Book Review: Medicine in Translation

Like the rest of you who live anywhere in or near the Mid-Atlantic region of the U.S., I have been mostly trapped indoors for the past several days while record amounts of snow have been falling. I used some of the time to read a few really good health-related books and thought I would start sharing selected reviews of my favorites on this blog. In the interest of full disclosure, I receive no payments from the author, publisher, or bookseller (nor do I plan to accept any such payment in the future) for writing book reviews. The following review of Medicine in Translation: Journeys With My Patients was originally published on Amazon.com.

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Medicine in Translation will appeal equally to fans of Danielle Ofri's previous two books (Singular Intimacies: Becoming a Doctor at Bellevue and Incidental Findings: Lessons from My Patients in the Art of Medicine) as well as those who have never had the pleasure of reading her work before. Consisting of a perfectly blended combination of anecdotes from patients in her clinical practice at Bellevue Hospital Center in New York, her family's extended stay in Costa Rica (which included the delivery of her third child), and her struggle to achieve competency on the cello, this book is my personal favorite of Ofri's collection to date. As a family physician who trained at Bellevue during medical school, I especially appreciated her portrayal of the frustrations of balancing a demanding career in primary care with family responsibilities. One priceless moment in the book is a scene in which an apparently clueless male patient who has recently had numerous screening tests performed (and with whom she must communicate through a translator) doesn't tell her that he already had those tests (including a colonoscopy!), resulting in a lengthy end-of-day visit that makes Ofri late for day care and late to get home. Still fuming while reading The Runaway Bunny during her children's bedtime routine, she thinks: "Let the damn bunny make it on his own."

As much that scene resonated, don't let me mislead you into thinking that this book is primarily about an overworked doctor and mother feeling sorry for herself. While she misses the idyllic life in Costa Rica when she returns to Bellevue after a yearlong sabbatical, Ofri continues to find her work rewarding in ways that have little or nothing to do with medicine itself. This extraordinary book is about making continuous human connections across the barriers of language, culture, and place of origin. Frances Peabody famously said, "The secret of the care of the patient is in caring for the patient." Ofri takes this philosophy a step further in Medicine in Translation by illustrating how listening closely to her patients' stories and appreciating their perspectives can improve the health of all involved.

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P.S. The subject of my next review will be The Immortal Life of Henrietta Lacks by Rebecca Skloot.

Guest Blog: Johnny Doe

An emergency medical technician for 12 years, Yvonne Estrada currently works as an ambulance driver for the Los Angeles County Emergency Medical Services Authority. "I have always written poems, and my job naturally presents adventures and situations that need to be written about, stories that need to be told," she says. Ms. Estrada reads the following poem (which was first published in Pulse Magazine) and others at http://www.guerrillareads.com/ (she's No. 8).

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JOHNNY DOE

Policemen pose like plastic toy soldiers,
point rifle barrels in every direction,
ghetto bird's spotlight glints off helmets.
Ambulance allowed across yellow tape,
diesel engine grinds up the sharp grade.
In no moon you glow fish white belly up,
streetlamp casts mottled shadows,
your blood a preschool finger painting
smeared on a sidewalk.
I am ordered to shear off your slick, soaked
jeans, to smash your chest, beat your heart
for you. Your arms extend savior-like,
needles are pounded into veins,
translucent bags held skyward
like offerings to a life-giving deity,
clear liquid bleeds in, your blood pours out,
three bullet holes versus six-minute
trip to emergency room. How old are you?
I think about my son asleep at home.
I wonder if your mother's at work.
I breathe deep, drive fast,
make the siren a prayer
too loud for your God to ignore.

- Yvonne M. Estrada

Of gatekeepers and unbridled imaging technologies

When I was a third-year medical student on my Surgery rotation at Bellevue Hospital in New York City, more than a decade ago, the assignment I dreaded most - more than "scut work" such as drawing blood samples or removing stitches - was going to the Radiology department to present clinical cases to the attending physician for permission to use the hospital's one and only CT (computed tomography) scanner. I learned to put together meticulously reasoned arguments about why images created by this precious piece of equipment were absolutely necessary to obtain a diagnosis that couldn't be made with an examination, blood tests, or ordinary x-rays. The attending's job was to be a gatekeeper - to make sure that the costly scanner was utilized only for high-priority diagnostic dilemmas. More often than not, that meant tearing the unlucky medical student's case to shreds.

Fast forward five years. I'm working in a private primary care practice in Arlington, Virginia, and can order imaging tests simply by checking off blanks in a form and scribbling a general symptom such as "headaches" or "abdominal pain." A patient of one of my colleagues who is on maternity leave presents to the office with vague pelvic pain and becomes incensed when the soonest I can schedule her for an ultrasound at the local hospital is in two weeks. She takes my prescription to a different radiology center and is scanned the next day for what turns out to be a large but benign ovarian cyst. By the time the report is delivered to my office, she has already had surgery to remove the cyst and tells me that she doubts she'll ever visit my practice again. In a city when 24 hour imaging services are available for the right price (or insurance), a two week wait is apparently grounds for malpractice.

Fast forward to the present day. I rarely see patients, yet receive phone calls every few weeks at my non-clinical office from for-profit imaging companies letting me know that there are spots open on the schedule for their MRI machine, in case I happen to see a patient that day "with an indication" (read: any patient with a symptom that I can't completely explain). An editorial in the Annals of Internal Medicine complains that CT colonography ("virtual colonoscopy") has been held to an unfair standard as a screening test for colon cancer, even though it's significantly more expensive than other tests and exposes patients to large doses of radiation.

In Ontario, Canada, the average waiting time for a non-emergency CT scan is 42 days, and for an MRI, 107 days. Opponents of single-payer health systems cite these kinds of statistics as proof of the superiority of American health care. But there are downsides to the widespread availability of imaging services in the U.S., in addition to the high costs of maintaining the technology. In some situations, such as ultrasonography for asymptomatic carotid artery disease or MRI for low back pain, imaging can cause more harm than good, by leading to unnecessary surgical procedures. And the tests themselves aren't harmless, either - recent studies have estimated that the radiation from 72 million CT scans performed in 2007 has led to thousands of cancers that wouldn't otherwise have occured.

So maybe it's time to bring back the gatekeepers, albeit in less intimidating guises. Barring that, you or I could choose to move to Canada, where they wait longer to get CT scans, but spend half as much money on health care, live 3-5 years longer, and report better emotional, physical, and mental health than do Americans.