FICTION

Jeff Collins, MD of Spokane, a past president of WSMA and widely read, offers the following review to members.

The Catastrophist
By Lawrence Douglas

Meet Daniel Wellington, art historian, academic star, devoted husband and futurephobe. Although he has known nothing but success, he is convinced that the future promises nothing but disaster. Daniel is a Holocaust expert at the fictional Franklin College in Massachusetts. What is a professor to do once he chooses a wife and sees tenure on the horizon? Some academic climbing, have a baby and get started on serial adultery. The problem is that the neurotic professor reacts to the everyday stresses of life with way over the top—catastrophic—introspection.

First, impending fatherhood sends him into a tailspin. Next, he imagines his wife having an affair with an androgynous grad student. In response he embarks on a series of his own unconsummated affairs, but not before getting entangled in a harassment lawsuit for e-mailing a former student suggesting a sex act involving a salami sandwich.

"Gradually I lost the ability to distinguish between my original dread and my dread of my dread," he says. "My anxiety reflected back on itself, like an object trapped between two mirrors.

"AS TRAGICALLY FUNNY AS WELLINGTON'S love life is, the most intriguing issues concern his Holocaust research. While awaiting the publication of a definitive work entitled "Art and Atrocity" on the philosophy of war memorials, Daniel is invited to participate in a commission for a Berlin Holocaust memorial. He has a disastrous interview with the director of the British War Museum and carelessly lies to reporters, claiming to be the child of death camp survivors. As his international reputation grows, this lie threatens to topple his entire academic career. Paralyzed by anxiety, he misses several opportunities to rectify his misstatement.

Outrageously funny, and a bit like the Seinfeld crowd, Daniel never seems to mature, never seems to learn any lessons. I felt a bit guilty watching this talented though neurotic Everyman unravel. We can all relate to at least some fear of failure and acknowledge that our response may be dysfunctional and self-destructive.

The story is plausible and full of a sharp, self-deprecating humor that emulates modern culture.

As is his fictional protagonist, Douglas is a professor of LJST-that would be Law, Jurisprudence and Social Thought. Douglas teaches at Amherst and is the author of an acclaimed study of war crimes trials. This is his first novel.

The Road
By Cormac McCarthy

Cormac McCarthy's Border Trilogy—All the Pretty Horses (1992, The Crossing (1994) and Cities of the Plain (1998)—brought him wide acclaim from readers and critics alike who treasured his incredible gift of lanaguage. This year McCarthy, 74, won the Pulizer Prize for Fiction for his novel, The Road, published in 2006. Despite its selection by the Oprah Book Club, I looked forward to reading this latest work.

From the Odyssey, to Huck Finn, to Jack Kerouac to popular music (Follow the yellow brick . . . . Ease on down the . . . . The long and winding . . . . ), the "road" has enduring appeal as a vehicle for literary and artistic expression. McCarthy's Road is a visually stunning, emotionally compelling story of the journey of a man and his son who, following the devastation of an unnamed cataclysm, are two of the last inhabitants of the Earth.

Writes McCarthy, "When he woke in the woods in the dark and the cold of the night he'd reach out to touch the child sleeping beside him. Nights dark beyond darkness and the days more gray each one than what had gone before. . . . Like the onset of some glaucoma dimming away the world."

There is a sense that this may have been a nuclear catastrophe, but it might just as well have been global warming, terrorism or some other modern threat. Civilization and most life on earth have been destroyed. Vegetation and animal life are gone; lifeless rivers are filled with soot. Ash covers the Earth and obscures the sun and the moon.

The unnamed father, who is literate and likeable, realizes that he and his son cannot survive a winter where they are. Using improvised face masks and pushing a grocery cart containing all their belongings, they head south, toward the ocean, following highways and roads for weeks and months. Along the way, they encounter multiple threats to their continued survival, including bands of cannibals, seemingly the only other remnants of humanity.

The father has a bloody cough, not a good sign, and they carry a gun with two bullets, reserved for suicide if they are caught by roving bands of "bad guys." Ultimately we learn of the mother's suicide in the face of complete hopelessness. Yet the boy and his father, "each the other's world entire," go on.

