The Laws of Medicine

In The Laws of Medicine Siddhartha Mukherjee uses his words and storytelling to elaborate on medical realities learned from invaluable education and experience.  Mukherjee is sets out to describe principles of medical practice, pointing out that practicing medicine is about knowing the strengths and weaknesses of knowledge gleaned from patients, tests, experiments, and one’s self, then making the best decision with that information. Mukherjee much more eloquently elaborates on that point, emphasizing his three “laws” or principles of medicine.

  • Before Mukherjee describes the three principles of his book, he sets them up in a forward. He wonders if medical jargon is partly subconsciously employed to escape unknowns. He briefly discusses the history of medicine from the cure-all treatments of the 1800’s to careful observance of the Hippocratic oath, using William Osler as an example. He mentions Lewis Thomas’s The Youngest Science: Notes of a Medicine Watcher. He is careful to differentiate the “laws” he is about to expose from more pure scientific laws such as those in Physics, Chemistry, and Biology.
  • Mukherjee explains that assessing a patient involves raising or lowering the probability of a diagnosis through interpreting test results in context. Mukherjee uses Thomas Bayes, an 18th century Philosopher and Clergyman, to illuminate the imperfect nature of tests.
  • Mukherjee continues his excellence use of relevant storytelling to explain how the unexplained abnormal results of tests or experiments are keys to better understanding of the whole. Hearkening back to history once more, Mukherjee uses Karl Popper’s The Logic of Scientific Discovery to point out that medical knowledge is scientific only when it carries a stipulation that can disprove it by new information or discovery.
  • Mukherjee adapts Heisenburg’s uncertainty principle to medicine to question how generalizable experiments are. He mentions that Paul de Kruif’s Microbe Hunters may have been apt in the early 20th century, but here in the 21st century bias is the prey of physicians. Mukherjee reflects on the role of physicians to hunt bias, including their own, while using imperfect information to help patients make the best decisions about their health.

In The Laws of Medicine, Mukherjee impresses a sense of understanding upon the reader through taking complex issues and breaking them down into manageable pieces of information. He doesn’t need to explain the science behind his examples to give the reader a little understanding of the big picture. Furthermore, bleeding through the pages are rich examples of medical history that incite an appreciation for great minds that have come before Mukherjee’s imparting knowledge for him to build upon.

Another theme of Mukherjee’s book is the uncertainties of the medical field. His comments on medical jargon and the imperfections of tests are humbling. Still a relatively young science, medicine continues to experience a boom in information and technology. These advancements may clarify some things while opening up new areas vast with questions.

Studies, companies, and patients all have opinions on medicine, and it seems correlations are often unexplained while being sold as causation to the public. Statistics, anatomy, physiology, epidemiology, pathology, advanced mathematics, history, etc. are subjects each worthy of in-depth study, but combine all of those subjects while adding many others and you will begin to understand the challenges of medicine. It’s edifying to see an author acknowledging the difficulties of his field while simplifying the principles within it.

With all the avenues with which information and opinion is accessed in today’s world, it is difficult to focus on what matters most. Focus is what Mukherjee encourages with his three laws of medicine. Sifting through a myriad of information to find relevance seems an ever-increasing challenge among today’s youth, whether or not they are interested in practicing medicine. With the precision of a great writer, Mukherjee illuminates invaluable principles learned through a wealth of experience. These principles help thin the overwhelming fog of information to be processed, and if put to use are likely to improve the work of those practicing medicine.

Mukherjee’s The Laws of Medicine is a short and worthy read for anyone interested in the practice of medicine. At less than 100 pages, The Laws of Medicine seems Mukherjee’s most concise and easy read as his other books, The Gene and The Emperor of All Maladies: A Biography of Cancer, are both over 500 pages. The Emperor of All Maladies: A Biography of Cancer was awarded the Pulitzer Prize for General Nonfiction in 2011, and Mukherjee has also written for NEJM, Cell, Nature, and The New York Times.

