The Soul of Medicine: Tales From the Bedside. By Sherwin B. Nuland, M.D. New York, Kaplan Publishing, 2009. Pages: 214. Price: $26.95.
In the interest of full disclosure, I will acknowledge that I have known Sherwin Nuland, M.D., in a professional capacity for more than 20 years. The distinguished author of numerous books, including How We Die (winner of the National Book Award in 1994), “Shep” Nuland is a clinical professor of Surgery at the Yale University School of Medicine (New Haven, CT) and a Fellow at Yale's Institute for Social and Policy Studies.
Dr. Nuland is a gifted storyteller whose humanity, candor, and perspicacity enrich his crisp literary style. He is also a noted medical historian with a deep understanding of the moral dimensions of human complexity, particularly in the context of the unique doctor–patient relationship. Indeed, Dr. Nuland excels in conveying the dynamics of complicated human relationships, especially those involved in the setting of physician–patient interactions, as well as those between a physician mentor and a student. Moreover, in the manner of Jerome E. Groopman, M.D. (Professor of Medicine at Harvard Medical School, Chief of Experimental Medicine at Beth Israel Deaconess Medical Center, Boston, MA), he is adept at communicating to readers without a medical background the particular way physicians approach various problems or apparent dilemmas.
The Soul of Medicine: Tales From the Bedside is, in my opinion, an example of Dr. Nuland's finest work. Loosely fashioned along the lines of Geoffrey Chaucer's Canterbury Tales , the book consists of more than 20 stories, predominantly narrated by senior physicians, of memorable patients they cared for in the course of their careers. To ensure confidentiality, the author disguises the identifying features of both the physician storytellers and their patients. He does not, however, alter any of the medical facts. The result is a captivating and moving collection of human dramas involving patients suffering from both rare (feculent empyema) and common conditions (diabetes and congestive heart failure) narrated by specialists spanning the alphabetical gamut from anesthesiologist to urologist. Although the neurosurgeon's two tales are particularly poignant, I was fascinated especially by the anesthesiologist's tale.
The narration contributed by the anesthesiologist featured a surgeon with bipolar disorder who unilaterally decided to discontinue his medication while on a 3-week vacation. When he returned to work to perform what was to be a routine cholecystectomy, the surgeon was dramatically changed in demeanor. The typically stolid physician seemed to be manic, greeting the surgical team in an aggressively vulgar manner, and then returning to the operating room in less than half the time it takes to do a 10-min scrub. He began operating in a frenzied fashion, taking the gallbladder out in approximately 3 min. The stomach was entered next, followed by the anterior wall of the aorta. The obviously crazed surgeon was wrestled to the ground, and a team of surgeons quickly converged on the bloody scene to save the patient's life. The anesthesiologist and several other physicians, including the chiefs of surgery at the two hospitals where the impaired surgeon practiced, suffered legal and personal repercussions. Till date, the anesthesiologist is haunted by guilt and remorse, “The guilt persists, and even grows, because although I have reviewed every aspect of the near-tragedy again and again, I always come away with the puzzle of why I behaved as passively as I did.” (Only a few weeks ago, I used this incident as a case study during my lecture to our new residents on ethics. We emphasized that the dictum “To do no harm” must also be profoundly understood as “to allow no harm.”)
This slim volume effectively delivers the message that physicians are well intentioned but imperfect human beings who, in the vast majority of cases, are dedicated and meticulous in their efforts to help patients. The practice of medicine is extremely challenging and frequently painful. Despite the panoply of technological advances and sophisticated tools currently available, the physician must learn to live with uncertainty, often relying most heavily, if not exclusively, on simply observing, listening, and caring. At the end of the day, judgment is the soul of the art of medicine.
Finally, I will mention that at the conclusion of these remarkable tales of unforgettable patients, Dr. Nuland invoked the “Narrator's Privilege” and selected the most memorable physician he had ever encountered. Happily, he selected an anesthesiologist, “Danny Farber,” who is readily recognizable as the late Emanuel M. “Manny” Papper, M.D., Ph.D. The book is worth far more than its price for this vignette alone!
Westchester Medical Center, Valhalla, New York. mcgoldrickk@wcmc.com
