BEING MORTAL

Medicine and What
Matters in the End

By Atul Gawande

Metropolitan. 282 pp. $26

(Neil Webb for The Washington Post)

DOCTORED

The Disillusionment
of an American Physician

By Sandeep Jauhar

Farrar Straus Giroux. 268 pp. $26

INTERNAL MEDICINE

A Doctor’s Stories

By Terrence Holt

Liveright. 273 pp. $24.95

Susan Okie is a clinical assistant professor of family medicine at the Georgetown University School of Medicine, a poet, and a former medical reporter and science editor at The Washington Post.

Doctors are under the microscope. They’re scrutinized for their role in our high health-care costs and graded on the quality of their care.Because of cuts in what insurance pays them, their incomes have not kept pace with inflation, creating pressure for practitioners to see more patients. Medical students, burdened by gigantic school debts, are migrating toward the highest-earning specialties and away from lower-paid primary-care fields, where doctors are in short supply.

Educators worry that physicians’ stressful training — focused on technology, information and time management — might stunt their ability to gauge patients’ emotions and inhibit them from discussing difficult subjects, such as a patient’s wishes at the end of life. Most of the beginning medical school students whom I teach are altruistic and caring, but they wonder whether medical school and residency will grind the empathy out of them.

In three remarkable new books, physician-authors illuminate aspects of medicine that members of the profession are often reluctant to talk about: the deeply flawed care of the old and the dying, how greed influences doctors’ clinical decisions, and a trainee’s searing encounters with patients who are beyond his medical help.

“Being Mortal,” the new book by surgeon and best-selling writer Atul Gawande, is an indictment of the way our health-care system fails people with fatal illnesses and those too infirm to live without assistance. In caring for both populations, according to Gawande, we fall short because we have allowed aging and dying to become medicalized, rather than trying to discern what is most important to those going through these stages of life. Doctors — by training and even by temperament — are ill-prepared to help people face their own mortality, he believes: Often, doctors can’t even begin to talk about it. “I am in a profession that has succeeded because of its ability to fix,” he writes. But “as people’s capacities wane, whether through age or ill health, making their lives better often requires curbing our purely medical imperatives — resisting the urge to fiddle and fix and control.”

Doctors are uncomfortable speaking with mortally ill patients about their fears and goals, so they tend to fall back on offering one drug or procedure after another, without explaining that during a disease’s late stages, many therapies are likely to increase suffering without significantly lengthening life or restoring health. More than 40 percent of cancer specialists acknowledge suggesting treatments that they believe are unlikely to work.

Consulted about a woman in her 30swith advanced lung cancer, Gawande admits that, like her cancer doctor, he found himself unable to talk honestly with her about her life expectancy and wishes. He shares his exploration of what palliative-care and hospice programs have to offer, and describes how learning about them improved his interactions with patients and even with his father, who developed a tumor of the spinal cord that eventually killed him. Palliative-care specialists taught Gawande how to begin a conversation about bad news: Rather than spouting medical information, they suggested, start by saying, “I am worried,” then try to gauge how much the patient wants to know. Such physicians “ask what you want to hear, then they tell you, then they ask what you understood,” Gawande writes, urging that all doctors be taught how to use this approach.

Research has shown that cancer patients who discussed end-of-life care with their doctors “suffered less, were physically more capable, and were better able, for a longer period, to interact with others” than those who did not. They were less likely to undergo cardiopulmonary resuscitation, to be on ventilators or to be treated in intensive-care units. Their family members were also less likely to be depressed six months after their deaths.

Gawande suggests that the United States is already moving away from the medical model of dying. The percentage of Americans who die at home has increased, from 16 percent in 1989 to 25 percent in 2007, according to the Centers for Disease Control and Prevention. Forty-five percent of Americans who died in 2010 were in hospice programs, with more than half of them receiving care at home. Gawande recounts how hospice care allowed his father to come home from the hospital, manage his pain, enjoy small pleasures such as his favorite Indian foods and spend his last weeks with his family. Hospice, Gawande learned, is not about aiding or hastening death, but about making each remaining day the best it can be.

Gawande’s other purpose in writing “Being Mortal” is to argue for an effort to de-medicalize the care of the elderly. As with caring for dying patients, he writes, the key is to listen to what people say is most important to them and to help them live by those priorities. He favors moving away from large, impersonal nursing homes that set rules and schedules largely for the convenience of their staffs, and toward smaller models that can provide community and assistance while allowing residents more control over how they spend their days.