 

Chi-Raq

Chi-Raq, directed by Spike Lee, is a film set in Chicago and focusing on the gun violence that has plagued many of the neighborhoods of that city in the 21st century. The movie stars music artists like Nick Cannon and Jennifer Hudson, who rhyme their way through dialogue and form the soundtrack for the film whether in the background or in the midst of the scenes. The movie tells compelling truths through lyric and rhyme.

The shocking number of homicides in Chicago since 2001 seems to be the inspiration for the film’s title. The number of murders in Chicago since 2001 rivals the number of deaths of United States Soldiers in Afghanistan and Iraq combined (From Secondary Source as of 06-Sep-2016). In Chi-Raq, Spike Lee pairs Chicago’s violent reputation with comedy, receiving help from Samuel L. Jackson, Wesley Snipes, Angela Bassett, John Cusack, and Dave Chappelle to portray the film’s characters.

Inspired by the ancient comedy Lysistrata, also the name of the main character played by Teyonah Parris, the film humorously weighs a man’s sex drive against his desire to brandish a gun. The movie is filled with other parodies, but the main plot point is a feminine vow of abstinence designed to deter gang violence. As the women involved with men of rival gangs continue to deny the libido of their significant others, the tension builds. The stubbornness of the men and determination of the women is tested.

If one attends the movie looking for a solution to solving the homicide rate in Chicago, one will likely come away disappointed. The movie doesn’t tally many points for realism, but it does make some important points about the violence in Chicago. The film provides comedic relief while raising awareness about frustrating and long-standing problems. In the climatic end scene, there is plea for truth in spite of consequence. How can there be acceptance, forgiveness, and reconciliation without honest truth-telling? In a city consistently marred by senseless tragedies, truth seems to be a prerequisite for positive change.

 

Post-Post Note (12-Nov-2017):

After recently hearing part of a stand-up performance by Trevor Noah in which he drew to the audience’s attention the per capita murder rates in U.S. cities other than Chicago, it’s important to note that Chicago appears to have received media attention disproportionate to its per capita murder rate in recent years.

For example: the January to June 2015-2016 Preliminary Semiannual Uniform Crime Report (UCR) by the Federal Bureau of Investigation (FBI): Offenses Reported to Law Enforcement by State by City 100,000 and over in population lists Chicago as having 213 and 317 reported murders per population of 2,728,695 in the first half of 2015 and 2016, respectively. In the same report, Kansas City had 37 and 51 reported murders per 473,373 population, Detroit had 135 and 103 reported murders per 673,225 population,  and St. Louis had 92 and 88 reported murders per 317,095 population in the first half of 2015 and 2016, respectively. Ranking risk of murder per population rather than number of murders per city looks like this…

Number of new cases of disease or injury during specified period  / Size of population at start of period =  incidence proportion (risk)

Chicago

Jan-Jun 2015:

213 / 2,728,695 = 0.000078 or 0.008 %

Jan-Jun 2015:

317 / 2,728,695 = 0.000116 or 0.01 %

Kansas City

Jan-Jun 2015:

37 / 473,373 = 0.000078  or 0.008 %

Jan-Jun 2016:

51 / 473,373 = 0.000107 or 0.01 %

Detroit

Jan-Jun 2015:

135 /  673,225 =  0.00020 or 0.02 %

Jan-Jun 2016:

103 /  673,225 =  0.00015 or  0.015 %

St. Louis

Jan-Jun 2015:

92 /  317,095 =  0.00029 or  0.03 %

Jan-Jun 2016:

88 /  317,095 = 0.00027 or 0.03 %

Based on the FBI UCR Jan-Jun 2015-2016, Kansas City ranks similarly to Chicago in risk of being murdered, and the risk of being murdered in both Detroit and St. Louis is higher than Chicago’s risk with the risk of being murdered in St. Louis nearly three times the risk of being murdered in Chicago during these time-frames. A clear look at the data is crucial to understanding the correct proportion of a problem. For these time-frames it appears Chicago should not have been the city receiving a disproportionate amount of attention for the risk of homicide.

The FBI UCR is a useful resource for examining statistics on crime in cities across the United States, and it can be found on their website.

