ABIM Foundation, 160–61
Accreditation Counsel for Graduate Medical Education (ACGME), 79–80
advertising, 90, 95–96, 216–17
alcohol. See intoxication
Allman, Neil, 178–84, 185, 190. See also CrossFit
alternative medicine, 138. See also herbal remedies
American Medical Association (AMA), 75–76, 159–60, 216–17
AmeriCorps, 192. See also Interfaith House
antipsychotic medications. See psychiatry: medications used in
appendix, 149
arete, 154. See also ethics: virtue ethics
“Army Surgeon” (Osler), 48, 50
Arnold P. Gold Foundation, 42–43
Asclepius, 201
Augustine (saint), 202
authority: for patients’ lives outside their illness, 255; physicians’ decision-making, 7, 8, 63, 123–24, 214–15
autopsies, 21–23, 26–30, 37. See also dissection of cadavers
Basil of Caesarea (saint), 203–5, 237, 254–55
Beaumont, William, 19–21, 22, 26, 47
Bichat, Marie-François-Xavier, 36
“Big Med” (Gawande), 115, 118, 124
billing codes, 2, 169. See also financial aspects of medicine
biological psychiatry, 246. See also brain; psychiatry
bipolar disorder, 10–11. See also case histories: Martha
Birth of the Clinic (Foucault), 36
Birth of the Hospital in the Byzantine Empire (Miller), 205
Bishop, Jeffrey, 61–63
bladder/kidney infection, 141
body: encouraging self-healing of, 134–35, 139–40; as machine, 1, 30–35, 111, 141 (see also parts, patients as); meaning of, 128–29; mortality of, 62, 220, 221; reading/telling the story of, 52–54, 60, 65, 253, 260. See also patients
bone box, 31
“Books and Men” (Osler), 50–51
Bosk, Charles L., 157
brain: autopsy of, 37; neuroscience and, 243–44, 246, 261; pressure on, 120–21, 127 (see also case histories: Tihun); psychotherapy and, 243–44; serotonin syndrome, 77–78; urinary tract infection and, 141. See also delirium; dementia; depression; paranoia; schizophrenia
Bregman, Paul, 212–14
burnout, 7, 40, 64, 174–75. See also physicians: stresses on
cadavers, dissection of, 32–36. See also autopsies
Cannon (intern), 69–70
cardiac catheterization, 101–3
care, logic of, 220–22
case histories: Aruna (psychiatric patient), 99–100, 102–4, 110–12; Bao (psychiatric patient), 84–86, 96–97; Terry Becker (Sweet’s patient), 135; cocaine-using patient, 166–67; Connie (psychiatric/geriatric patient), 131–33, 136–39, 141–42; Cyrus (marijuana smoker), 208–9, 222; Demetrius (AIDS patient), 56–58; Doreen (psychiatric patient), 150–52, 161; Eleanor (dementia patient), 239–41, 243, 244–53, 255, 257; Franciszek (alcoholic patient), 191–94, 204; Gloria (cardiac patient), 2–4, 6, 42; Gregorio (psychiatric patient), 258–67; Jonah (mute pediatric patient), 223–27, 231–32; Joshua (psychiatric patient), 177–78, 186–88, 189; Luther (Verghese’s patient), 61–63; Marcus, Zeke, and Salvador (drug users), 209–10, 212, 214; Martha (bipolar patient), 10–11, 23; St-Martin (Beaumont’s study subject), 19–23; Tihun (vegetative patient), 120–22, 127, 129; Veronica (suicidal patient), 162–65, 173–74; Libby Zion, 77–79
Catholic Worker, 198–99
CBT (cognitive behavioral therapy), 169, 171, 187, 244–48
Chalmers, Sir Iain, 93–94
character of physicians, 40–41, 156–58. See also impatience; morality; virtue; wisdom
Chassin, Mark, 106
Checklist Manifesto (Gawande), 102
checklists, 100, 101–5, 107–9, 110–11, 169. See also standardization
Cheesecake Factory, 115–18, 122, 129, 130. See also restaurant analogies
choice, logic of, 219–21
Choosing Wisely campaign, 160
chronic disease, 7, 135, 187, 224. See also specific conditions
clavicle, 31
clinical epidemiology, 87, 89–91. See also evidence-based medicine
clinical trials, 90, 92–94, 96. See also Cochrane reviews
coaches: CrossFit coach (see Allman, Neil); physicians as, 186–90, 260
Cochrane, Archibald Leman (“Archie”), 91–93, 97, 98, 144, 149, 214, 245
Cochrane Collaboration, 94, 98. See also Cochrane reviews
