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Volume 6, Number 3

BOOK REVIEWS

It's Always Something
New York: Simon and Schuster, 1989; 269 pp; $17.95 (US)
Gilda Radner

I met Gilda Radner at a summer camp many years ago. I was the camp physician and she a camper. I remember her well. She was young, lovely, creative, sensitive and full of life and hope for the future.

Writing this book review awakened long dormant memories. How does one who has everything to live for deal with terminal cancer? This specific focus is part of the larger existential question - why? In this book Gilda Radner grapples less with the "why" than the "how". Graphically she presents the steps she took to conquer. Of course, the poignancy is greater for the reader, who now knows Gilda didn't win. She did, however, give it her best effort.

Her nightmare began on different fronts at different times: a tiredness that spread like a fog, rolling over her, keeping her bedridden for days, sharp pains in her legs that would not go away, an appetite that came and went, feeling better but never well -all with no apparent cause. The search for the cause was itself a nightmare. We are brought up to believe that doctors are gods, an unfair assumption surely but none the less real. Doctors will have the answers and make everything better. Nothing, including the illness, is more frightening than finding that the doctors do not know what's wrong and cannot make us better.

Because we see doctors as gods, we forget that they are human beings. Sometimes, though, doctors forget that patients are human: in some cases, Gilda experienced this impersonality. "She should go to the hospital", "Let's give her the weekend", "Schedule her early", and Gilda is lying on the examining table right next to them, hearing it all but invisible to them.

The Wellness Clinic was helpful partly because they saw her as a person. She mattered to them and they showed it. Granted, they had the luxury to do so. Doctors frequently don't have that luxury. Gilda's macrobiotic cook, Anthony, had one patient, lived with her, spent hours encouraging her, became one of the family. When she returned to the medical establishment, she had four nurses, who alternately gave her the daily intravenous feeding, spent the day talking to her, listening to her and trying to allay her fears; not just as a patient but as Gilda. In her personal life, her most important sustaining force was her husband, Gene.

As she says, she had the money to hire the best surgeons, oncologists, internists and nurses, but that did not guarantee concern for the whole Gilda. That many of the medical professionals were so caring is especially striking in the book because they almost seem to be the exception.

As Gilda's physical symptoms intensified so did her emotional responses - anger, denial, resentment, withdrawal from people, frantic activity, complete isolation and then back through all the responses again. Toward the end of the book she seems to have struck a balance - not quite so frantic, a more "we'll lick this somehow" stance.

The reader, knowing the final outcome, follows Gilda through her ordeal with the added pain of knowing that there will be no happy ending. To a certain extent one can share the terror, the hope, the confusion, the anger, but until a doctor looks at you and says, "It's cancer and it's terminal", each of us is aware of the safety of distance, of relief, of gratitude.

Underneath each line of her book there is a sense of Gilda's courage and her awareness of others' feelings and pain that bodes well for the human spirit. Somehow "it" (whatever the catastrophe) doesn't kill the spirit, whatever it does to the body. Somehow, one deals with "It's always something."

Gilda was in a terrible war -a hand-to-hand combat with a most formidable enemy -cancer. I am reminded of lines from William Shakespeare's Henry V:

He that outlives this day,
And comes safe home,
Will stand a tip-toe
When this day is named.

Gilda did not survive the day. She lost the battle against cancer. However, she won the war. Even though she is no longer among us, her spirit and courage still exist. She taught us to laugh and not to take ourselves so seriously, even in the face of inevitable oblivion.

Ronald E. Trunsky, MD
Associate Professor
Department of Psychiatry
Wayne State University School of Medicine
Detroit, Michigan


Physicians, Ethics and AIDS
Ottawa: Canadian Medical Association Department of Publication, 1989; 35 pp; $6.95
A Discussion paper by Norbert Gilmore and Margaret A. Somerville

This pamphlet reports on a discussion paper that was commissioned for the Council on Health Care of the Canadian Medical Association in 1989. Its recommendations for physicians are founded on principles that have governed the medical profession for centuries: first, do no harm; second, where possible, do good; and third, act with justice.

The issues of the acquired immunodeficiency syndrome involve a complex combination of medical, ethical, social, economic and legal parameters. These recommendations provide a useful guide to some of the most difficult of these.

The discussion paper is divided into three parts relating to human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS). The first addresses the generation of information, the second concerns the communication of information, the third addresses health care services.

Part one covers issues concerning HIV-antibody testing. Voluntary, mandatory and compulsory testing are all defined and discussed. The authors conclude that testing should be voluntary. Under rare circumstances, mandatory testing is acceptable, but compulsory testing is unjustified. Medically indicated testing should only be done voluntarily and with informed consent. Routine screening is never justified. Under certain circumstances, patients and physicians have an obligation to notify each other of their antibody status. This part of the report also addresses the care of medical records in order to maintain confidentiality.

