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Country Doctor, A Memoir
Book Reviews DILIP RAMCHANDANI, M.D. BOOK REVIEW EDITOR
Communication With the Cancer Patient: Information and Truth Edited by Antonella Surbone and Matjaz Zwitter New York, The New York Academy of Sciences, 1997 Annals of the New York Academy of Sciences Series ISBN 0–89766–986-X, $90.00, paperback Reviewed by Howard L. Field, M.D.
B
ooks on the psychological aspects of cancer tend to fall into one of several categories: theoretical, clinical, hortatory, autobiographical, or practical. This book, edited by Antonella Surbone and Matjaz Zwitter, is quite different. It is a sprawling collection of 54 chapters by 80 contributors from 6 continents, focusing on the crosscultural aspects of communication with cancer patients. The principal theme of the book is the universal tension between disclosure and concealment of diagnosis and how this is handled by various peoples throughout the world. There are also detours into allied questions such as “do not resuscitate” orders, power inequalities between doctor and patient, and other ethical issues. The editors have deep philosophical interests, as shown by an early chapter with citations to Aristotle, Heidegger, Kant, Mill, and Wittgenstein among the references. But this not an academic philosophical treatise; several contributors give specific step-by-step instructions in communicating bad news to patients. As one might expect in a col-
534
lection, quality varies. Some chapters are long; some, short. Some are terse descriptions of circumstances; others, research articles. Some are comprised of case vignettes; others, presentations of the authors opinions. I found the descriptions of communication between doctor and patient in various countries very worthwhile. The chapter about the effect of New York state legislation on patient care and hospital staff morale was fascinating. It made New York seem even more exotic than far more distant places. One would be foolish to draw firm conclusions about the role of culture in medical communications except to say that it is omnipresent and powerful. Some things are clear. In patriarchal cultures the head of family gets the information and makes the decisions. In places where family ties are paramount, the physician’s communication is primarily with the family. In authoritarian cultures the balance of power favors the physician. The chapters from developing countries are a melancholy reminder of the state of health care in the third world. Although many of the accounts are fascinating, this book is not one to breeze through at a sitting. It will be very useful for students and residents seeking to understand cultural differences in communication between physician and patient. It will provide a handy reference for those of us in multicultural societies, bewildered by the task of speaking to patients and families from unfamiliar places. It will also provide an opportunity for the reader to broaden his or her horizons.
Dr. Field is clinical professor of psychiatry, Jefferson Medical College.
Country Doctor, A Memoir By Benjamin Dlin, M.D. Prince George, BC, Caitlin Press 262 pp., $18.95 Canadian (paperback) Reviewed by Thomas N. Wise, M.D.
B
arney Dlin, well known to Academy members as an urban, witty psychoanalyst from Philadelphia, has made many important contributions to psychological aspects of both coronary artery disease and inflammatory bowel disorders. He played a significant role in elevating the Academy of Psychosomatic Medicine into a leading psychiatric organization. His memoir reveals a new picture of Dr. Dlin, known as “Ben” to his Canadian family and friends. His early years were spent in Bruderheim, a small village in northwest Alberta. Early memories of visiting the blacksmith’s shop and coping with arctic winters served him well in his subsequent primary care career. His family eventually moved to Edmonton where Ben developed a work ethic that has continued throughout his life. Fresh out of internship, Ben chose to join a family physician in a small farming village, Eckville, Alberta, population 159, which was 130 miles from the major referral center. Bad roads, treacherous weather, and no air support made Eckville very remote. During his first week on the job Ben assisted on two appendectomies, one
Psychosomatics 42:6, November-December 2001
Book Reviews hernia repair, six tonsillectomies, one cesarean section, and a variety of tooth extractions, in addition to a large number of medical outpatients and house calls. This sets the stage for 14 months of exhausting but exhilarating work. Ben utilized help from his teachers at the University of Alberta via telephone when needed, but he was often left to his own skills in managing very serious medical situations. Despite such front line responsibilities, both Ben and his mentor always practiced a very simple rule, “if you are not sure of something . . . then recommend a consultation and send them to the most qualified person you know” Realistically, however, this was not always possible, and the book outlines some of the most complicated situations imaginable. Ben ended up repairing mangled limbs and faces from farm accidents and animal bites, as well as treating profoundly ill cardiac patients. He learned how to stabilize devastating eye injuries until the individual could be transported to a referral center. His many deliveries included both cesarean and complicated breach deliv-