Cochrane reviews, 90–91, 94–96, 98, 218
coercion, 236, 237–38, 261–62, 265–66
cognitive behavioral therapy (CBT), 169, 171, 187, 244–48
Colorado, 207–9, 211–12. See also Denver Health; marijuana
Columbia University, 42–43
communities: CrossFit community, 185–86, 188–90; partnering with, 229–30; physicians’ need for community, 197–98; religious, 45, 186, 190, 194–99 (see also Dominican orders; Hildegard of Bingen; Judeo-Christian tradition); and the renewal of medicine, 257; ties between physicians and, 14–15, 35, 53, 129–30, 260 (see also Verghese, Abraham)
community clinic, volunteer service in, 49–50, 199–200
complex trauma, 231–32
computers, 16–17. See also technology
conscientiousness, 158–59
controlled substance database, 211
Cosmas and Damien (saints), 197, 199
craftspeople, physicians as, 147–48, 152–53
CrossFit, 176–90
customer service agents, physicians as, 219–22
Dartmouth Atlas of Health Care, 143–44
Day, Dorothy, 198, 244. See also Catholic Worker
death: of author’s first patient, 2–6, 42; avoidance of, 128; of Demetrius (AIDS patient), 56–58; due to medical error, 77–79; impact of patients’ deaths on doctors, 61–63; inevitability of, 62, 220, 221; of Luther (Verghese’s patient), 61–63; of Martha, 10–11; official cause often incorrect, 26; physician’s role and, 255–56; taboos around, 35; of Libby Zion, 77–79, 82. See also autopsies; dissection of cadavers
dementia, 239–41. See also case histories: Eleanor
Deming, W. Edwards, 106–7
Denver Health (hospital), 107, 205–6, 260, 261. See also case histories; Micah bench
depression, 163–64, 174–75, 231. See also case histories: Eleanor
diagnosis: inaccuracy of, 26; psychiatric, 263, 264–65 (see also psychiatry: patient assessment); symptom descriptions and, 263; wisdom and practice and, 153–54. See also case histories; judgment
digestion, Beaumont’s study of, 19–21, 26. See also St-Martin, Alexis Bidagan dit
dissection of cadavers, 32–36. See also autopsies
Dix Hospital, 71–75
doctor, as title, 8. See also physicians
Dominican orders, 194–96, 199. See also Gutiérrez, Gustavo
drug abuse, 150–52, 162–65, 207–10. See also intoxication; marijuana
drug companies. See pharmaceutical companies
duty hours, 79–82
Effectiveness and Efficiency (Cochrane), 93
effectiveness of interventions, 92–93. See also clinical epidemiology; Cochrane reviews; intervention
efficiency: avoiding errors, 114–15 (see also medical errors); Cochran and, 93; overscheduling and, 84; restaurant analogies, 114–17, 119; time with patient and, 2. See also quality improvement
Eli Lilly, 47
Emergency Department: Bao and, 84; drunk patient treated, 191–94; headaches treated, 164, 165; heart attack treated, 2–4; Psychiatric, 259
epidemiology, clinical, 87, 89–91. See also evidence-based medicine
errors. See medical errors
Escoffier, Auguste, 116–17
ethics: and interventions, 119–21, 127, 129; and professionalism, 215; virtue ethics, 125, 154–55. See also Judeo-Christian tradition; morality
evidence-based medicine: checklists and, 101–5; Choosing Wisely campaign, 160–61; dangers of, 97–98; depression treatments, 163; medications not always warranted, 140; origins, 86–88, 93; and physicians’ judgment, 88, 122, 126, 149–50, 160; promise of, 13. See also checklists; clinical epidemiology
exam, physical. See physical examination
exercise. See CrossFit
expert-based medicine, 86–87
failures of medicine, 4–5, 223–27. See also medical errors
faith, author’s, 244
family: author’s, 71, 75, 77, 249; communicating with patient’s, 3–4, 120–22, 127 (see also case histories: Tihun); Jonah’s, 223–26, 231–33
Farmer, Paul, 228–31, 235, 237, 244