Part one deals almost exclusively with antibody testing, issues that are troublesome to most physicians. The recommendations are clear and helpful. This pamphlet does not address the generation of information relating to HIV/AIDS as it relates to research - another area of difficulty for many physicians concerned with HIV/AIDS care.

Part two discusses communication of information relating to HIV and AIDS. It outlines the concept of informed consent and asserts that there can be no implied consent. It also discusses the issues of notification and counselling. In the communication of information to others, the physician must adhere to the principles of confidentiality and privacy and must obtain specifically informed consent. The authors recommend that no names be provided in reports to the public health department and that the law be amended to specify this. They assert that contact tracing is necessary when it is done to protect other persons. In these cases, the procedures should be those that are "the least restrictive and the least invasive". Contact tracing is done when it is an effective means of informing identified or readily identifiable persons who otherwise would not be aware that they were at risk of acquiring HIV, or that they had acquired the virus already. In this connection, physicians have an obligation to educate themselves, their patients and the community.

The third part of this discussion paper addresses health care services under the headings: allocation, access to resources, research and novel therapies. It also examines standards of care and the physician's obligation to refer patients. The paper concludes by recommending that the Canadian Red Cross establish an autologous blood-transfusion service.

Although contaminated blood and blood products are possible sources for transmission of HIV, their role in the present epidemic is extremely small. In this paper, a description of the physician's ethical obligation to interrupt the spread of the virus by other, more common modes would have been more useful. Thus, the recommendation concerning blood transfusions seemed out of context in this discussion paper.

This is a useful document. The day-to-day care of people with HIV/AIDS involves many extremely complex and confusing issues. It is important to remind physicians of the principles that traditionally have guided medical conduct and to evaluate and adapt these to the HIV epidemic.

The pamphlet is somewhat difficult to read. Obviously the authors have chosen the terminology carefully but the reader needs close concentration especially at the beginning. The introduction and overview are too long and redundant.

The layout of the pamphlet is good. The key recommendations are set out in bold type to assist ready reference. It is concise and its succinct recommendations deal with some of the most difficult questions facing physicians today. AIDS has forced us to rethink, not only our medicine, but also our society, our law and our ethics.

Anne M. Phillips, MD, FRCPC
Department of Infectious Diseases and Microbiology
Toronto General Hospital Toronto, Ontario M5G 2C4


The Doctor, the Patient: the Personal Journey of a Physician With Cancer
Miami: Editech Press, 1989; 168 pp; $9.95 (US)
Allen Widome

Dr. Allen Widome writes about his harrowing experience suspecting a cancer, having it diagnosed and ultimately treated. He writes simply, in short, readable 5- to 10-page chapters. At the beginning, we see Widome as a man unaffected by prejudices, loyal to duty and driven by a strong belief that the patient is a complete person who deserves respect and the best care possible. Simultaneously, we learn that Widome believes he has cancer. The book moves quickly from his experience as a doctor to his experience as a patient.

Widome enters this process expecting special treatment, believing that his colleagues will listen to him and that his distress will be validated and relieved. However, as a patient, he experiences a frustrating, demeaning and dehumanizing series of encounters with consultants. The ancillary staff question him about reimbursement and his capacity to pay. The rushed consultations rely heavily on the results of high-technology tests, most of which are intrusive and painful. Frequently the result is a perfunctory dismissal or, at best, another referral.

Eventually his symptoms worsen and he goes to the nearest academic centre. The distance between doctor and patient is even greater at the new centre as the technology is more elaborate and often more painful. When the answer finally comes, he sees that it had been there all along, and much of his suffering would have been avoided if an earlier test had been interpreted properly.

Once the diagnosis has been made, Widome seeks out a local doctor who is humane and who guides him through treatment and recuperation. The book closes with the plea that doctors not "practice by the numbers" but attend to "the science of humanity". He also has some instructions for other patients: make sure you understand the diagnosis or procedure, ask for a second opinion if you feel uncertain and do not accept care that is inadequate but, rather, fight for respect and control over your own treatment.

This book provides a disquieting view from the patient's bed. It makes clear how standard procedures, such as multiple "stabs" when starting an intravenous infusion or unexplained delays in surgery, can torture the patient.

The major resistance to a book such as this is the reaction it creates in the medical reader. After all, no one likes to be admonished. It is easier to dismiss this book (or not read it at all) than to question one's own behaviour. Perhaps this reluctance is an insight into the author's experience. If doctors are to be human, they will not only be humane, they will at times take refuge from the distress they see and sometimes cause. The patient may experience this as withdrawal or callousness. To back away from a patient who makes us uncomfortable may deprive us of insights that would enable us to achieve a relationship that the patient would experience as empathic and caring. It is his doctors' failure to be open to such insights that Widome protests about most of all.