THE FATHER'S IMMEDIATE CHALLENGE is to keep his son alive, but he also manages to sustain some sense of goodness in his son amid the inescapable corruption around them. These efforts are wrenching as they scavenge to exist with meager food, shelter, safety, companionship or hope.

At one point, the boy is convinced he sees another young boy in a town they have stopped in. The father insists they cannot save him. "Are we still the good guys?' the boy asks in one more moment of confusion. His father insists they are. "This is what good guys do," he explains. "They keep trying. They don't give up."

"We should go to him Papa," says the son. "We could get him and take him with us . . . . I'd give that little boy half of my food." How to explain the necessity of abandoning others to certain death while maintaining that we are "the good guys?"

MCCARTHY'S WRITING IS SO EXQUISITE that the reader senses the mysterious changes between father and son that cannot be articulated.

In the end, after extreme hardship, but without finding salvation, the father dies, leaving the boy alone on the road. Seemingly doomed, but with a bullet remaining in the gun, he encounters a man with a family. "Are you one of the good guys?'' the boy asks, and the man says that he is. The family takes him in, a poignant vindication of the father's commitment to stay alive and keep going.

McCarthy's Road is written in a stark, minimalist style. It is frightening, relentless and compelling. I read it on one sitting. It drags you to places you really don't want to go; yet, I could not put it down. The prose is powerful, full of contrasts, bleak but still hopeful, cryptic but a crystal clear reflection of the best and the worst we are capable of, relevant to our daily lives in a world of uncertainty and potential catastrophe.

Special Topics in Calamity Physics
By Marisha Pessl

Another in a series of first novels by new authors presented by Elliott Bay Book Company in Seattle, this book sat quietly in my "to be read" stack for several months. Then it landed on the New York Times list of 10 best books of 2006, so I figured I better get to it.

Pessl has written a delightful story, a thriller set against the teenage angst of an upscale Southern prep school. The central character is Blue van Meer who has spent most of her life traversing the country with her brilliant and necessarily eccentric professor father, Gareth van Meer. (Her mother, it is later revealed, committed suicide when Blue was in kindergarten.) Blue is brilliant herself, but she needs some friends. At the elite St. Gallway School in North Carolina, she finds them, a clique known as the "Bluebloods."

At the outset, we learn of the death of Hannah Schneider, a charismatic teacher of film. We are gradually introduced to the Bluebloods: Jade, the wealthy but promiscuous latchkey kid; Leula, ethereal and pearl skinned but pathologicically reclusive if not depressed; sturdy, chain-smoking Milton; scrawny, brainy Nigel and heartthrob Charles. Each possesses secrets that are disclosed along the way.

And there is dear old dad. Gareth van Meer, reportedly brilliant, itinerant nevertheless. Is he simply not appreciated by the academic establishment, or is there more to his underachievement?

Finally, there is Hannah. Mysterious, with a pull on the Bluebloods that is hard to explain. She sets her sights on Blue and brings her into the group. She initiates the decisive camping trip with the Bluebloods that leads to her death. Sounds like a horror movie, but this is where the novel really takes off as a compelling thriller with an imaginative twist.

The book is LONG—over 500 pages. It's structured like a class in literature, with each chapter titled with a literary reference, and the ultimate solution to the mystery in a sort of final exam that ends the book. Blue is really too smart and far too loquacious—she scarcely utters a single noun without a modifier in the entire book.

There is something pretentious and sophomoric about all this literary-ness, but once I stopped trying to understand each obscure reference (chapter titles, for example), I was able to enjoy the pace and rhythm of the prose, particularly in the last half of the book.

On the one hand, this book is too wordy, the style is a bit too affected and the narrator is a bit annoying.

All in all, there is much fun to be had along the way. The plot is clever, the characters are well drawn and for the most part interesting, and the story is resolved nicely. Hip, ambitious and imaginative.

NON-FICTION

The Revenge of Thomas Eakins
By Sidney D. Kirkpatrick

Book reviewed by James C. Detter, MD

The artist Thomas Eakins (1844-1916) spent most of his life in Philadelphia except for an early period of study in France. He was most associated with Philadelphia's Pennsylvania Academy of the Fine Arts, but he had his difficulties with that famous institution.