financial aspects of medicine: advertising medical services, 216–17; costs to patient, 203; healthcare as exchange offering, 203; intervention encouraged by evidence-based paradigm, 97–98; intervention encouraged by profitability, 144; patients as money, 1–2, 4, 203, 243, 266–67; pill mills, 216; salaried physicians, 261; specialization more remunerative, 54, 155; time per patient, 2; wealthier patients preferred, 228
Flexner, Abraham, Report of, 14–15, 22, 27, 206
Forgive and Remember: Managing Medical Failure (Bosk), 157
Frank, Jerome, 170–71, 173, 174, 243
Freud, Sigmund, 232, 244, 246, 253–54
Gandhi (intern), 69
gardeners, physicians as, 134–35, 137–40, 175, 260
Gawande, Atul, 102, 115, 118–19, 122, 124
genome of patient, 12
Girl Who Died Twice (Robins), 77–78. See also Zion, Libby
God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine (Sweet), 133–34
Gold, Arnold P., 42–44
grand rounds, 64–65
Gregory of Nyssa (saint), 202
Guerrasio, Jeanette, 158
Guide to Effective Care in Pregnancy and Childbirth (Chalmers et al.), 94
Gutiérrez, Gustavo, 229–30
Guyatt, Gordon, 87–88
haloperidol, 70, 77, 78, 150–51, 262
Hauerwas, Stanley, 197–98, 200–201, 205, 219
healing relationships, 170–71
healthcare reform: as call for physicians to see much, 256; as competing initiatives, 5, 24; control on a mass scale, 118; efficiency as, 12, 114–15; evidence-based medicine, 83, 86–88; as fads, 13–14, 261; problems of, 7; quality improvement (QI), 16; restaurant analogies, 13, 114–17, 119, 122, 124–27; as variations on parts and money, 266–67. See also renewal of medicine
healthcare system, failures of, 4–5, 223–27. See also medical errors
health coaching, 186–87
heart: cardiac catheterization, 101–3; heart attack, 2–4 (see also case histories: Gloria); in specimen jar, 32
Hellenistic medicine, 200–201, 205
hierarchy of medicine: internal conflicts, 70; interns and, 40, 69–70; medical training and, 40, 43–44, 117; specialization and remuneration, 54, 155; white coats and, 40, 43
Hildegard of Bingen, 132–35, 138–40, 143, 151, 153
Hilfiker, David, 199
Hill, Austin Bradford, 92
Hippocratic medicine, 200–201
hope, 175, 241–44, 248, 251–55
hospitals, 143; author’s roles in, 256; checklists in, 101–5, 109, 110–11; clinical training of medical students, 55–58; compared to airports, 100–101; coordinating care in, 81, 83, 101–2, 125–26, 233; as factories, 123–26, 147, 188, 227; for the indigent ill, 204–6 (see also Denver Health); medical errors, 77–79, 81, 105–7, 114–15, 222 (see also quality improvement); medical hierarchy, 40, 43, 54, 70; patient discharge, 235; and the poor/indigent, 133, 143, 204–6, 227–28; premodern history of, 133–34, 203–5; psychiatric consults, 99–100; psychiatric hospitals/units, 131–32, 142, 183, 236–37 (see also Dix Hospital); salaried physicians, 261; shifting priorities, 113, 155–56; standardization in, 118–19, 122–30; T-shirts, 146–47. See also system, healthcare as
humanism in medicine, 38–39, 42–44, 46–51, 63–64. See also On Doctoring; professionalism
Illich, Ivan, 123–24
impatience, 162, 166–67. See also patience
indigent ill. See poor, the
Institute of Medicine, 79–80
interns: author’s internship, 71–75; duty hours, 79–80; and medical errors, 77–79; and the medical hierarchy, 40, 69–70. See also residency
intervention: effectiveness of, 92–93; encouraged by evidence-based paradigm, 97–98; ethics and, 119–21, 127, 129; evaluating need/value of, 120–21; financial incentive for, 144; limits of, 124–25
intoxication, 104, 110–11, 191–94. See also drug abuse; marijuana
jailers, physicians as, 265–66
JAMA (Journal of the American Medical Association), 87–88
James, Kenneth, 116–17
Jerome (saint), 202
Jesus, 202–3
John Chrysostom (saint), 202
Johns Hopkins University School of Medicine, 15, 65, 75. See also Osler, Sir William
Journal of the American Medical Association. See JAMA
Judeo-Christian tradition, 198–99, 201–5