This is not an inflammatory text but a plea that we view the patient holistically. Observe and listen to all of the patient and do not withdraw no matter what the discomfort; then your answers to the patient's questions, if not any clearer, are certain to be more acceptable.

Jonathan J. Hunter, MD, FRCPC
Fellow in Psychotherapy
Department of Psychiatry
Mount Sinai Hospital
600 University Avenue
Toronto, Ontario M5G 1X5


Going for the Cure
New York: St. Martin's Press, 1989; 295 pp; $18.95 (US)
Francesca Morosani Thompson

Francesca Morosani Thompson, MD, at 42 years of age is a wife, a mother of two teenagers, a New York City orthopedic surgeon and in the prime of life when routine laboratory tests reveal that she has an anemia and a bone marrow biopsy shows multiple myeloma, a type of bone marrow cancer. Suddenly, she, like all patients in whom cancer has just been diagnosed, finds her life is topsy-turvy.

She learns that multiple myeloma is considered an incurable hematologic neoplasm; its natural history is unfamiliar to her and to most physicians with the exception of oncologists or hematologists. She discovers that, in managing this disease, specialists use new diagnostic techniques and have high-technology treatments available. Research protocols, autologous bone-marrow transplantation, bone-marrow purging, institutional review boards and informed consent become part of her new vocabulary.

Dr. Thompson writes clearly. The book is an adventure story that starts with the diagnosis and then proceeds through her initial chemotherapy and bone-marrow transplantation; at the time of writing (18 months later) she is still in complete remission. Dr. Thompson describes in detail how she copes with this potentially fatal illness. Initially she tells only her closest friends, partners and immediate family. She continues in the active practice of medicine with appropriate adjustments in her treatment schedules. She is a person with a positive attitude, who says "I don't have time to be sick. I can and will be cured with new technology." Those of us who deal daily with these illnesses know patients who have the power of positive thinking. Francesca took as a good omen for her own success the win by her beloved New York Mets in the 1986 World Series. She also acknowledges that luck plays a role in patients who undergo a successful bone-marrow transplantation.

Other books on my shelf were written by individuals who experienced cancer. I find these invaluable for patients as references and Going for the Cure will be added to this shelf of my patient library. Frequently, I send home with my patients Stuart Allsop's, Stay of Execution (Lippincott, 1973) and Rebecca Lovato's Special Holidays in My Life (Morgan Press). "Cure" would not have been in our vocabulary when treating Allsop's leukemic syndrome or Lovato's recurrent breast cancer. Their message concerned quality of life and the necessity of taking each day at a time. Dr. Thompson would agree with that philosophy, while at the same time she hopes to forward the frontiers of science. As technology advances, books by patients about their illness will follow the technology. This book could not have been written 5 years ago. In the future, we will see more such books as we develop more aggressive and hopefully more biologically specific treatments which offer the hope of cure to these patients.

Going for the Cure is a powerful real-life drama peopled by warm, competent, caring physicians and coloured by the excitement of high technology. This book will be valuable to attending oncologists as well as patients who must undergo aggressive, high-dose treatment that carries a high risk of toxicity but a real potential for long-term remission and cure. The fact that Dr. Thompson has set up a cancer research foundation with her royalties provides a fitting footnote to this book.

Paul R. Duncan, MD, FACP
Director, Medical Oncology
St. Joseph Medical Center
Albuquerque, New Mexico USA 87102


Life and Death: the Story of a Hospital
New York: Random House, 1988; 357 pp; $18.95 (US)
Ina Yalof

In many ways this book epitomizes everything that is good and bad about the American health care system. It gives a sense of an institution, the Columbia Presbyterian Hospital in New York, which, notwithstanding the individual's economic circumstances, is committed to treating the sick and injured. In doing so, it reflects the strong philanthropic commitment of the American people. However, this book also underlines the fact that health care is not a right, but for many is something they receive only through the contributions of others.

The reader will seek in vain any sense of the client in this book. The patients appear on the periphery in anecdotes which focus on the staff and their roles. Although many of the staff are kind to the patients, in some ways the institution puts the needs of the staff before those of the patients. It is interesting to note that a physician in the emergency department set a standard for seeing a new admission within 1 hour - hardly a challenging goal.

