Up to My Armpits: Adventures of a West Texas Veterinarian Book

This book wss filled with about 25 anecdotes flimsily tied together by Gawande's less than inspiring reflections. I have the book in front of me at the moment and I am paging through rereading sections that I noted along the way:

"I had come into residency to learn how to be a surgeon. I had thought that meant simply learning the repertoire of move and techniques involved in doing an operation or making a diagnosis. In fact, there was also the new and delicate matter of talking patients through their decisions - something that sometimes entailed its own repertoire of moves and techniques." pg 217

Next to this paragraph I had written "NO SHIT!"

The book is full of these minor, pseudo-epiphianic moments that come off as weak aphorisms. However, given the audience of this book (everyone) he does well to treat people about how uncertain medicine really is and how it really comes down to the tricky nature of making decisions and how they should be made in the medical setting:

"But the conundrum remains: if both doctors and patients are fallible, who should decide? We want a rule. And so we've decided that the patients should be the ultimate arbiter. But such hard and fast rule seems ill-suited both to a caring relationships between docotr and patient and to the reality of medical care, where a hunderred decisions have to be made quickly... The doctor should not make all of these decisions, and neither should the patient. Something must be worked out between then, one on one - a personal modus operandi. Where many ethicits go wrong is in promoting patient autonomy as a kind of ultimate value in medicine rather than recognizing it as one value among others...(A)s the field grows ever more complex and technological, the real task isn't to banish paternalism; the real task is to preserve kindness." pg 223-4

This simply makes sense, nothing new here.

The best part of the book is the last two paragraphs (and is all you really need to read have said that you have read the book, in my opinion.):

"The possibilities and probabilities are all we have to work on within medicine...What we are drawn to in this imperfect science, what we in fact covet in our way, is the alterable moment- the fragile but crystalline opportunity for one's know-how, ability, or just gut instinct to change the course of another's life for the better. In the actual situations that present themselves, however, [...] we can never be sure whether we have such a moment or not. Even less clear is whether the actions we choose will prove either wise or helpful. That our efforts succeed at all is still sometimes a chock to me. But they do. Not always, but often enough." pg 251-2

In a way, the whole thesis of this book (which I think is summed up in the sentence in bold above) is pretty remarkable. There is so much talk about the fallibility and humanity in medicine right now... fallibility is so hot right now. However, as is apparent in this book, the medical community is only at the stage of recognizing this fallibility. Gawande doesn't do what I thought he would: suggest what we should do given the increase visibility of the fallibility of the practice of medicine. He really doesn't have any good ideas. In all his articles, he seems to be advocating a technocratic answer (using checklists etc.). The biggest problem I have with the book is the way Gawande seems to view the profession medical community of independently-acting people, who, in the aggregate, are not too of an impressive lot. In this, Gawande is entirely old-school. He fails to recognize the possibility of alternative ways to approach patient care. In a way, I think that he is dangerously anecdotal. Maybe it is just me being tired of reading anecdotal medical non-fiction, but it just seems like a lame format (don't hold these words against me because I really don't know what I am looking for, or what type of book I would write). He treats them like data points. I believe that the book could be reduced by about 80% for someone like you or I who are as far in the medical field as we are.

However, I believe there to be value within this book. I am really really happy that millions of people (future patients) are reading books like this and Groopman's "How doctor's think" as it really does educate them to get real about what medical care is all about. It will serve to empower people and get them involved in their care and think about how they want it to go down. But, to me, I really did expect a lot more from this guy. The reviews that it got are ridiculous, they are way over the top! It is pretty incredible- it goes to show how easy it is to be heard once you have written for the New Yorker and got a MD from Havard. I will keep reading his books, though, for no other reason than that he is so hot right now, millions are reading him. I at least have to know other people are thinking about.