judgment: acquiring clinical, 35; evidence-based medicine and, 88, 122, 126, 149–50, 160; prudential, 148–49; technical vs. moral errors, 157. See also character of physicians; maxims; wisdom
justice, 234. See also social justice
Kandel, Eric, 243–44
kidney infection, 141
Kinney, Michelle, 190
Kondrad, Elin (author’s wife), 71, 75, 77, 249
lab coats. See white coats
Leape, Lucian, 105
liberation theology, 229–30
life guards, physicians as, 184
“local” movement: CrossFit and, 188; in food, 129, 143, 152; healthcare and, 129–30, 143, 152–53, 188, 257. See also communities
Logic of Care: Health and the Problem of Patient Choice (Mol), 219–21
Lohr, Jacob, 144–45
Matthew, Gospel of, 202–3
Maudsley, Henry, 232
maxims, 148, 152. See also slogans
McHugh, Paul, 263
McMaster University School of Medicine, 87, 93
meaning: of a patient’s life/body/illness, 63, 65, 119, 122, 128–29, 253 (see also Verghese, Abraham); psychotherapy and the meaning of events, 171, 243–44
Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. See Flexner, Abraham, Report of
medical errors: and death of Libby Zion, 77–79; from failures of communication, 81, 222; medication errors, 8, 115, 217; from overwork/exhaustion, 79–80; preventing, 105–7, 114–15; statistics, 106; technical vs. moral, 157. See also quality improvement
Medical Nemesis (Illich), 123–24
“Medical Professionalism in the New Millennium” charter, 68
medical training: admission to medical school, 158; apprenticeship, 14, 42, 147; author’s clinical training, 55–58, 68–71; author’s first weeks, 1; author’s internship and residency, 71–75, 78–81, 84–86, 90, 99–100, 167–70, 239, 246 (see also case histories); autopsies and, 26–30; body-as-machine perception taught, 30–35; cadaver dissection, 32–36; hidden /null curriculum, 49; hierarchy of, 40, 43–44, 117; humanistic education, 48–49 (see also humanism in medicine; On Doctoring); identifying student strengths/weaknesses, 180; inefficiency and ineffectiveness of, 115; learning to practice independently, 80–81; learning to speak with patients, 49, 165–67; lectures suffered through, 54, 55; Osler’s influence on, 15, 21–22; premodern, 35, 147–48; in psychotherapy, 167–70; reference books, 45; residency (generally), 75–76, 79–82; rigor of, 14–15; specialization encouraged, 15; and standardization, 15–16; and student character/morality, 156–58; student failure, 156; talks on the future of medicine during, 12–13; teaching methods, 30; teaching techniques, 172–73, 175, 179–80, 182–83; virtue ethics and, 155; white coat ceremony, 38–45. See also interns; residency
medications: automatic reliance on, 173; considering alternatives to, 139–40; considering use in individual patients, 85–86, 96, 97; controlled substance database, 211; errors in prescribing/dispensing, 8, 115, 217; involuntary, 266; marijuana as, 164–65, 207–14; pill mills, 216; prescribing, 85–86; psychiatric medications, 72, 77–78, 95–96, 150, 173, 217–18, 261; widespread use of, 217. See also clinical trials; pharmaceutical companies; specific medications
medicine: Basil on, 254–55; as calling/vocation, 155; as craft, 147–48, 152–53; failures of, 4–5, 223–27; history of, 35–36, 147–48, 200–205 (see also specific individuals); languages of, 263; like dance, 109–10, 111; limits of, 124–25; physician guilds, 159–61; regional variations in medical care, 143–44; relation to the body, 128–29
Mending Bodies Saving Souls: History of Hospitals (Risse), 201, 205
Mennonite Mental Health Movement, 236–38
mental illness, 210–11, 236–38, 259–60. See also case histories; psychiatry; specific types of mental illness
methamphetamine, 150–52
Micah, book of, 202
Mol, Annemarie, 219–21
money, patients as, 1–2, 4, 203, 243, 266–67. See also financial aspects of medicine
morality, 127–28, 156–58, 221. See also character of physicians; ethics; social justice
Morden, Nancy, 161
