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Title: The Laws of Medicine: Field Notes From an Uncertain Science
Author: Siddhartha Mukherjee
Publisher: TED Books/Simon & Schuster
Publication date: October 13, 2015
Price: $16.99; hardcover, 96 pages
The Emperor of All Maladies, written by the Indian-born American oncologist Siddhartha Mukherjee, MD, PhD, won the 2011 Pulitzer Prize for General Nonfiction. His 500-plus-page book traces the history of cancer from its first recorded identification 4,600 years ago by the Egyptian physician Imhotep. Dr. Mukherjee recently published another book, The Laws of Medicine, which—given that it’s 96 pages—is a flyweight compared with its heavyweight predecessor. A central reason for the book’s slenderness is that it was derived from a TED talk, which is usually limited to 18 to 20 minutes.
TED has joined forces with publishing titan Simon & Schuster to create a new imprint called TED Books. It’s a clever concept, since a lot of very bright people showcase their bright ideas in TED talks, which, if interesting enough, can now be packaged as a book.
Perfect Decisions With Imperfect Information
Dr. Mukherjee has a flair for heavy messaging with colorful anecdotes. In his prologue, for example, he tells a story from his days as a medical resident at Massachusetts General Hospital. The central character of the story is Dr. Castle, a hard-nosed surgeon from Texas who was so technically adept at surgery that he allowed his students to do most of the operating, knowing that he could anticipate their mistakes and correct them swiftly thereafter.
This book is about information, imperfection, uncertainty, and, according to its high-minded author, the future of medicine. To that end, the author describes a woman in her 50s with a modest-sized tumor in her intestine, who is in the operating room as a resident begins the surgical procedure to excise the tumor, under supervision by the famous Dr. Castle.
The case takes a quick turn for the worse when the resident reaches down to cut the tumor out, and the blood vessels surrounding it begin to leak. He goes into slow-motion panic, but under Dr. Castle’s supervision, the procedure ends a success. Nevertheless, after the successful operation, Dr. Castle uses the experience to summarize the dilemma of modern medicine: “It’s easy to make perfect decisions with perfect information. Medicine asks you to make perfect decisions with imperfect information.” This is the crux of Dr. Mukherjee’s thesis.
Point of Enlightenment
After graduating from medical school, and during his internship, residency, and fellowship, Dr. Mukherjee found himself running into as many questions as answers. It’s worth noting that this is not an uncommon point of enlightenment for many bright young doctors who are not as famous as the author. He writes, “My medical education had taught me plenty of facts, but little about the spaces that live between facts…. I wondered if the compulsive naming of parts, diseases, and chemical reactions … was a mechanism invented by doctors to defend themselves against a largely unknowable sphere of knowledge.”
Perhaps a Pulitzer Prize winner can get away with sweeping accusations that doctors invent mechanisms to defend themselves against things that they simply do not know. Still, it’s a soft statement that needs to be backed up by anecdotal data. But this is not a book that is data driven. That’s not necessarily a problem, as long as you don’t stray too far into musings that wax poetic but are at odds with the reality of clinical care.
Dr. Mukherjee likes to use evocative prose and analogy in his writing. In the buildup to his “three laws of medicine,” he lays the philosophical underpinnings in recalling his early days as a resident at Massachusetts General Hospital, running along the banks of the Charles River and ruminating “on cases that I had seen that week. By the end of the first 6 months, I had witnessed more than a dozen deaths, including that of a young man, no older than I, who died of organ failure while awaiting a heart transplant.” Unfortunately there are just so many viable hearts available. You can’t fault the system for that.
In the same section, Dr. Mukherjee has a moment of insight while recalling a patient: “Illness reminds you that spontaneity, too, is a human right.” Putting aside the shakiness of that assumption, Dr. Mukherjee segues directly into this: “Part of the horror of hospitals is that everything is on time: medicines arrive on schedule; the sheets are changed on schedule; the doctors round at set times; even urine is collected in a graduated pouch on a timer.” Imagine if urine wasn’t collected on time?
“Horror” is an aggressive noun denoting a very strong feeling of fear, dread, and shock. It doesn’t fit, especially when the author blames hospital efficiency for that horror. Perhaps Dr. Mukherjee is pointing out that in a health-care system based increasingly on guidelines and digitized protocols, we begin to pay less attention to the art of medicine. It’s a valid point, and as a cancer specialist, he should know that the oncology community wrestles with technology and guidelines that too often rob doctors of precious one-on-one time with their patients, which is so needed in quality care.
The Three Laws
The Laws of Medicine is structured around three laws, and for reductionist readers, Dr. Mukherjee’s honing the solutions to the problems of our $3 trillion health-care system into three laws over a measly 96 pages might be satisfying.
These are his three laws:
Law One: A strong intuition is much more powerful than a weak test.
Law Two: “Normals” teach us rules; “outliers” teach us laws.
Law Three: For every perfect medical experiment, there is a perfect human bias.
Dr. Mukherjee devotes a chapter to each law and begins each with a well-written historic example of a forward-looking doctor or scientist who understood that outliers and intuition coupled with critical thinking skills could lead to positive change in the practice of medicine. He also offers his own vivid experiences in the clinic to make his points.
For example, he describes a compelling diagnostic conundrum he faced with a patient experiencing weight loss, fatigue, malaise, and other symptoms that could point to cancer. After putting his patient through a battery of standard tests, he remained flummoxed. He then had an epiphany triggered by simple observation of his patient’s social environment. Without the patient’s explicit knowledge, Dr. Mukherjee tested him for HIV and discovered that the patient had AIDS, the point being: Dr. Mukherjee conducted his own investigation outside the constraints of standard testing.
Vital Factor
As Dr. Mukherjee eloquently points out in his three laws, we need to embrace the art of medicine. He uses anecdotes and some data to make this point, much of which is cancer-based. For instance, he offers some clarity about the ever-contentious prostate-specific antigen–screening debate as well as the emerging field of immunotherapy. He stresses, above all, that human decision-making remains absolutely vital to medicine. “The medical revolution will not be algorithmized,” he declares.
He’ll get no argument from The ASCO Post readers. Although windy at times, there are little gems within this slim book worth searching for. The Laws of Medicine is a recommended read. ■
