Reviews and reflections David A. Bennahum, MD, and Jack Coulehan, MD, Book Review Editors

There are a thousand ways that rective dose of potassium is the rem- things can go wrong when you’ve edy. And too much potassium can got a patient with a stab wound. But stop the heart, as well—that’s how everyone involved got almost every the states execute prisoners. step right—the head-to-toe exami- The senior anesthesiologist nation, the careful tracking of the asked to see the potassium bag that patient’s blood pressure and pulse had been hanging. Someone fished and rate of breathing, the monitor- it out of the trash and that was when ing of his consciousness, the fluids they figured it out. The anesthesiol- run in by IV, the call to the blood ogist had used the wrong concentra- bank to have blood ready, the place- tion of potassium, a concentration ment of a urinary catheter to make one hundred times higher than he’d sure his urine was running clear, intended. He had, in other words, everything. Except no one remem- given the patient a lethal dose of bered to ask the patient or the emer- potassium.p6 The Checklist Manifesto: How gency medical technicians what the To Get Things Right weapon was. The patient was lucky and survived, “Your mind doesn’t think of a but Gawande uses these stories to argue Atul Gawande bayonet in San Francisco,” John for a simple method to prevent such New York, Metropolitan Books, 2009 could only say.p3 errors, a checklist. In the first chapter Reviewed by David A. Bennahum, he writes about problems of extreme MD (AΩA, University of New Mexico, The staff knew that the patient had complexity and how training and prac- 1984) been stabbed, but he was comfortable tice can achieve astonishing results; and talking so no one thought to ask but he argues that in medicine we ex- with what and then consider the possi- pect miracles such as that offered by n The Checklist Manifesto, his latest ble consequences of a deep stab wound. penicillin. We have lost the discipline lucid and elegantly written analysis In the second case, a patient under- that a methodical approach requires. Iof how to improve health care, Atul going surgery to remove a cancer of the More than 50 million operations are Gawande addresses the idea that the stomach suddenly went into cardiac performed annually in the United States simple introduction of checklists to pa- arrest. Because the patient had a low and Americans undergo an average of tient care can reduce costs and save potassium before surgery the anesthesi- seven operations in a lifetime. Yet we lives. In each of his books and essays ologist had given him corrective dose of suffer 150,000 post-surgical deaths each Gawande has engaged the reader’s in- potassium. Gawande in his understated year. Gawande writes: terest with stories that illustrate specific but dramatic style quotes the surgeon. points and problems. Here he begins Moreover, research has consistently with a surgical case that had been I was chagrined at having missed showed that at least half our deaths recounted to him by a physician this. An abnormal level of potas- and major complications are avoid- colleague about a patient who sium is a classic cause of asystole. able. The knowledge exists. But had almost exsanguinated It’s mentioned in every textbook. however supremely specialized and from an abdominal stab I couldn’t believe I overlooked it. trained we may have become, steps wound so deep it had Severely low potassium levels can are still missed. Mistakes are still cut the aorta. stop the heart, in which case a cor- made. p31

46 The Pharos/Winter 2011 To better understand this idea Gawande finds that checklists “are Gawande turns to the introduction not comprehensive how-to guides, of checklists in 1935 by the U.S. Army whether for building a skyscraper or Aircorps when it was flight-testing the getting a plane out of trouble. They aircraft that would become the B17 are quick and simple tools aimed to bomber, the famous Flying Fortress. buttress the skills of expert profession- After a number of flight failures the als.” p128 He writes that on January 14, aeronautical engineers realized that the 2009 the World Health Organization complexity of the modern airplane re- came out with a “Safe Surgery” check- quired not better test pilots but rather list. The very next day Captain Chesley a simple method to prevent mistakes, B. Sullenberger III saved U.S. Airways the checklist. He follows this by remind- Flight 1549 after a flock of Canada geese ing the reader of the four vital signs to flew into and stalled his aircraft’s en- which a fifth sign, pain, has recently gines. While the cool demeanor, good been added and asks whether these are judgment, and experience of the pilots not checklists that guide nurses. and crew were crucial, no less so were The Jump Artist Gawande recounts the remarkable the years of attention to detail and the experience of Dr. Peter Pronovost at relentless discipline of their aviation