growth, however remote. They'd speak of success in terms of statistics, in terms of the malignancy being the enemy, and stopping it our goal. They wouldn't mention the nausea, the diarrhea, the inability to swallow, or to enjoy food, the prolonged hospital stay, the bills. No one wanted to think about that, after all. "We have a chance, and we're going to take it," was the message on which they focused.
  • I've worked with neurosurgeons who acted like cowboys, for whom a spinal surgery was the chance to showcase the state of the art, to do work that was considered science fiction a few decades ago, for whom the body was a laboratory and the person the gatekeeper to the laboratory.
  • But I've also worked with compassionate oncologists and neurosurgeons, people who didn't aim to do what they were capable of, but instead to ask what the patient wanted, and to do that. People who started the difficult discussion about quality of life and risks of treatment. People who brought in palliative care at an early stage, and who weren't afraid to admit defeat to cancer.
  • I remember palliative care teams, likely the most inspiring providers with whom I've ever worked. They sat, listened, patiently. They helped patients and families confront and work through the stages of grief. They didn't just provide pain medicine and leave. They negotiated a way for patients to live and die on their terms, and they advocated for patients, even if they had to do so in opposition to their doctors.
  • I thought of a common reactionary rhetorical question classmates would ask after humanism classes: "When your dad needs surgery, are you going to go with the brilliant jerk surgeon or the mediocre nice one?" Gawande quite literally argues against the rhetorical answer, speaking from his own father's experience.
  • I thought of the frequently discussed paradox - that we supposedly rank rather low amongst industrialized countries when it comes health care expenditures per capita, quality of health care, satisfaction with health care, life expectancy, mortality around childbirth, etc. while we pride ourselves for providing services that are the newest, fastest, most expensive and therefore, we feel, the best.
  • I thought of how quick we are to spend thousands of dollars on seemingly futile novel chemotherapeutic agents, and on the last days and hours of life spent in the ICU, but we can't find ways to reduce deaths due to heart disease and diabetes; how someone whose diabetes has led to kidney failure has all of his dialysis treatments paid for in perpetuity, but that same person likely couldn't afford to manage his diabetes so as to prevent kidney failure.
  • I thought about how efforts to compensate doctors for end-of-life discussions with patients were thwarted when a blogger alleged that politicians were trying to create "death panels" that would aim to kill our grandparents in order to cut costs. I wish Gawande got into this, though I suspect he meant to make the book apolitical and optimistic. It's more important to him, and to our country, that we find and follow hope than that we rage against those who've held back progress in this regard.
What impressed you most about Gawande's writing?
His humility. He asks questions of providers, the answers to many of which we've all learned in med school, such as whether hospice care means stopping treatment. In doing so, he doesn't let assumptions go unchallenged, and he is able to glean and pass on wisdom from experts on mortality. He's non-judgmental when discussing other doctors and facilities, as his goal appears to be for all of us to get better at dealing with mortality, and not to criticize and direct blame.

Were there any lines you'd want to highlight?
Plenty:
Pg. 91 - The services [at Park Place, a unique assisted living facility] were, in most ways, identical to the services that nursing homes provide. But here the care providers understood they were entering someone else's home, and that changed the power relations fundamentally. The residents had control over the schedule, the ground rules, the risks they did and didn't want to take.
Pg. 106 - A colleague once told her, Wilson said, "We want autonomy for ourselves and safety for those we love." That remains the main problem and paradox for the frail.
Pg. 160 - "The difference between standard medical care and hospice is not the difference between treating and doing nothing," she explained. The difference was in the priorities. In ordinary medicine, the goal is to extend life. We'll sacrifice the quality of your existence now - by performing surgery, providing chemotherapy, putting you in intensive care - for the chance of gaining time later. Hospice deploys nurses, doctors, chaplains, and social workers to help people with a fatal illness have the fullest possible lives right now.
Pp. 173-4 - We imagine that we can wait until the doctors tell us that there is nothing more they can do. But rarely is there nothing more that doctors can do. They can give toxic drugs of unknown efficacy, operate to try to remove part of the tumor, put in a feeding tube if a person can't eat: there's always something. We want these choices. But that doesn't mean we are eager to make the choices ourselves. Instead, most often, we make no choice at all. We fall back on the default, and the default is: Do Something. Fix Something. Is there any way out of this?

Any concerns about the writing?
I felt it took a while before I really trusted Gawande. At first, it felt as though he was just going to give example after example illustrating very simple points. If you feel that way, give it some time. Before long, you'll be reading of amazing, seemingly fantastical experiments in this field, and you'll see that the patients to whom Gawande introduces you will really drive his points home. I also thought the ending a bit odd, like that of a novel. It was also odd for focusing on his father's story exclusively when the rest of the book wasn't structured in that way. On the plus side, the last scene reminded me of one of my favorite lines in literature - the last line in The Great Gatsby.

What do you think Gawande would want the reader to do after reading this?
  • Discuss goals and dealbreakers in life with your loved ones. Fill out, sign, and share advanced directives.
  • When treating a patient, before insisting on a certain course of action or striving to achieve a goal, ask yourself, "About whom/what are we really concerned? Our liability? We are treating a person, someone who doesn't care about treatment guidelines, who might not have the same goals as we, and has lived long enough to determine for himself what matters.
Is there anything you'd want us to do in addition to reading this book?
Sure!
  • Watch the movie 50/50. When the oncologist says the word, "cancer," everything else goes unheard by the patient. Listen carefully, and you'll hear the doctor say all the things Gawande speaks of, all the things you've heard yourself and the rest of us say to patients, as if they were interested in the same things as your colleagues.
  • Check out the poem Aubade by Philip Larkin 
  • Read the poem Do Not Go Gentle Into That Good Night by Dylan Thomas, to which Stephen Jay Gould refers when quoted by Gawande.
  • Read and follow "Don't Do Something; Just Sit There
  • Understand what's called in Motivational Interviewing (a technique used in motivating patients to make healthful changes, e.g. eating healthier, giving up substance use) the Righting Reflex, through which we, as doctors, attempt to fix perceived problems in patients by telling them what they "need" to do, only to find that this invariably leads to resistance.
"Being Mortal" is an impactful and important book. I hope it will effect change throughout the US health care system at a time when care of an aging population is paramount. More practically, though, it will help the reader and the patients s/he treats to feel more satisfied and successful, and for each of us to be better equipped when dealing with these issues in our own lives and those of our loved ones.

P.S. If you'd like to hear a little more from Atul Gawande, here's a 19-minute long TED Talk he did in 2012:

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Dr. Birju Patel

Dr. Birju Patel

Birju has specialized in tutoring the MCAT since 2003. He served 2 years with Princeton Review, a year with Bright Future Learning Center (NJ), 7 years with Examkrackers, and roughly 10 years as an independent private tutor, including the last 3 with MedSchool Tutors. Birju is graduating from UMDNJ-NJMS and is now in his second year of psychiatry residency at Einstein-Beth Israel Medical Center.
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