motivational interviewing, 186–87
Moviegoer (Percy), 267
My Own Country (Verghese), 47, 51–53, 60–63
National Health Service (Great Britain), 93, 94, 98
neuroscience, 243–44, 246, 261. See also brain
Nicomachean Ethics (Aristotle), 154
numbers, communicating with, 88–89
nuns, 195–96. See also Hildegard of Bingen
nurses, 101; and checklists, 102–4, 110–11; collegial relations with, 70; and coordination of care, 101; ED, 2–3; failings of, 191–93, 204; importance of, 8; nuns as, 196; and production-line medicine, 118–19; psych, 72, 74–75, 177, 233, 234–35, 259, 262, 266; training of, 34; and Zion’s death, 78
Oath of Maimonides, 44
On Doctoring (anthology), 38, 45–48
One-Minute Preceptor Method, 172–73
Osler, Sir William: about, 17–18, 21–22; Aequanimitas (collected speeches), 47, 50; autopsies performed by, 23, 26–27; and Beaumont’s work, 20–21, 26, 47; body of, after death, 37; and books, 46, 50–51; clinical epidemiology vs., 91; humanism of, 42, 44, 46, 48; as ideal, 36–37, 44; “physician as ship’s captain” metaphor, 50–51, 82–83; and residents, 75; on seeing much/seeing wisely, 14, 15, 18–19, 23–24; teaching methods, 31, 35, 65 (see also medical training); unethical practices, 23; and white coats, 39
owl pins, 148–49
Oxford Database of Perinatal Trials, 93–94
pagers, 67, 68–69, 71, 75, 82, 99
paliperidone, 95–96
paranoia, 136, 209, 214. See also case histories: Connie
Paré, Ambroise, 254
Parsons, Talcott, 215
Partners in Health, 229–31
parts, patients as: and acute vs. chronic conditions, 135; as aspect of seeing much, 21; difficulties posed by focus on parts, 141; learning to see, 1–5, 27–37, 49, 55, 141, 203; vs. patients as people, 126, 173–75, 266–67; physical examination and, 60; psychiatrists and, 243, 261, 265; seeing meaning vs. seeing parts, 121–22, 128–29; standardization and, 119; St-Martin’s stomach, 19–23; true problem missed through seeing, 224–27. See also autopsies
Pathologies of Power: Health, Human Capital Rights, and the New War on the Poor (Farmer), 228–29
pathology, 35–37. See also autopsies; dissection of cadavers
patience, 166–67, 169, 219. See also impatience
patients: acute vs. chronic conditions, 135; assessment of, 73–74, 99–100, 131, 162–66, 239, 262–63; as consumers, 216–17, 219–21; death of (see death); dehumanization of, 1–4, 28–30, 49, 126 (see also autopsies; dissection of cadavers); discharging, 235; drug use by, 78, 164–65, 207–14; effectiveness of interventions, 92–93 (see also clinical epidemiology; Cochrane reviews); engaging in system, 123–24; evaluating medication for particular patients, 85–86, 96, 97; evaluating value of intervention for, 120–21; exploitation of, 19–23; genome of, 12; goals of, 221–22; healthcare costs, 203; as individuals, 256–57, 267; and the limits of medicine, 124–25; as money, 1–2, 4, 203, 243, 266–67; needs vs. wants, 214; as outcome measures, 16; patient choice, 219–20; paying attention to, 59; physician-gardener approach to, 134–35, 175; physicians’ perception of, 24, 29–30, 34–35 (see also body: as machine; parts, patients as); poor/underserved patients, 133, 143, 198–204, 227–28; preselection of, 228; as products, 124; religious beliefs of, 127–28 (see also case histories: Eleanor); safety of, 106–7, 118 (see also medical errors); seeing the whole patient, 84–86, 127; self-efficacy, 174; and the sick role, 215–16; speaking with, 49, 144–45, 165–67, 222, 223, 262–63; stigmatization of psychiatric, 264; time spent with, 2, 135, 144–45 (see also gardeners, physicians as); as training manuals, 200; willingness to change, 163–64, 171, 186–87. See also case histories; physician-patient relationship
Penson, Richard T., 64
Percy, Walker, 267
Persuasion and Healing: A Comparative Study of Psychotherapy (Frank), 170–71, 174
pharmaceutical companies, 47, 90–91, 95–96, 217
