Thursday, September 5, 2013

One Doctor by Brendan Reilly - Book Reviw


One Doctor: Close Calls, ColdCases, and Mysteries of Medicine by Brendan Reilly MD (Atria Books - Random House, 2013, 464 pages, $28.00) is an important, substantive, gripping story about the inner life and challenging medical practice of one of the country's leading medical clinicians, teachers, and administrators. Drawing on over forty years of practice in top hospitals undertaking the toughest cases and jobs, Brendan Reilly accomplishes what few people who write doctor books for the general reader can or are willing to do. He takes an on-call period in his current job as Executive Vice Chair of Medicine at New York Presbyterian Hospital (one of the finest teaching hospitals in the world) to frame the challenges faced by the nation in its medical system, by individuals doctors seeking to practice medicine within this new world of changing technology and economics in medicine, and his own personal experiences as he faces intractable medical problems with his students and the impending deaths of his own parents. During a harrowing week on call, doing rounds with his students while he manages his parent's illnesses and infirmities, Reilly explores with courage and insight his own life and learning experience in medicine and the medical crises faced by key patients. He does this with a style of personally exploring his own reactions, feelings, and actions which is rare among doctors. The result is a gripping story that often reads like a novel (or, for those with a visual imagination, looks like the TV program ER, which was conceived and filmed during his tenure at Cook County Hospital) while examining issues facing the larger medical community and the nation.

The major thesis of this fine book is that in the increasingly complex world of possibilities placed before us by medical technology it becomes essential that individuals have a physician they see as “their” doctor, a doctor who knows and understands them as a human being in addition to as an organism requiring treatment. Meanwhile, today's world of medical practice places greater and greater emphasis (and rewards for young physicians) on specialties and sub-specialties which treat a part of the body rather than the whole person. This leads to a separation between disease and illness, with illness being the complex interactions of the physical problem combined with the background, experience, and feelings of the person suffering from the disease to be treated. Just as the need for a person who can view the big picture becomes more necessary, the ability to do so is disappearing because of the incentives driving young doctors to specialize. Working with brilliant young residents in a range of specialties, Reilly seeks to find not only what will solve the problem, but what the patient wants in terms of quality of life and is willing to endure in terms of suffering and pain to get to his goal. As might be expected in this great hospital, most of the patients Reilly's team encounters are very sick, on the verge of death, making these decisions increasingly complex and difficult and calling even more on compassion and understanding to complement knowledge and skill.

Sometimes Reilly's style seems discursive and confusing as, in the middle of a case, he jumps to another patient somewhere in his past or a different story within his present practice. And then it becomes clear that he has bigger fish to fry than medical stories, no matter how riveting and fascinating each one might be. Reilly is concerned with the big questions of contemporary medical practice in a world seemingly governed more by money than by compassion. How can we be sure that the patient's needs are being met when the patient is too sick to communicate? How has the power of medical directives changed when a feeding tube or a ventilator might be temporarily necessary to help achieve a larger goal? How can doctors tell the difference between temporary delirium and worsening dementia? Who has the courage to take responsibility for decision making in life or death situations? How can we break out of a setting where a patient's economic background determines the quality and extent of the medical care they receive? What is the role of medical error, and how can it be reduced? What is the role of personally becoming invested in determining and owning medical error for physicians? How does fee-for-service medical payment distort effective decision making? What is the role of insurance companies in rationing health care? These are some of the big questions standing behind the sick and dying people we meet and come to care about throughout this book as Fred and Martha, Mr. Warner, Mr. Principo, Ms. Finch, and Reilly's elderly parents face the realities of their illness. 

Brendan Reilly, MD

Dr. Reilly received his medical degree in 1973 from Weill Cornell Medical College (formerly Cornell University Medical College) and completed his residency training at Dartmouth, where he served as chief medical resident. He subsequently was named chief of the Division of General Internal Medicine and served on the Board of Governors of the Dartmouth Hitchcock Clinic until 1989. He then moved to the University of Rochester to become professor of medicine, chair of the Department of Medicine at St. Mary's Hospital, and founder and director of Rochester Health Reach. In 1995, he was appointed to lead the Department of Medicine at Cook County Hospital in Chicago. He is now serving as executive vice chair for clinical affairs in the Department of Medicine at NewYork-Presbyterian Hospital/Weill Cornell Medical Center and Weill Cornell Medical College. He is known for his advocacy of evidence- based medical practice, and he was featured in Malcolm Gladwell's popular book Blink. Reilly's narrative links each case to lessons learned from specific previous ones throughout his long career inevitably leading towards his championing the need for a skilled internist acting as the patient's advocate and directing care. For patients, this means that while still healthy it has become even more essential to build a relationship with a specific doctor who can assemble a treatment team treating the patient's best interests rather than just his disease. This doctor's job is to partner with patients to help decide what is best for them, to recognize that the most care is not necessarily the best care.

One Doctor: Close Calls, Cold Cases,and Mysteries of Medicine by Brendan Reilly MD (Atria Books, 2013, 464 pages, $28.00) is a fascinating and engaging book carefully structured to merge personal and the professional, the technical with the clinical, research with experience to present the opportunities and challenges presented by modern medical practice. In doing so, he attempts to examine many of the issues attacked by the Affordable Care Act (Obamacare) from the point of view of a practicing physician and hospital administrator. It is carefully annotated with interesting additions to the main text. It stands as one of the most readable and comprehensive (comprehensible, too) books on medicine I've read. The book was provided to me by the publisher as a digital download through Edelweiss: Beyond the Treeline. I read it on my Kindle.