Austin Ratner Johns Hopkins in 2001. Provonost iden- checklists. New York, Bellevue Literary Press, 2009 tified five steps that a physician must This is a marvelous and elegant Reviewed by Jeffrey L. Ponsky, take to place a central line and then book. It is an important if very simple— MD (AΩA, Case Western Reserve asked the nurses to observe whether but not simplistic—contribution to the University, 1971) every physician unfailingly followed medical literature, as is almost every- each step. In more than a third of the thing that Gawande writes. While most patients, doctors skipped at least one. of the book focuses on the application n the tradition of Chekhov, Somerset Pronovost then persuaded the hospital of checklists to technical practice, there Maugham, and William Carlos administration to allow the nurses to is one point that I found very appealing. IWilliams comes another MD who writes stop any physician who had skipped a Gawande describes that as a surgeon beautiful and compelling literary fic- step. Over the next year “the ten-day introducing the checklist to his own tion. Austin Ratner, a graduate of Johns line-infection rate went from 11 percent surgical teams he now asks that they Hopkins Medical School, turned to fic- to zero.” p38 Only two line infections begin each operation by reintroducing tion as a career after receiving his MD. occurred over the next fifteen months! themselves to each other, thereby level- His debut novel, The Jump Artist is a Pronovost had proven that checklists ing the distinctions between physicians, worthy addition to the ranks of literary raised baseline performance. nurses, and technicians and creating historical fiction. Gawande then goes on to explore the a team of the moment for the ben- The history that forms the basis for use of checklists in several industries efit of the patient. Captain Sullenberger the novel is fascinating and largely un- and the literature on complexity. He pointed out that he and his crew were known. Philippe Halsman was a young reports that researchers have defined also a team, each equally important to Latvian Jew hiking with his father in three categories of problems: simple, the final outcome. At the core of The the Tyrolean Alps when his father such as baking a cake; complicated, Checklist Manifesto is a plea for an ethic fell to his death while walking behind such as sending a rocket to the moon; of relationship between individuals who Philippe on the hiking path. In an af- and complex, such as raising a child. He work together on any project and espe- fair dubbed in Europe “The Austrian notes the evidence in favor of checklists cially for those with a commitment to Dreyfuss Affair,” Philippe was arrested for simple and complicated problems, excellent patient care. and convicted of his father’s murder then asks whether checklists are also and imprisoned in an Austrian jail for helpful in situations of great complex- Dr. Bennahum is a book review editor for two years, despite only circumstantial ity. To address that question he cites The Pharos and a member of its editorial evidence. The young, still adolescent data from the building industry about board. He is emeritus professor of Internal Halsman was thrown into a world of the construction of massive skyscrap- Medicine at the University of New Mexico horror and only released by a pardon, ers. And there again he found checklists School of Medicine. His address is: not an exoneration, after the tireless at every level and “an annual avoidable 1707 Notre Dame Drive NE efforts of his sister Liouba and the as- failure rate of less than 0.00002 per- Albuquerque, New Mexico 87106 sistance of human rights activists all cent.” p71 E-mail: [email protected] over the world, including such notables

The Pharos/Winter 2011 47 Reviews and reflections

as Albert Einstein, Thomas Mann, and world and, as the novel builds, we root family afloat financially and to further Eleanor Roosevelt. After being released for his success, hoping he will overcome her favorite child’s ambitious goals. This from prison, the young Halsman was the tragedy of his youth. It is not just the story is interwoven with the history of expelled from Austria permanently and story that stays with you, it is Halsman the gradual recognition of Hodgkin’s went to Paris, to try fulfill his father’s the human being. disease as an entity, from Thomas dream for him of becoming an engineer As physicians we are always strug- Hodgkin’s original cases to Dorothy or doctor. After much struggle, Philippe gling to understand the human condi- Reed’s defining pathologic description, became a well-known Parisian photog- tion. This stunning novel does what all as well as the development of radiation rapher, only to flee Paris as the Nazis in- truly fine novels should do. It illumi- therapy from a scientific curiosity to a vaded. Penniless and stateless, Philippe nates an understanding of the human emigrated to the United States and rose condition through