pharmacists, 8. See also medical errors: medication errors
physical examination, 54–55, 60, 62, 139
physical therapists, 8
physician-patient relationship: authoritarian approach, 162, 166; Beaumont and St-Martin, 19–20; change needed in, 261; changing roles, 111; checklists and, 107; decision-making authority in, 63; dissection as inauguration into, 32–35; healing relationships, 170–71; inequality of, 110; and the logic of care, 220–21; and patient choice, 220; patients’ empathy toward doctors, 265–66; patients’ hopes for, 241–44, 254–55 (see also case histories: Eleanor); physician as coach, 186–90, 260; physician as gardener, 134–35, 137–40, 175, 260; physician as teacher, 173–75; physicians’ distance from patients, 38, 40; in psychiatry, 111–12, 166–67; seeing and being seen, 265–67; seeing the whole patient, 127; and the “sick role,” 215–16, 218–19; speaking with patients, 49, 144–45, 165–67, 222, 223, 262–63; therapeutic alliance, 111–12, 140, 144–45, 174; time spent with patients, 2, 135, 144–45; Verghese on, 52–54, 61–63. See also checklists; patients; physicians
physicians: advertising by, 216–17; author’s decision to become one, 191–98; burnout, 7, 40, 64, 174–75; character of, 40–41, 156–57 (see also impatience; morality; virtue; wisdom); and checklists, 107, 109; as coaches, 186–90, 260; communal identification of, 46, 47; and communities, 14–15, 35, 53, 129–30, 260; as craftspeople, 147–48, 152–53; as customer service agents, 219–22; decision-making authority, 7, 8, 63, 123–24, 214–15; empathy of, 40, 48, 50; and evidence-based medicine, 87, 89; flexibility and judgment required, 126; as gardeners, 134–35, 137–40, 175, 260 (see also Hildegard of Bingen); hope of, 253; humanism and professionalism of, 42–44, 48; impact of practicing medicine on, 40–41; as jailers, 265–66; judgment of, 35, 88, 122, 126, 148–50, 157, 160; as life guards, 184; and medical marijuana, 164–65, 207–8, 210–14; need for community, 197–98; nuns as, 196; and pagers, 67–69, 71, 75, 82, 99; and patients’ deaths, 61–63; paying attention to patients, 59; perception of patients, 24, 29–30; as prescribers, 139, 216, 217–18; primary care physicians, 2–6; professional distance, 38, 40; as readers/storytellers of the body, 52–54, 60, 65, 253, 260; reluctant to care for the poor, 227–28; as scientists (see scientists, physicians as); as servants, 196–201, 204, 206, 253–54, 260 (see also Farmer, Paul; Judeo-Christian tradition); as ships’ captains, 50–51, 82–83, 254, 255–56, 261; speaking with patients, 49, 144–45, 165–67, 222, 223; stresses on, 7, 61–63, 73–75, 77, 79–80, 199, 212–13; superfluousness of, 92–93, 98; surgeons, 69, 121–22, 148–49; as teachers, 171–75, 179–80, 182–83, 254, 260; as technicians, 54, 123–27, 134–35, 196, 253, 260; training of (see medical training); virtue ethics and, 155; white coats, 38–45, 50; as witnesses, 235, 237–38, 252, 254, 260; workload, 2, 14, 79–82. See also diagnosis; physical examination; physician-patient relationship
Platonic medicine, 200
poor, the: burdens of illness suffered disproportionally, 228–29; healthcare services for, 133, 143, 198–200, 204–6, 227–31 (see also Denver Health; Laguna Honda); reluctance to care for, 133, 143, 227–28; tradition of charity/service to, 198–205, 229–31
Porter, Theodore, 88–89
prescription drugs. See medications; physicians: as prescribers; specific medications
primary care physicians, 2–6
professionalism: deficits in, 156–58; and ethics, 215; humanism and, 42–44, 48, 50–51, 63–64; importance of, 67–68; and the logic of care, 220–21; and patient choice, 220; professional distance, 38, 40; regulation of duty hours and, 80–82; and service, 219 (see also servants, physicians as); white coat as symbol of, 38–45, 50