With the possible exception of John Singer Sargent, Eakins today is probably the most respected of American portraitists. Two of his most famous paintings, The Gross Clinic (1875) and the Agnew Clinic (1889) feature these two surgeons at the operating table. These paintings were not universally acclaimed until much later because of the realistic exposition of the actual surgical procedure, including the bloody scalpel. Eakins' understanding and ability to paint the intricacies of human anatomy were undoubtedly rooted in his early interest in medicine and his experiences as a medical student before turning to painting. But his knowledge of the human form and his ability to paint with meticulous accuracy also caused him considerable difficulty—he was dismissed from the Pennsylvania Academy after insisting on the use of both male and female nude models, in contravention of the Victorian mores of the era.

EAKINS APPARENTLY DIDN'T NEED TO EARN much income from his painting since few of his paintings sold and he gave many away. At his death a large number were donated to the Philadelphia Museum of Art. A number of his paintings, however, are located in collections throughout the United States. My favorite is his portrait of Walt Whitman (1887-88, Pennsylvania Academy of the Fine Arts). At Whitman's 72nd birthday celebration, the artist and the poet held a particularly amusing conversation. Eakins: "I'm not a speaker." Whitman: "Much the better. You are more likely to say something." (p. 405).

Readers will find this book carefully researched and well written.

Dr. Detter of Seattle is professor emeritus in the Department of Laboratory Medicine at the University of Washington School of Medicine.

Anne Fadiman, who won the National Book Critics Circle Award for Nonfiction in 1997 for this book, recounts the struggle of an immigrant Hmong family with the American health care system.

Nao Kao and Foua Lee, refugees of the CIA-run war in Laos, came to the United States with their children because they had no other choice. The refugee camp in which they had been living in Thailand was scheduled to close, and they could not return home to Laos because they faced certain persecution. They settled in a community of fellow Hmongs in Merced, California where their daughter Lia was born.
Lia suffered a seizure when she was about three months old, an event her family attributed to the slamming of the front door by an older sister. They felt that the fright had caused Lia’s soul to flee her body and become lost to a malignant spirit. Western medicine, unsurprisingly, saw it otherwise. Dedicated and energetic pediatricians Neil and Peggy Ernst diagnosed Lia with what the American doctors called epilepsy, and what her family called quag dab peg, or “the spirit catches you and you fall down.”

Fadiman beautifully and poignantly weaves together the story of the Lees, their doctors, and the social and political history of the Hmong people and their unwilling immigration to the United States. The family attempts to cure Lia through Shamanistic intervention and the home sacrifices of pigs and chickens, and the medical community intervenes and ultimately insists that Lia be taken from her deeply loving parents, with tragic results.

Seeing disaster unfold with each medical intervention by the system we believe exists to treat the sick and the vulnerable is excruciating. Equally distressing is realizing that there seems to be no solution to the miscommunication between the family and the dedicated medical professionals.

The suspense of the child’s precarious health, the understanding characterization of the parents and the doctors, and the insights into the Hmong culture make this a book you can’t put down.

In one of the final chapters, Fadiman suggests ways in which physicians and other health care providers can improve their ability to care for patients whose backgrounds are different from their own. Holding a “diversity” or “multicultural” day in a hospital or medical school is wholly inadequate to the task. To provide high quality, appropriate care for the diverse populations using the U.S. health care system, health care providers and organizations must adequately and honestly assess the need for resources. This book illustrates how much time, energy, and commitment are necessary to understand another culture’s perspective on health and wellness and to translate that understanding to the day-to-day practice of medicine.

Redefining Health Care: Creating Value-Based Competition on Results
By Michael E. Porter and Elizabeth Olmsted Teisberg

If America had a state religion, it would be worship of the marketplace. How then, with continuing efforts to help the market solve the problems in health care, has our “system” of health care delivery become so reliably dysfunctional? Do we need more regulation or less? Is it possible that a single payer is the only solution?

Michael Porter, well-known business guru at the Harvard Business School, and Elizabeth Olmstead Teisberg, associate professor at the Darden Graduate School of Business at the University of Virginia, in earlier work concluded that skewed regulatory and private sector incentives were driving undesirable results in terms of rising costs. Later they came to believe that the strategies, organizational structures, pricing approaches and measurement (or lack thereof) were distorting competition. In this book, they expand on their premises and discuss the strategic and organizational implications for the major players.