On Statues

Statue4

 

There are certainly some persons who deserve to be remembered more than others, but does anyone deserve a statue molded in their likeness? Should any man or woman be memorialized by a larger than life image?

First hearing by word of mouth of the controversy in Charlottesville, Virginia last Sunday, it was hard to be surprised. There have been many acts of terrorism in the news lately, and one more senseless act added to the numbness. Terrible, egregious, disgusting, inhuman, evil… these words may be accurate descriptors, but they often fall short of empathy and feeling. It’s one thing to describe an incident, and it’s another to live it.

Later that night after having some time to reflect on the incident, a discussion with a friend commenced over a game of pool. What motivated the event? Why now? Is our society in regression or experiencing growing pains?

Then came the discussions of this week. Historical figures were compared, and the differing perspectives on their memorials were illuminated. Oppressive or defensive? Worthless or worthy? Hate or heritage?

During another brief personal discussion came the words “…understand both sides…”. “Understand” was inaccurate, and “both sides” was a poor choice of words. Some emotion brewed in a friend’s face as he asked if a memorial to Hitler would be appropriate? The question was rhetorical, but thoughts comparing Confederate leaders to Nazi leaders immediately came to mind… Do these men deserve to be memorialized?

Is there enough goodness in those Southern soldiers that is worth remembering? Or, does the obvious and overwhelming evil that these soldiers died defending rule out a position of honor for their statues? Is felling a Confederate leader’s memorial ignoring history, or would destroying theses statues be an acknowledgment of past crimes? It’s clear that history often, if not always, remains up for interpretation.

Another reality is that honorable intentions do not right injustices. Every human seems more dynamic than people are willing to admit, and stereotypes or generalizations often cloud the complexity of a life. However, are there things that must not be condoned, even if done by a generally good man?

The most accurate interpretations of the integrity of the men who’s statues are being debated should be left up to those honest individuals willing to search historical records and primary sources for the facts. That is not the subject here. The more relevant issue seems to be one of putting the present into historical context.

The men memorialized by these statues lived through events that changed the course of history. The nation that was split in two reunited, but were wrongs righted? Were all hurts healed?

Roughly 8 years after the inauguration of President Obama…

  • nearly 50 years after the death of Dr. King…
  • approximately 70 years after Robinson first swung a major league bat…
  • around 116 years after Booker T. Washington published Up From Slavery
  • something like 154 years after the formation of the 54th Massachusetts Infantry…
  • 160 years since the Supreme Court’s decision on Dred Scott v. Sanford…
  • 184 years after the death of William Wilberforce and the subsequent abolition of slavery in the British Empire…
  • nearly 200 years since the birth of Frederick Douglass…
  • thereabouts 243 years after General George Washington halted the recruitment of black soldiers for service in the Continental Army…
  • 228 years after the publication of Olaudah Equiano’s autobiography…
  • give or take 398 years since the first Africans were enslaved on American soil in Jamestown…
  • more or less than 516 years after Saint-Domingue (Santo Domingo) became an international slave port…
  • and circa 525 years since Columbus planted the seeds of European colonialism in the Caribbean – what would prove to be a tragic omen for millions of indigenous people in Africa and the West…

…these American lands are still reeling over past sins – sins that cannot be made right.

While there is no way to right the wrongs of the past, there is hope in the present.

  • First, those who have ancestors that were responsible for the injustices of genocide, slavery, or other acts of racist oppression and/or those who have benefited from systematic social hierarchies resulting from a history of white-European colonialism, would do well to seek recognition of how evils of the past have influenced their current circumstances.
  • Besides an awareness of the history of these injustices and their effects on the present, regret for the racially motivated decisions of the past would benefit current societal relationships.
  • Third, “white-guilt” is not something to be ashamed of, in the sense that feelings of remorse for generational transgressions lead one to self-hatred. Rather, this guilt is something to act on.

There is no shame in discouraging voluntary segregation or prejudice, even if one’s blood-line may have systematically oppressed the ancestors of another ethnicity or people-group, and vice-versa.