psychiatry: algebra analogy, 239, 241, 245; author’s decision to enter, 70–71; author’s internship and residency in, 71–75, 84–86, 90, 99–100, 167–70, 239, 246 (see also case histories); availability of treatment, 150; complex trauma, 231–32; consults, 99; contemporary medicine compared to, 6–7; Emergency Department, 259; five-factor model, 158; hospital psychiatric units, 131–32, 142, 183; medications used in, 72, 77–78, 95–96, 150, 173, 217–18, 261 (see also specific medications); patient assessment, 73–74, 99–100, 131, 162–66, 239, 263; patient goals, 221–22; questions of exploitation relevant, 23; self-efficacy, 174; somatization, 232–33; stigmatization of psychiatric patients, 264; supervision notebook, 167–68; therapeutic alliances, 111, 142, 143, 174, 233–34; therapeutic techniques, 169–71, 186–87, 243–47, 253–54 (see also cognitive behavioral therapy; psychotherapy); treatment teams, 233. See also case histories; mental illness; specific mental illnesses
psychoanalysis, 246–47, 253–54. See also case histories: Eleanor
psychodynamic therapy, 246–47
psychotherapy, 167–70, 174, 186–87, 243–44. See also psychiatry
pull-ups, 180–81
quality and safety movement, 106–7, 118, 130. See also quality improvement
quality improvement (QI), 106–7; about, 16; benefits, 122; control on a mass scale, 118; limitations, 122–23, 126–30; outcome measures, 16, 227; and physicians’ judgment, 149–50; restaurant /factory analogies, 114–17, 119, 122–27, 129–30; speaker on, 114–15; widespread support for, 125. See also quality and safety movement; standardization
quantification, 88–89, 96–98. See also clinical trials; Cochrane reviews; evidence-based medicine
randomized trials. See clinical trials
record keeping, 59
reforms. See healthcare reform
regional variations in medical care, 143–44. See also “local” movement
regulation: and duty hours, 79–80, 82; and healthcare advertising, 217; and healthcare safety, 105–6, 118, 130, 222 (see also quality and safety movement; quality improvement); and outcome measures, 155; and patient discharge, 235; and patient goals, 221–22; and professionalism, 82; and standardization, 135
religious communities, 45, 186, 190, 203. See also Dominican orders; Judeo-Christian tradition
Remaking the American Patient: How Madison Avenue and Modern Medicine Turned Patients into Consumers (Tomes), 216–17
renewal of medicine, 175; author’s hopes for, 235–36, 257, 261; fostering professionalism, 67–68; “full responsibility” paradigm and, 65–66; physician-as-teacher approach, 173–75; physician-gardener approach, 134–35, 137–40, 175, 260; reenchanting medicine, 140–41; Schwartz Center Rounds, 64–65; slow medicine proposal, 143; as social justice work, 228–31 (see also Farmer, Paul); therapeutic alliances and, 111–12, 140, 174, 257; Verghese’s vision, 53, 59–60. See also healthcare reform; quality improvement
residency: author’s internship and, 71–75, 78–81, 84–86, 90, 99–100, 167–70, 239, 246 (see also case histories); duty hours, 79–82; history of, 75–76; and medical errors, 77–79, 81; selection process, 159; white coat worn, 40. See also interns
responsibility of physicians: and burnout, 174–75; Gold on, 43; handed off, 81, 83, 101, 126, 226–27; for interpreting the body, 52, 53–54, 61–63, 65–66; residents, 80; shared with patient, 111; ship’s captain analogy and, 255–56; Spencer on, 49; Verghese on, 52, 62–63, 65; white coat ceremony and, 44
restaurant analogies, 13, 114–17, 119, 122, 124–27, 129–30
Reynolds, Richard C., 47–48
Robert Wood Johnson Foundation, 46–47
Robins, Natalie, 77–78
robots, 17
Rockwell, Norman, 45
Rogers, Stewart, 40–41, 43, 45, 50, 157, 167
Rooted in the Earth, Rooted in the Sky: Hildegard of Bingen and Premodern Medicine (Sweet), 132–33
Rousselot, Pierre, 153–54
rules, following, 108–9. See also checklists; standardization