He traces the rise of nursing homes in the mid-20th century and follows a handful of tough, sympathetic elderly Americans as they cope with old age and struggle, along with their families, to find a place where they can live safely yet with some independence. He describes the work of pioneers such as Keren Brown Wilson, who founded the first “living center with assistance” based on helping residents stay in their apartments, and Bill Thomas, who introduced the idea of the Green House, a communal home with no more than 16 elderly residents, along with caregivers who focus on two or three residents each. Gawande makes a persuasive case that better solutions to housing and caring for our country’s elderly already exist: We simply need to pay attention and replicate models, such as the Green House, that allow people more freedom, social interaction and opportunities to live meaningfully.

Perhaps, he suggests, we’ve become too focused on safety at the expense of emotional needs. Nursing homes are rated on whether residents eat regularly, take their medicines and are prevented from falling, but not on whether they feel lonely or isolated. As a result, our nation’s elderly too often end up living “a life designed to be safe but empty of anything they care about.”

While “Being Mortal” examines the medical field at large, “Doctored,” a memoir of cardiologist Sandeep Jauhar’s first few years in practice, is a dispiriting portrait of how working as a physician feels. Equal parts confession, rant and exposé, the book describes how money worries and an excessive workload led the newly minted specialist to lose sight, at least for a while, of the ideals that had motivated him to become a doctor. Jauhar, the grandson of a New Delhi physician, admits that he embarked on his first job as a heart specialist with unrealistic expectations about the prestige and earning power it would confer. Partly in defense of his actions, he offers a blistering critique of the business of medicine as he experienced it — a business that, in his view, corrupts doctors by rewarding them for providing unneeded tests and treatments.

For example, doctors are paid by an insurance system that rewards them more generously for surgical procedures or tests requiring special technology and expertise — such as a treadmill stress test or an echocardiogram — than for talking with a patient or performing a complete history and physical examination. “It is too easy to prescribe tests when you know an insurance company will pay for them,” he writes.

Because specialists’ income depends on referrals from other doctors, many of them refer patients to doctors who they know will refer others back to them, a practice that has contributed to the increasing use of specialists by U.S. physicians, with attendant rises in medical costs. “Among my colleagues I see an emotional emptiness created by the relentless consideration of money,” Jauhar writes.

As a child, Jauhar immigrated to the United States from India with his family. After finishing his training, he decided to specialize in treating congestive heart failure — a common, disabling and eventually fatal condition — and took a job at Long Island Jewish Hospital near New York, where his brother was already on the staff.

Jauhar and his wife, Sonia, also a physician, had high household expenses — including medical school loans, a newborn and a rented apartment in Manhattan — and with Sonia staying at home, his was the only salary. To make ends meet, he began looking for additional sources of cash. First, he agreed to give paid speeches to help a drug company promote its heart-failure medication, which he prescribed and found effective. But Jauhar writes that he stopped speaking on the company’s behalf after a study in a medical journal linked the drug to increased deaths among heart-failure patients.

He next took a job moonlighting for another heart specialist in private practice, caring for his hospitalized patients and, on weekends, seeing office patients while also supervising and interpreting cardiac tests. The specialist told Jauhar that he sometimes ordered unnecessary tests “to break even” or because patients demanded them, but he argued that if he didn’t do it, patients would just get the same tests elsewhere. “I always felt as if I were selling my soul,” Jauhar writes of his weekend shifts in the other doctor’s Queens office.

Eventually, Jauhar lost his moonlighting job because he was not bringing in enough business. He became depressed, and his marriage seemed to be unraveling. He consulted a guru, then a psychiatrist. Overworked and suffering from burnout, he cut corners to see more patients, sometimes missing a diagnosis because he failed to do a careful physical examination. He heard colleagues express similar feelings of exhaustion and loss of meaning. “And yet,” he writes, “there was almost never a sense that we were to blame too. That we had abandoned our course.”

Jauhar details his increasing desperation for more than 200 pages before a solution appears, and it’s such an obvious one that readers may wonder what took him so long. His wife goes back to work. The family cuts expenses by leaving Manhattan and moving to a house on Long Island. They send their son to public school. No longer needing to moonlight, Jauhar finds renewed satisfaction in his hospital job and deep pleasure in spending more time with his wife and children.