its moving explora- to become one of the country’s most tion of trauma, suffering, and redemp- celebrated photographers of the 1950s tion. and 1960s. His name may be unfamiliar, but his work we all know: the famous Dr. Ponsky is the Oliver H. Payne Profes- headshot of Albert Einstein, Marilyn sor and chairman of the Department of Monroe in a white dress backed into a Surgery at Case Western Reserve Univer- corner, Salvador Dali with the curling sity and the Surgeon-in-Chief of University moustache, the Duke and Duchess of Hospital at Case Medical Center in Cleve- Windsor jumping in the air. Halsman land. His address is: had more Life magazine covers to his University Hospitals, Case Medical credit than any photographer in history. Center The story of The Jump Artist is Department of Surgery compelling as an arc from despair to 11100 Euclid Avenue, LKS-5047 triumph, but it is not in the straightfor- Cleveland, Ohio 44106 ward telling of the story that this strong E-mail: [email protected] debut novel succeeds. Rather, Ratner writes the inner life of a human being Henry Kaplan and the Story of therapeutic tool. By the time Dr. Kaplan who has experienced a level of trauma Hodgkin’s Disease graduated from Rush Medical College beyond imagination. His vivid descrip- Charlotte De Croes Jacobs in 1941, a rudimentary understanding tions of prison, of helplessness, and of Stanford, California, Stanford University of the disease with which he became so the unearned, but agonizingly felt, guilt Press, 2010 identified existed and radiotherapy had of a victim and survivor are so richly been used as treatment. imagined that the reader feels that he Reviewed by William M. Rogoway, Dr. Jacobs outlines Henry Kaplan’s comes to know the interior Halsman. MD rapid professional trajectory from We feel his adolescent struggles with trainee to chairman of Radiology at a father whom he loved and venerated he 1960s and early ’70s were times Stanford Medical School at age twenty- but was irritated by, his haunting sense of significant change in the ap- nine; the remainder of the book is de- of loss, his shocked passivity in the face proachT to cancer therapy in this country. voted to his diverse and impressive of victimization, and his self-loathing, As the hazards and potential benefits of scientific and personal achievements. so common in victims of trauma. As radiation therapy became more widely The over-riding theme is that of a bril- he tries to make sense of his surreal appreciated, it became a powerful treat- liant physician driven to ever-more am- experience, he moves to art just as the ment tool. At the same time, drugs were bitious goals. surrealist movement is gaining sway in developed that not only led to tumor Where does one begin? The Stanford Europe, and his use of the camera be- shrinkage, but, in the case of child- linear accelerator that permitted higher gins to move him into the outside world. hood leukemia, could eradicate disease. energy and more targeted x-ray therapy, The camera captures the full range of Henry Kaplan was a towering figure in the willingness to deliver higher doses human emotion, from the surreal to this heady time of oncologic creativity. of radiation to wider fields in the quest the playful to the beautiful. As Halsman Charlotte Jacobs traces Kaplan’s be- for Hodgkin’s disease cure, the identifi- slowly allows love and art into his life, ginnings in Chicago as the older son cation of the mouse leukemia virus and he reclaims his life. Ratner’s use of lan- of Russian immigrants, recounting the the search for a human viral etiology for guage and his strong artistic storytelling early death of his father and his deter- malignancy, attempts to create antibod- draws the reader deep into Halsman’s mined mother’s struggles to keep the ies to human tumors. Kaplan gained

48 The Pharos/Winter 2011 credit for all these, sometimes leaving research and NCI independence. a complex and flawed man, but indeed the contributions other investigators Throughout his career, HSK de- a visionary who brought a scientific played in these advances forgotten or veloped a few close professional and rigor to the practice of oncology and little noted. While he played a pivotal personal relationships. These were sig- helped move Hodgkin’s disease from an role in the clinical development of the nificant scientists whose common char- untreatable malignancy to one for which accelerator and aggressively pushed its acteristic seemed to be the same drive, cure is now the rule. Dr. Jacobs’ book is use forward, other clinicians at other ambition, and dismissiveness toward a riveting read, meticulously covering a centers were moving in the same direc- others less forceful. Perhaps most in- time of dramatic creativity in American tion. Dose escalation and contiguous teresting is the thorough account of his medicine while also revealing the per- uninvolved field therapy built heavily on evolving friendship with Dr. Vincent sonal infighting that