schizophrenia, 90, 95–96, 132, 136, 150, 259, 263–64. See also case histories: Connie, Doreen, and Gregorio
Schromm, Emily, 179
Schwartz Center Rounds, 64–65
scientists, physicians as: birth of modern medicine and, 5; dissection and, 35–36; medical training and, 15–16, 46, 76; Osler’s influence, 15–16, 22–23; white coats and, 39, 45, 50. See also Beaumont, William
seeing much: and automation, 17–18; Cochrane reviews and, 91; evidence-based medicine and, 89; focusing exclusively on medicine, 76; healthcare reform and, 256; mastery through repeated experience, 14–15; and outcome measures, 16; recognizing patterns, 135–36, 137; as requirement for seeing wisely, 18–19; residency programs and, 72–74, 80–82; seeing more patients, 14
seeing wisely, 18–19, 23–24, 257. See also wisdom
self-efficacy, 174
serotonin syndrome, 77–78. See also Zion, Libby
servants, physicians as, 196–201, 204, 206, 253–54, 260. See also Farmer, Paul; Judeo-Christian tradition
ship’s captains, physicians as, 50–51, 82–83, 254, 255–56, 261
slogans, 146, 147. See also maxims
slow medicine proposal, 143. See also gardeners, physicians as; “local” movement: healthcare and; Sweet, Victoria
Smith, Dean, 112
smoking, 207. See also marijuana
social context, 108–9
social justice, 228–31. See also Farmer, Paul; poor, the
Social System (Parsons), 215
social workers, 8, 131, 192, 233, 234
somatization, 232–33
specialization, 15, 54, 155, 159–60
specialized knowledge, 16–17
Spencer, Donald, 49
squats, 182
standardization: benefits, 15–16, 122; in hospitals, 118–19; limitations, 122–30; measuring outcomes, 227; quantification and, 89; restaurant /factory analogies, 114–17, 119, 122–27, 129–30. See also quality improvement
Stanford 25 (list), 60
stem cells, 12–13
St-Martin, Alexis Bidagan dit, 19–23, 26, 47
Stone, John, 47–48
suffering, witnessing. See witnesses, physicians as
Suffering Presence (Hauerwas), 197–98
suicide, 162–65, 174–75. See also case histories: Eleanor, Veronica
Sweet, Victoria, 132–35, 139–40, 143, 206
system, healthcare as, 123–26, 129. See also healthcare reform; healthcare system, failures of
systematic reviews, 94
Taylor, Charles, 108–9. See also healthcare reform
teachers, physicians as, 171–75, 179–80, 182–83, 254, 260
teaching techniques, 172–73, 175, 179–80, 182–83. See also Allman, Neil
technicians, physicians as, 54, 123–27, 134–35, 196, 253, 260. See also quality improvement; standardization
technology, 16–17, 59, 89, 123–24, 125
therapeutic alliances: case histories, 142, 143, 233–34; Dr. Lohr’s example, 144–45; and the renewal of medicine, 111–12, 140, 174, 257. See also gardeners, physicians as; physician-patient relationship
time: governance of physicians’, 67, 68–69, 72–75, 79–82, 101 (see also pagers); needed for healing, 135; record keeping and, 59; regulation of duty hours, 79–82; spent with patient, 2, 135, 144–45 (see also gardeners, physicians as)
“To Follow a Rule” (Taylor), 108–9
Tomes, Nancy, 216–17
Trust in Numbers: The Pursuit of Objectivity in Science and Public Life (Porter), 88–89
T-shirts, 146–47
vegetative state, 120–21, 122, 127
Verghese, Abraham, 47, 51–55, 57–63
viriditas, 134. See also gardeners, physicians as
virtue, 154, 159, 161, 202–3; virtue ethics, 125, 154–55. See also character of physicians; Judeo-Christian tradition; servants, physicians as
volunteer work, 49–50, 199–200
Weber, Max, 140–41
Wiman, Christian, 141
wisdom: invoked but not practiced, 161; learning wisdom, 148–49, 153–54; need for, 161; renewal of, 257; seeing wisely, 18–19, 23–24, 257; seeing with knowledge, 153. See also judgment
witnesses, physicians as, 235, 237–38, 252, 254, 260. See also case histories: Jonah
Wittgenstein, Ludwig, 107–8
WNL, meaning of, 60
Yager, Joel, 170
Yeux de la foi (The Eyes of Faith; Rousselot), 153–54