eries. He saved many lives including that of a 2-year-old child upon whom he performed his first tracheotomy. Dr. Ben became part of this community and describes life in this town, which was primarily a social center for the many farms in the area. Eventually, Ben hungered for more knowledge and wished to specialize. Choosing between psychiatry and surgery he opted for psychiatry due to his ongoing interest in people and their psychiatric makeup. Although a loss for the town of Eckville, it is indeed fortunate that Barney, as we know him, chose psychiatry. The book in many ways is a testament to a vanishing breed of true country doctors such as Dr. Dlin’s partner in Eckville. Dr. Coppock tragically died at 57 of coronary disease. One wonders whether he worked himself to death! An essential theme throughout the book is the role of the healer. Such physicians knew their patients and their families. Their interventions were as good as their knowledge base, which was often without adequate consultation or help. They offered care, support,
Psychosomatics 42:6, November-December 2001
and compassion regardless of one’s ability to pay. The downside was the isolation of the practice setting and the lack of convenient referral options. Dr. Dlin closes his memoirs with the stark comparison between his experiences and contemporary primary care in a managed care era. There were no preauthorizations for care or endless forms to fill out. The financial rewards were meager, but the satisfaction was significant. Perhaps the greatest problem was the broad range of knowledge required and the sense that specialization might have a greater intellectual reward. This is one question that primary care medicine must continue to answer. Dr. Dlin has given us a wonderful description of frontier medicine but also has posed some serious questions about where medicine should be going. Dr. Wise is professor of psychiatry, Georgetown University, Washington, DC; chairman, Department of Psychiatry, Fairfax Hospital, Falls Church, VA; and editor-in-chief of Psychosomatics.
535
Communication With the Cancer Patient: Information and Truth Edited by Antonella Surbone and Matjaz Zwitter New York, The New York Academy of Sciences, 1997 Annals of the New York Academy of Sciences Series ISBN 0–89766–986-X, $90.00, paperback Reviewed by Howard L. Field, M.D.
B
ooks on the psychological aspects of cancer tend to fall into one of several categories: theoretical, clinical, hortatory, autobiographical, or practical. This book, edited by Antonella Surbone and Matjaz Zwitter, is quite different. It is a sprawling collection of 54 chapters by 80 contributors from 6 continents, focusing on the crosscultural aspects of communication with cancer patients. The principal theme of the book is the universal tension between disclosure and concealment of diagnosis and how this is handled by various peoples throughout the world. There are also detours into allied questions such as “do not resuscitate” orders, power inequalities between doctor and patient, and other ethical issues. The editors have deep philosophical interests, as shown by an early chapter with citations to Aristotle, Heidegger, Kant, Mill, and Wittgenstein among the references. But this not an academic philosophical treatise; several contributors give specific step-by-step instructions in communicating bad news to patients. As one might expect in a col-
534
lection, quality varies. Some chapters are long; some, short. Some are terse descriptions of circumstances; others, research articles. Some are comprised of case vignettes; others, presentations of the authors opinions. I found the descriptions of communication between doctor and patient in various countries very worthwhile. The chapter about the effect of New York state legislation on patient care and hospital staff morale was fascinating. It made New York seem even more exotic than far more distant places. One would be foolish to draw firm conclusions about the role of culture in medical communications except to say that it is omnipresent and powerful. Some things are clear. In patriarchal cultures the head of family gets the information and makes the decisions. In places where family ties are paramount, the physician’s communication is primarily with the family. In authoritarian cultures the balance of power favors the physician. The chapters from developing countries are a melancholy reminder of the state of health care in the third world. Although many of the accounts are fascinating, this book is not one to breeze through at a sitting. It will be very useful for students and residents seeking to understand cultural differences in communication between physician and patient. It will provide a handy reference for those of us in multicultural societies, bewildered by the task of speaking to patients and families from unfamiliar places. It will also provide an opportunity for the reader to broaden his or her horizons.