  • Feeling fear of unknowns at the site of a dinner party crowd of different cultures or skin tones should incite an urge to join their company rather than remain in the comfortable circle of more predictable commonplace.
  • Discussions of injustice driven by petty things such as skin color, wealth, or greed should not be constantly avoided but addressed with humility, authenticity, and caution – especially regarding an experience a person could not understand unless she or he took on the appearance, heritage, environment, and event of the one who lived it.
  • Having affections for an individual of a skin color quite opposite from one’s own may feel odd at first, but it should not feel wrong simply for sake of appearance or avoidance of surface-level judgement.
  • Lastly, if such affections should turn towards romance or marriage, know that color line was crossed long ago and is littered with the footprints of many joyful couples.

On statues, carved or modeled – molded or assembled, they are lifeless things meant to represent or honor something greater. What benefit do these motionless creations have to offer besides reminders of higher ideals and heroic deeds? At best, statues are but a caricature of the people they are meant to emulate. Far from the beating hearts and original minds of the persons they represent, statues are cold giants that use size and art to vainly seek to make up for whatever piece of humanity that was lost.

This humanity is not flawlessly set as sinner against saint or hero versus villain. As much as people aspire to glorious perfection, it has yet to be reached by any of the finite creatures that populate this planet. Rather, each memorial should be purposed to bring out the best of this human condition while acknowledging the truth of the times which the figure represents.

An effective memorial should not encourage people to wallow in its presence or rage against its existence but carry on with their lives, taking with them a memory that will spark to light part of what it means to be truly human. There has been far to much tragedy in this world already. While history must be remembered for what it was, humanity needs not to abide memorials that recall and breed division in the present.

Statues should be constructed to promote a sense of righteous resolve, connectedness, or hope.  History has afforded many examples of individuals and events, flawed, but resulting in courageously righteous action. Uplift that which will uplift. If statues fail to meet this criteria, history can continue to be honestly maintained while the figure is respectfully and democratically removed from a place of honor or, disrespectfully, torn down.

On Truth

OnTruth

On Truth, written by Harry G. Frankfurt who was a professor of Philosophy at Princeton University, is a book defending and elaborating on the concept of truth. The first thing Frankfurt does is dispose of the fallacy that truth does not exist as disproving  itself (i.e. saying truth does not exist would be an absolute truth). The second thing Frankfurt does is emphasize that he is not writing about what is true and what is not true, but about the vital concept of truth itself.

Frankfurt then examines the importance of truth within modern society and some of the ideologies surrounding the idea of truth. Frankfurt indirectly invites the reader to consider if a person’s idea of truth is determined by her or his experiences and environment. The author emphasizes the importance of truth in regards to being honest about one’s self and in regards to a healthily functioning society. He discusses Baruch Spinoza’s idea that people who love themselves and their lives tend to love truth because of the role truth plays in life.

In the second half of “On Truth”, Frankfurt seems to continue his consequentialist approach to truth as he describes the importance of a person accepting reality for what it is regardless of whether or not she or he agrees with it. Though he continues to elaborate on the necessity of truth in living a fulfilled life, Frankfurt’s dialogue brings some fundamental questions. Is it better to utilize truth for one’s own gain, for the gain of a group, or for the gain of society as a whole? Is it better to exercise delayed gratification or immediate gratification?

For example:

The issue of the growing national debt of the United States government is discussed with every election cycle, and this topic must influence decision making on the part of U.S. citizens. Is it better to allow the debt to continue increasing to bolster the U.S. economy now or should the U.S. government make severe budget cuts now to avoid long-term consequences? One could argue that both approaches can be motivated by a consequentialist perspective (i.e. one seeks to benefit people in the present and the other seeks to benefit people in the future), but which approach provides the most benefit for the greatest number of people?

When considering a consequentialist approach an important distinction must be made between what benefits the individual (or the individual’s group) and between what benefits the greatest number of people in society. Though these discussions will likely make decisions much more complicated, they should also serve to make decisions more intentional in beneficence or non-beneficence and more effective in reaching set goals. A gray reality of conflicting information and viewpoints beckons for reasoning on principle / truth rather than impulsive black and white decision making based on preset preferences / experiences and incomplete information.