took place behind the work of the Canadian Vera Peters, DeVita, who was key in developing cu- the scenes. and an understanding of the logical rative combination drug therapy for pattern of Hodgkin’s disease spread was Hodgkin’s disease that rivaled Stanford’s Dr. Rogoway is a member of the editorial very much a product of his colleague radiotherapy efforts and who ultimately board of The Pharos and emeritus adjunct Saul Rosenberg. Kaplan never did iden- became the director of the National clinical professor of Medicine at Stanford tify the elusive human tumor virus and Cancer Institute. In interviewing over University. His address is: monoclonal antibody success was left one hundred of his colleagues, patients, 266 Old Spanish Trail to others. friends, and family members, Dr. Jacobs Portola Valley, California 94028 Kaplan’s lasting scientific achieve- was able to bring detail to HSK’s fas- E-mail: [email protected] ment was the rigorous investigation of cinating and multifaceted life and his Hodgkin’s disease. He and his associates impact on others. Particularly revealing pioneered the randomized clinical trial, are first-person recollections of con- answering one question and proceeding frontations with associates and friends to the next in single institution studies whose views differed from his. His with the single-minded goal of curing close, though imperfect, relationship the disease and lessening the complica- with his children is tenderly presented. tions of therapy. Dr. Jacobs has authored a loving ac- Concurrent with his science, HSK, as count of a powerful figure. While the his associates knew him, attempted to chronology is painstaking, I’m not sure reshape Stanford’s medical school in his that one comes away with a balanced image. From the time he became chair- picture of this giant of American medi- man of Radiology, he assumed a leader- cine. As Dr. Jacobs writes toward the ship role in creating a research-oriented end of her book, “anonymity wasn’t school as the university moved its medi- Henry’s way. If you had the chance to cal school campus from San Francisco reach your goal, you grabbed it.” p310 He to Palo Alto. He was instrumental in re- began poor with a very visible physical cruiting a sterling faculty that included deformity, a brilliant mind and a desire The National Institutes of three future Nobel Laureates. As his to achieve. He worked tirelessly and Health: 1991–2008 department grew, he envisioned a na- with tremendous self-assurance built John Kastor tionally sanctioned comprehensive can- a scientific career that was outstand- New York, Oxford University Press, cer center, but as his dream threatened ing. While not detailed in the book, at 2010, 271 pages to dominate the school, close colleagues a time when radiation oncology was a withdrew support and the center never relatively new discipline, his early train- Reviewed by Jack Coulehan, MD happened. This was a devastating and ees became department chairs at half (AΩA, University of Pittsburgh, 1969) embittering defeat. His struggles, some- a dozen academic medical centers. He times very contentious, with deans and had talents and a drive beyond most, other faculty were legendary, his failures but alienated many associates and his hen I did my internship at the and successes are carefully chronicled. own brother. While warm and compas- Hospital of the University of There were forays as well in the na- sionate toward patients, he could be dis- WPennsylvania, John Kastor was a rising tional scientific scene and HSK played missive to associates. While he was very star in Penn’s Division of Cardiology. a key role in refining the 1971 National public in much of what he did profes- He was also one of my favorite attending Cancer Act that paved the way for a sionally, his humanitarian work was car- physicians, partly because of excellent dramatic increase in funding for cancer ried out with much less flourish. He was teaching and obvious commitment to

The Pharos/Winter 2011 49 Reviews and reflections

patients, but also because of his compas- ­employs over one thousand scientists recruiting physician investigators for its sion for students and house officers. At at its Bethesda campus, as well as a intramural programs. However, the NIH the end of my rotation with Dr. Kastor, large number of trainees. The final five still provides the major source of finan- he invited our whole team to his home percent of the budget was devoted to cial support for the training of physician for dinner. And a splendid evening it administration. The individual research scientists through its Medical Scientist was! I remember that dinner as an is- Institutes range in size from the enor- Training Program (MSTP), which sup- land of warmth and conviviality in the mous National Cancer Institute (NCI, ports MD/PhD students in medical often turbulent sea of internship. Since $4.8 billion budget) and National Heart, schools throughout the country. then, Kastor has become