Dr. Field is clinical professor of psychiatry, Jefferson Medical College.
Country Doctor, A Memoir By Benjamin Dlin, M.D. Prince George, BC, Caitlin Press 262 pp., $18.95 Canadian (paperback) Reviewed by Thomas N. Wise, M.D.
B
arney Dlin, well known to Academy members as an urban, witty psychoanalyst from Philadelphia, has made many important contributions to psychological aspects of both coronary artery disease and inflammatory bowel disorders. He played a significant role in elevating the Academy of Psychosomatic Medicine into a leading psychiatric organization. His memoir reveals a new picture of Dr. Dlin, known as “Ben” to his Canadian family and friends. His early years were spent in Bruderheim, a small village in northwest Alberta. Early memories of visiting the blacksmith’s shop and coping with arctic winters served him well in his subsequent primary care career. His family eventually moved to Edmonton where Ben developed a work ethic that has continued throughout his life. Fresh out of internship, Ben chose to join a family physician in a small farming village, Eckville, Alberta, population 159, which was 130 miles from the major referral center. Bad roads, treacherous weather, and no air support made Eckville very remote. During his first week on the job Ben assisted on two appendectomies, one
Psychosomatics 42:6, November-December 2001
Book Reviews hernia repair, six tonsillectomies, one cesarean section, and a variety of tooth extractions, in addition to a large number of medical outpatients and house calls. This sets the stage for 14 months of exhausting but exhilarating work. Ben utilized help from his teachers at the University of Alberta via telephone when needed, but he was often left to his own skills in managing very serious medical situations. Despite such front line responsibilities, both Ben and his mentor always practiced a very simple rule, “if you are not sure of something . . . then recommend a consultation and send them to the most qualified person you know” Realistically, however, this was not always possible, and the book outlines some of the most complicated situations imaginable. Ben ended up repairing mangled limbs and faces from farm accidents and animal bites, as well as treating profoundly ill cardiac patients. He learned how to stabilize devastating eye injuries until the individual could be transported to a referral center. His many deliveries included both cesarean and complicated breach deliv-
eries. He saved many lives including that of a 2-year-old child upon whom he performed his first tracheotomy. Dr. Ben became part of this community and describes life in this town, which was primarily a social center for the many farms in the area. Eventually, Ben hungered for more knowledge and wished to specialize. Choosing between psychiatry and surgery he opted for psychiatry due to his ongoing interest in people and their psychiatric makeup. Although a loss for the town of Eckville, it is indeed fortunate that Barney, as we know him, chose psychiatry. The book in many ways is a testament to a vanishing breed of true country doctors such as Dr. Dlin’s partner in Eckville. Dr. Coppock tragically died at 57 of coronary disease. One wonders whether he worked himself to death! An essential theme throughout the book is the role of the healer. Such physicians knew their patients and their families. Their interventions were as good as their knowledge base, which was often without adequate consultation or help. They offered care, support,
Psychosomatics 42:6, November-December 2001
and compassion regardless of one’s ability to pay. The downside was the isolation of the practice setting and the lack of convenient referral options. Dr. Dlin closes his memoirs with the stark comparison between his experiences and contemporary primary care in a managed care era. There were no preauthorizations for care or endless forms to fill out. The financial rewards were meager, but the satisfaction was significant. Perhaps the greatest problem was the broad range of knowledge required and the sense that specialization might have a greater intellectual reward. This is one question that primary care medicine must continue to answer. Dr. Dlin has given us a wonderful description of frontier medicine but also has posed some serious questions about where medicine should be going. Dr. Wise is professor of psychiatry, Georgetown University, Washington, DC; chairman, Department of Psychiatry, Fairfax Hospital, Falls Church, VA; and editor-in-chief of Psychosomatics.
535