Frankfurt’s realization of the variation / grayness of life is refreshing. At one point Frankfurt implies that a lie may have consequential utility in one situation while being a burden to society in another situation.

For example:

Comedians lie frequently about their experiences to create a more humorous punch line. This is one example of how manipulating the reality of a situation may be of benefit to a great number of people. Often jokes are dependent upon realizing the untrue nature of a statement, and such sarcasm may serve to mock a falsity and admire a truth.

If the example of comedians seems like a weak defense of the utility of a lie, the genocidal examples of a German lying to the Gestapo about the location of Jews or of a Rwandan lying about her or his ethnicity to avoid being a victim of mass slaughter should serve as a more potent example. Frankfurt makes his points effectively without use of such examples, and he goes on to illuminate why lies can be so uncomfortable, even when they have some consequential utility.

Lies keep the hearer from some reality. The full truth of a situation is shrouded. That aspect of a lie is always negative, regardless of the lie’s consequential utility. The nature of a lie is entertaining a thought or an idea that is false, and this serves to explain why lies should be naturally less popular than truths (i.e. the nature of reality causes lies to be self-defeating).

“On Truth” is a short, reflective read that provides a good defense of the overall utility and vital nature of absolute truth while acknowledging the existence of various situations in which complete, raw honesty about truth is unknown, undesirable, or not of the most immediate beneficence. Truth has a self-evident nature which always makes falsity somewhat undesirable even if an untruth is useful. Frankfurt’s approach entertains the complex nature of truth while upholding truth’s integrity, and when discussing and deliberating what is likely the most important concept in life, such a balanced and rational approach is a good thing.

 

 

 

 

The Real Doctor Will See You Shortly

TheRealDoctorWillSeeYouShortly

The Real Doctor Will See You Shortly by Matt McCarthy is a book about the author’s first year as a resident after graduating from Harvard Medical School. The book is a raw story about the stressful ups and downs of life as a medical resident. Not all residents may feel the same kind of stress or sense the same kind of life-altering experiences that Doctor McCarthy reflects on in his book, but the experiences of residents must have a large impact on the courses of their futures as physicians. McCarthy’s book demonstrates how his experiences have impacted his career, and provides a valuable resource for students aspiring to a career in medicine.

The book opens with McCarthy exiting the world of academia for the work of residency. He travels from the cardiac care unit to a local outpatient clinic to the infectious disease service to the general medicine floor to intensive care unit during his residency at Columbia University Medical Center. He exchanges 2nd year resident mentors for which he has a constantly changing “scut” list of services to provide for patient care. He experiences triumphs and tragedies as he endeavors to survive his first year of residency.

McCarthy has authored other books, and his writing is not bland or above the level of the reader. He shares mnemonics like “ABC”, “VINDICATE”, “AEIOU”, and “NAVEL” to illustrate the rigors of remembering keys to good patient care, but he never expects the reader to take an interest in the academics of medicine. McCarthy writes for the sake of the story. He describes the emotions of patients and their caregivers, he illustrates the harsh physical realities of diseases and medical procedures, and he reflects on the good and bad things about life as a resident.

McCarthy also demonstrates a refreshing sense of humor and humanity. He makes corny jokes, illustrates some humorous situations that often arise in healthcare, and talks about the importance of periodically cutting loose from the serious nature of medical care. Healthcare professions can be a frustrating, and McCarthy’s humor provides welcome relief for the doctor and the reader.

The Real Doctor Will See You Shortly is a good read, especially if one is interested in working in the medical field. Working as a Medial Doctor is a very well-respected job for many reasons. The hard work and discipline that it takes to graduate from Medical School demonstrates a willingness to sacrifice time, energy, and wealth to achieve an admirable goal, and more importantly, providing quality patient care demonstrates a dedication to protecting the lives of others. As more readers delve into the pages of Dr. McCarthy’s telling first year, perhaps their confidence to sacrifice time, energy, and wealth for the sake of those who lack access to quality healthcare will grow as well. After all, it is not easy, becoming a doctor, but for the sake of others, it’s definitely worth it.