The book reinforces a "high-tech" culture by focusing on heroic medicine; there is little discussion of the chronic illnesses that are the major problems in today's health care systems. The section on heart transplantation is the longest in the book, taking up 50 pages. One might ask why a program that serves a relatively small number of patients should receive such a high priority in this history, particularly in a city that has an infant mortality higher than that in any other developed nation. The staff seem to see no inconsistency in offering second transplants to individuals who did not modify a dangerous life style after an earlier transplant.

An intern in medicine gives us some insight into the staffs philosophy by acknowledging that the hospital's culture and terminology implies that rather than owing a duty of care and advice to patients, the staff are inconvenienced by them.

The anecdotes and their emotional content suggest that the author has directed the book at a lay audience. For her caricatures, she has chosen subjects everyone can identify in every institution. In the operating room, there is the archetypal Scottish dragon who rules the roost and barks out her orders; the mother hen in the department of medicine acts in loco parentis to her brood of residents and in the emergency room the golden-hearted orderly goes the extra mile for all his patients. The professional will find little of interest here because many of the characters receive only superficial sketches and are shown at their best. It is hard to believe that an institution the size and complexity of the Columbia Presbyterian Hospital does not have some fascinating internal dynamics and political situations. Given that Ms. Yalof is a medical sociologist who spent 3 years in the hospital gathering her material, either she has had her head in the sand or has chosen to ignore much of what she has seen. In its stead she offers the reader one big happy family; nice, but unreal and at times boring.

The cover jacket asserts that this book "reveals the real life triumphs and tragedies, the humor and the poignancy comprising our most familiar, most mysterious institutions of all the hospital". If hospitals are indeed mysterious places, this book does little to lift the veil; its superficiality will leave the reader unsatisfied, and the soul of the institution never appears.

Peter H. Ellis, MD
President and Chief Executive Officer
Sunnybrook Medical Centre
2075 Bayview Avenue
Toronto, Ontario M4N 3M5


A Safe Place: Laying the Groundwork of Psychotherapy
Cambridge, MA: Harvard University Press, 1989; 162 pp; $22.50 (US)
Leston Havens

Leston Havens, a sympathetic and comforting writer who explores psychotherapy and psychiatry in a philosophical way, describes a psychotherapeutic relationship as "a safe place". In this long essay, he describes his own concepts, philosophies and approaches to patients rather than any particular technique. Although many of the more significant contributors to the therapeutic literature are mentioned, from Freud to Winnicott to Sullivan, this book does not give a clear picture of what they contributed to either psychiatry or psychotherapy. The author's intention seems to be to stimulate our thinking by describing his own work with patients and thus produce a sense of method rather than to teach technique directly.

Havens begins by describing his "own" doctor - that is one of the first physicians he treated. He then discusses psychoanalytic psychotherapy as "Freud's invention", comments on "words as deeds" and uses all of this to support his theme that one can make a psychotherapeutic environment into a safe place.

The book has four major sections. The first has already been described. In the second, the author talks about reinventing the interview. By this he means that each interviewer must develop a style that is comfortable and secure in order to produce reliable findings. In three short chapters entitled "Dangerous places" he discusses suicide, schizophrenia and psychopathy. These are almost pulled out empirically from the author's experience. It is hard to determine why he chose these three topics and cases and what lessons he intends us to learn about psychotherapy from these chapters. This section concludes on the topic of "Today and tomorrow" and the author completes his ideas with a discussion of Sullivan's work and conjectures about the future of healing.

Havens' writing is a mixture of personal ideas and some sound psychotherapeutic principles; however, there are other principles with which I, as a psychotherapist with 30 years' experience, disagree. He does not make a sufficient distinction between what he believes and what he attributes to others. Also, I would have drawn different conclusions and used different therapeutic approaches in some of the cases he described. I suspect that he is technically more precise than he appears to be in this book.

Of his humanity and warmth, one can have no doubt. His experience and thoughtfulness are obvious. It is also obvious that he likes some writers and creative spirits more than others. He quotes Bernard Shaw several times, for example, "If you tell the truth, make them laugh, or they will kill you". Here I disagree with both Havens and, indeed, Shaw, if the latter was serious when he said this. One of the keynotes to good therapy is helping patients to express their anger without the fear of being killed.

This is a book for evening reading, for leisurely contemplation and for careful thought about how a physician works with his or her patients in a humane and therapeutic fashion. This book does not give much information about treating people successfully with psychotherapy and, in my view, should not be used in the teaching of psychotherapy. For devoted readers of Leston Havens, it is a success and as usual, is clear, a pleasure to read and stimulates us to review own thoughts about working psychotherapeutically with patients.

Harry Prosen
Chairman
Department of Psychiatry and Mental
Health Sciences
Medical College of Wisconsin
8701 Watertown Plank Road
Milwaukee, Wisconsin USA 53226