This is an important book. It is a long and heavy read, but authoritative, challenging and occasionally inspiring. It offers much to all who care about health care in the U.S.

The book is structured in eight chapters beginning with the scope of the problem. Nothing here will surprise anyone. We pay a lot more for health care in the United States than other developed countries, in absolute and relative terms, and have less to show for it, in terms of access and measurable results.

The second chapter covers the root cause of the problem: zero-sum competition and a vortex of misplaced and non-productive incentives that led to round after round of cost shifting and consolidation with complete disregard for quality and access. Next is a recap of how market-based reform attempts of the 1980s and 1990s went wrong. Again, no revelations. This chapter might have been titled as either Unintended Consequences or No Good Deed Goes Unpunished.

The full cycle of care
The real substance of the book is in chapter 4, Principles of Value-Based Competition, although by the time you get to these pages, you will be very tired of the phrase “value-based competition on results.” The authors’ basic argument is that results are what really matter. Outcome measures should include the full cycle of care, not just individual interventions, and must be adjusted for risk. Physicians and medical societies should participate in defining outcome measures, and experts should be able to check and correct the accuracy of data. The best care costs less because of better and quicker results and fewer errors and rework. Given access to this information, purchasers at all levels will be able to make truly informed decisions and transform health care in a way that tinkering with organizational schemes, payer consolidation or cost shifting cannot.

Porter and Teisberg write, “Value-based competition is positive-sum, [not zero-sum]. When providers win, patients, employers and health plans also win because quality and cost will improve markedly.”
Chapter 5, focused on providers, discusses the concept of “integrated practice units” (IPUs) and the development of market services based on excellence, uniqueness and results. If a provider could not reach the top 10% in a service line, he should eliminate that line of business. Eventually, the market would adjust so that top-tier providers would fill in each niche and the remainder would not survive in the quality-driven market.

There are two appendices, one on the “care delivery value chain” and one on integrated practice units. The Cleveland Clinic Cardiovascular Center is an example of an integrated practice unit, focused and driven by service excellence and quality data. It’s a good illustration of what the authors describe in earlier chapters of the book.

Value not really defined
Physicians and hospitals throughout the United States are trying to maintain their balance against buffeting financial pressures, with one eye on rising clinical costs and the other on shrinking payments while the bigger-picture policy debate focuses on issues such as the level of economic competition and how to align competition in a way that makes sense and preserves the market in some fashion.

Missing from this admirable work is some really useful definition of value. The authors define this as quality per dollar spent, but that definition remains inadequate, particularly when we have de facto irrational rationing. We cover pregnant women but not poor non-pregnant women. We do not cover poor men, unless they are over 65. We cover everyone over 65, wealthy or otherwise.

So, how do we define value, and how do we ensure that patients, payers and providers do not endure, pay for, or deliver health care that has poor or no value?

Maximizing value in health care, however defined, is clearly an economic imperative. It is an ethical imperative as well, and will require physicians to be involved in helping define quality and at the same time advocate for our patients not only through cycles of care but through the complex realities of their lives.

Flawed assumption
Porter and Teisberg also make a key—and I think, flawed—assumption: that patients can be assigned to a physician or to a practice that will have primary responsibility for their care. The recent study by Pham et al in the NEJM notes that Medicare beneficiaries saw a median of two primary care physicians and five specialists working in four practices from 2000-2002. Further, their care does not remain stable over time with particular physicians. This reflects not only the fragmentation of the current delivery system, but the fact that patients, particularly those with chronic illness who consume the bulk of health care, tend to have multiple conditions concurrently. Should patients, then, seek top-decile practice units for their diabetes, coronary disease, arthritis and BPH, or are we to assume that interventional cardiologists will now master the prostate exam and figure out how to administer NSAIDs along with anticoagulants? Given the dispersion of care across both physicians and practices, I’m not sure further fragmentation based on conditions is entirely helpful. Patients are not conditions or cycles of care, and in the complex universe of health care they need our assistance with coordination of care over time and across multiple chronic conditions.

Primary care is given particularly short shrift, but perhaps I am overly sensitive.

The authors have a lot to offer with this book, but these really smart people don’t really appreciate the disconnect between economic theory and the realities of taking care of sick people.