“Doctored” is a troubling diagnosis of the financial pressures and conflicting incentives facing U.S. physicians. Perhaps the advice offered by Jauhar’s father at the beginning of his son’s midlife crisis — “Live within your means” — is also the best prescription.

Despite its deceptively bland title, “Internal Medicine,” Terrence Holt’s new collection of stories, captures the feelings of a young doctor’s three-year hospital residency — the powerlessness, the exhaustion, the chaotic and seemingly endless shifts, and above all, the intensity of being with people in moments of extremity — better than anything else I have ever read.

Holt left a professorship in literature and creative writing at Rutgers to enter medical school at the age of 40 and is now a specialist in geriatric medicine at the University of North Carolina. He took 10 years to write these nine stories, or “parables” as he calls them. Most revolve around the narrator’s interactions with a single patient, a person who is sick or suffering, mad or dying, but whose inner life is largely opaque to the doctor trying to help. These characters live somewhere between fact and fiction. As Holt writes, “They are at most assemblages drawn from a variety of sources, compiled from multiple cases.” He says he is “seeking to capture the essence of something too complex to be understood any other way.”

There’s the middle-aged woman whose lungs are failing and who refuses to wear her oxygen mask, whose terrifying breathlessness defies the brand-new resident’s stratagems on his first night in the hospital. There’s the 20-something woman in the emergency room with the odd smile, who knows there’s a lot more the matter with her than appendicitis but keeps that information to herself. The resident is called to see a mental patient who keeps getting sick from eating garbage, and another whose breath catches mysteriously whenever she moves, making her grimace in pain and surprise. Each is real and closely observed, yet unknowable. For me, they brought back memories of other confounding patients, endless nights and moments of helplessness.

“During those years,” the narrator recalls, “I always felt that I knew nothing. And no matter how much you did know, there was always more you didn’t. . . . What made it worse was that you were required — by the patient, the family, the intern — to look as if you knew what you were doing.”

Holt writes that he hoped to convey something “not narratable”: “I needed to understand how those years in the hospital had transformed me.” Because these are stories, the doctor-speaker in “Internal Medicine” traces the arc of what happens to his patients in a way that a trainee can rarely do in real life, when residents are always rotating to another part of the hospital and patients are constantly being discharged, to be replaced by new ones. He sees some of his patients die. He finds out what was really wrong.

In “The Surgical Mask,” one of the most moving chapters, he spends a month visiting terminal patients with a hospice nurse, learning what dying at home sometimes entails. He attends a woman whose oil paintings show people accompanied by brilliant tropical birds; she wears a mask covering the lower half of her face because cancer has eaten away her nose, mouth and tongue. “Are you afraid?” she asks him, slurring her consonants. When he starts to admit that he is afraid of what is happening to her, she brushes his lips with her fingers. “The touch of them was electric,” he recalls. “To this day I still feel it.”

Holt’s unadorned prose and pitch-perfect dialogue contribute to the realism of these stories. At times they have the atmosphere of a hospital version of film noir, the narrator sounding as tough as Raymond Chandler’s Philip Marlowe in his effort to be efficient and unflappable. “I hated her,” he says of an exasperating patient. “ ‘Hated’ may be too strong a word. At that time, I hadn’t the energy for hatred.”

But as with Marlowe, the reader can always tell that this narrator’s heart isn’t frozen through. “Residency passed like a bad dream,” he tells us, “and on awakening I found I cared again. Perhaps too much.”

“Internal Medicine” is the antidote for the notion that medicine has become nothing more than a business. I intend to recommend it to my first-year medical students who are worried about losing their empathy. Anyone who’s considering becoming a doctor, or anyone who wants to know what’s at the core of a doctor’s initiation, should read this book.

Susan Okie is a clinical assistant professor of family medicine at the Georgetown University School of Medicine, a poet, and a former medical reporter and science editor at The Washington Post.

BEING MORTAL

Medicine and What Matters in the End

By Atul Gawande

Metropolitan. 282 pp. $26

DOCTORED

The Disillusionment of an American Physician

By Sandeep Jauhar

Farrar Straus Giroux. 268 pp. $26

INTERNAL MEDICINE

A Doctor’s Stories

By Terrence Holt

Liveright. 273 pp. $24.95