one of the na- Lung and Blood Institute (NHLBI, $2.9 Finally, I learned for the first rime tion’s most prominent cardiologists and billion) to the tiny National Institute for about the “Roadmap for Medical a leading figure in American medical Nursing Research (NINR, $139 million). Research,” a strategic plan developed education. He is the author of several It requires over seventy separate admin- in 2002 and 2003 by then-NIH director important books on academic medi- istrative entities—and their acronyms— Elias Zerhouni. Zerhouni wrote, “It was cine, including Governance of Teaching to fully characterize the structure and clear to me that science had changed, but Hospitals (2003), Specialty Care in governance of the NIH. Fortunately, the the NIH had not.” p179 A “convergence of the Era of Managed Care (2005), and reader need not internalize most of this concepts and methodologies” had made Selling Teaching Hospitals and Practice alphabet soup to gain a basic under- many of the traditional rigid distinctions Plans (2008). These works focus, in par- standing of the organization, although between disciplinary Institutes outdated. ticular, on issues of governance in large for the interested masochist Kastor pro- Zerhouni initiated a process to answer health care institutions. vides an appendix listing every single such questions as “What are today’s In his new book, The National acronym and its meaning. scientific challenges?” and “What are Institutes of Health: 1991–2009, Kastor As an academic physician, I found the roadblocks to progress?” This led turns his attention to “the premier or- some of the trends described in The to a strategic plan, which, among other ganization for performing and fund- National Institutes of Health especially things, placed new emphasis on clinical ing biomedical research in the United interesting. First, although I was aware research. Zerhouni also set aside funds States.” pxi The book is primarily a de- that the NIH budget had grown in for Roadmap projects, a practice later scription of the structure, function, mis- the 1990s, I had no idea of how much. endorsed by Congress when it created sion, finances, and priorities of the NIH During the six-year period 1998 through the “Common Fund” as a separate pool over nearly two decades, a period that 2003, its budget more than doubled of money to support the initiation of in- spans the terms of three NIH directors: from $13.6 to $27.1 billion, an average novative interdisciplinary projects. Bernadine Healy, Harold Varmus, and increase of about fifteen percent per In The National Institutes of Health: Elias Zerhouni. While the author pres- year. Even more amazing was the sus- 1991–2008, John Kastor has written a ents plenty of “hard” historical facts, tained average annual eight and a half clear, concise, and highly informative the real energy of his book arises from percent increase over the preceding book that will serve as a useful entry- its human perspective: 222 interviews twenty-seven years (1971–1997). On the point for anyone interested in gaining of present and past NIH administrators other hand, during most of the Bush era a basic understanding of the structure and scientists and other knowledge- (2003 through 2008), the NIH budget, and inner workings of the NIH. As a able observers, conducted over a nearly when corrected for inflation, suffered an bonus, the book also presents a human two-year period. The text relies heav- annual decline. perspective on the NIH’s recent history, ily—and appropriately—on quotations Another interesting point was the with fascinating insights on the process, from these interviews, which provide historical trend of the NIH’s intramu- as well as examples of the content, of the reader with a sense of living history. ral research training program. Kastor NIH intramural research. The NIH consists of twenty research writes of the “yellow berets,” physicians Institutes and seven Centers, five of commissioned in the United States Dr. Coulehan is a book review editor for which serve as providers of infrastruc- Public Health Service and assigned to The Pharos and a member of its editorial ture and support for the institutes. The the NIH in the 1950s, ’60s and ’70s, board. His address is: NIH budget in 2008 was around $29 who provided the nation with a large Center for Medical Humanities, Com- billion, eighty-five percent of which pool of budding physician scientists. In passionate Care, and Bioethics supported extramural research, i.e., subsequent decades, as the doctor draft HSC L3-080 grants to universities, hospitals, and ended and NIH research training be- State University of New York at Stony laboratories throughout the United came less attractive to young physicians, Brook States. Another ten percent funded the the size of this pool decreased, result- Stony Brook, New York 11794-8335 intramural research program, which ing in the NIH having more difficulty E-mail: [email protected]

50 The Pharos/Winter 2011