Who Killed HealthCare? America's $2 Trillion Medical Problem—and the Consumer-Driven Cure
By Regina Herzlinger

Regina Herzlinger, a professor in the Harvard Business School, in 1996 wrote one of the first books to define and promote the concept of consumer-driven health care. In this follow-up book, she prescribes a more wide-ranging solution to the problems that plague health care delivery in America.

This book and Michael Porter's Redefining Health Care, which I reviewed in the May/June 2007 WSMA Reports, share a general thesis about the shortcomings of the American health care system. They both outline fairly well the maddening inefficiencies, poor communication and perverse incentives in health care.
But Herzlinger, unlike Porter, relies heavily on hyperbole, sweeping generalizations and character assassination that eventually compromises her integrity and misportrays a system that is admittedly substantially flawed.

Herzlinger describes the "killers" of health care as the insurers, the general hospitals, the employers, the U.S. Congress and the academics. No one, except physicians, interestingly, escapes her wrath. Most unfortunately, however, she attacks Arnold Relman, the former editor of the NEJM and a passionate defender of professionalism in medicine.

Once she's taken almost everyone to the woodshed, she details her vision for consumer-driven health care (CDHC). In Herzlinger's view, the ideal CDHC system would have a universal mandate (and require coverage for catastrophic care), subsidies for the poor, tax-free purchase of health insurance not restricted to government-run markets and transparency. Consumers, empowered by information organized in the manner of Consumer Reports, would purchase the insurance and medical care they need. The market would adjust to produce high quality, efficient health care. Out-of-step providers would not survive.

She describes other countries where CDHC is successful, but regrettably, she focuses mostly on Switzerland. Switzerland may resemble Massachusetts, but it does not resemble the U.S. in terms of population, size, diversity or economy. Further, by her own account, the Swiss system is highly regulated, prices are controlled and transparency about quality is absent. What it does have is government subsidy and a universal mandate, which seem to account for much of its success.

In later chapters, Herzlinger defines the tactics needed (carrots, sticks and laws) to make CDHC a reality. The carrots are entrepreneurial insurance products, delivery models like the "focused factories" espoused in her first book (a health care example would be a hospital that performs only abdominal hernia repair), and competition without the Stark laws that restrain self-referrals.

The sticks are primarily information (transparency will cure all) and government policing. She praises the SEC, Wal-Mart and the U.S. auto industry as examples of market successes.

Neither Herzlinger nor Porter demonstrates any understanding of the coordination of medical care. Care coordination is generally not supported in our current system nor is it addressed by a consumer-directed system based on focused factories. Neither author demonstrates any understanding or interest in a safety net. Certainly, both insist that universal coverage is needed and that will help, but what if a fully informed consumer spends her insurance dollars on liposuction and facial peels and then develops ESRD? I suspect we will take care of her.

Most seriously, neither author appreciates the persistence of old-fashioned beneficence. Many physicians and hospitals today are concerned with declining reimbursements and income, but we have largely maintained a fundamental dedication to the welfare of our patients. When we face a patient, our concern still is what is the most likely diagnosis and what is the best treatment. Sick people are uniquely vulnerable and their needs must come before our own.When you buy a car or a toaster or a mutual fund, you can read the ratings in Consumer Reports, but the person who sells you the goods is fundamentally not interested in your welfare.

Herzlinger and Porter authoritatively demonstrate that our current system of health care delivery is no longer making most people healthier, but is instead generating inequality and insecurity. Continued technological advances bump against financial and ethical limits. Physicians, as we all know, are increasingly dispirited, patients dissatisfied.

Among my peers, I sense an air of resignation that such iniquities are simply the way it is and can't be changed. But do we want our lives and our careers to be Let's Make a Deal? Just a money grab? Call me an optimist, but I don't think so. As Dr. Relman has repeatedly reminded us, medicine is more than a business.

Insurance companies that deny coverage, drug companies that charge a lot of money, or employers that don't offer their workers benefits are in truth all acting rationally. They are businesses, and businesses are designed to make profits, which, it turns out, is not always in the best interest of people who are sick. If you want a different outcome, you need to come up with a different system.

This list was taken from our 2007 WSMA Reports newsletters. To see current book selection, go to the Good Books List. To see past book selections, go to the Good Books List archives—2005, 2006, and 2008.