Medical students are taught that the evaluation of a patient should proceed in a discrete, linear way: you first take the patient’s history, then perform a physical examination, order tests, and analyze the results. Only after all the data are compiled should you formulate hypotheses about what might be wrong. These hypotheses should be winnowed by assigning statistical probabilities, based on existing databases, to each symptom, physical abnormality, and laboratory test; then you calculate the likely diagnosis. This is Bayesian analysis, a method of decision-making favored by those who construct algorithms and strictly adhere to evidence-based practice. But, in fact, few if any physicians work with this mathematical paradigm. The physical examination begins with the first visual impression in the waiting room, and with the tactile feedback gained by shaking a person’s hand. Hypotheses about the diagnosis come to a doctor’s mind even before a word of the medical history is spoken.
–Jerome Groopman, How Doctors Think

I’ve had some notably bad doctors’ appointments. According to How Doctors Think by Jerome Groopman, as a patient struggling to communicate with doctors, I’m not alone. The book opens with the true case of a young woman incorrectly diagnosed for fifteen years (!!!) with anorexia nervosa with bulimia, when she actually had celiac disease. As her weight kept drastically lowering, she was encouraged to eat simple carbohydrates in the form of cereal and pasta to gain weight. She consulted, according to Groopman, “endocrinologists, orthopedists, hematologists, infectious disease doctors, and, of course, psychologists and psychiatrists.” All of them missed the diagnosis of celiac. Out of desperation, the woman went to see a gastoenterologist, who looked beyond the previous diagnoses and discovered that it was the very foods she was encouraged to eat which were making her ill.

As the title suggests, this book is a sometimes terrifying, sometimes triumphant exploration of the way doctors think. Groopman talks to colleagues and experts in many different fields of medicine about their mistakes regarding judgement or emotion, the errors they often see other doctors making in practice or training, and cases that were remarkable because of their success or failure.

Groopman is a doctor himself, but that doesn’t keep him from needing medical care, and one chapter is devoted to his experiences seeking treatment from hand surgeons for his painful, inflamed wrist. Many of the top-rated surgeons present him with nonsensical diagnoses, and seem rushed or reluctant to answer questions. If this is how a fellow doctor is treated, I wonder, how can any of us without medical training expect to fare in this world of 15 minute appointments?

But this is why Groopman wrote How Doctors Think –to give those of us who can’t normally get inside a doctor’s brain, and may feel quite uncomfortable sitting in an exam room garbed only in a paper gown, a chance to communicate more clearly with the people who often make snap judgements about our health and livelihoods.

Groopman gives practical suggestions, including language or phrases patients can use to help doctors avoid cognitive errors. He recommends that patients acknowledge stereotypes they may fall into, as doctors rely on pattern recognition to do their work quickly and usually place patients into stereotypical categories. Acknowledging that you come across as a bit neurotic, but you do think you have a health condition despite this, can prevent a doctor from dismissing your concerns as hypochondria. He suggests mentioning your main fear to your doctor, even if it is something you saw while Googling or heard as a horror story about a friend of a friend. He also suggests discussing it directly if your doctor is having a hard time communicating with you or seems to dislike you. (However, when doctors were asked what they would do if they were seen as a patient by a doctor who had difficulty communicating, they answered that they would just get a new doctor.) I absorbed as a crucial point of the book that acknowledging medical care as a relationship consisting of communication between two people, with emotions and judgements and all that comes along with two individuals, can result in better health care.

There are some alarming statistics mentioned and then not explored too much–that doctors like sick patients the least, and that the physical symptoms of the mentally ill are often neglected, as their complaints are written off as part of their mental illness. If there was one thing I found unbalanced in the book, it was a lack of exploration surrounding the studies cited about doctors’ feelings towards their patients and medical bias in general.

Most of the book consists of Groopman’s interviews with other medical specialists about their thoughts on how they, and other, doctors think. They share with Groopman the memorable times they have been right, and the shattering times they have been wrong. All of this makes a great narrative, but amounts to anecdotal evidence of success or failure in medicine. Most of us aren’t able to see the shining stars of medicine that Groopman speaks with, which makes me appreciate the book’s practical advice more than its stunning examples of life-saving care.

How Doctors Think by Jerome Groopman on Amazon.com/Powell’s.com/Indiebound.org

If you like this book, try reading:

• How We Do Harm: A Doctor Breaks Ranks About Being Sick in America by Otis Webb Brawley, M.D. with Paul Goldberg
• Bad Pharma by Ben Goldstein
• God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine by Victoria Sweet

What could be more chilling than the most prolific serial killer in history? The cool and calculated corporations he worked for, hiding his tracks every step of the way.

 

On a windy day, the sort of day I call “earthquake weather” with no idea what earthquake weather feels like, imagining an anxiety in the air that starts at dirt level and works its way up to my sensory organs, my friend Lindsay and I sat in SFO’s cell phone lot. Our world-traveling friend Wendi was finally due to arrive home after months of globe-trotting. As we waited for any news of Wendi’s delayed flight, we watched the sun fade and others around us get the magic call from family members or friends and rush off towards the terminals, released from cell phone lot limbo. The wind blustered around our parked SUV, and we sat there, facing forward, and somehow realized the radio was cooing calmly about nursing and murder.

On NPR, journalist Charles Grabner was being interviewed about his book The Good Nurse. The not-so-good night nurse Charlie Cullen, referenced in the book’s title, may be the greatest serial killer of all time. He slipped his patients deadly cocktails, or stuck needles in random IV bags, and left a trail of devastation behind him so vast that even he isn’t able to recall all his victims.

Occasionally, sitting in the car, my friend would exclaim after some soundbite (angel of mercy, elderly deaths, autopsy, countless suicide attempts) “God, what are we listening to!” She’d threaten to turn off the radio. But we kept the radio on, as the car around us got dark, and when we ran out of things to talk about we listened to Grabner’s voice telling us what seemed to be an impossible yet true story of a murderer flitting from hospital to hospital, unstopped.

Finally, we got the call cell phone lots were made for: the flight had finally landed and our friend Wendi made it back to that California state of mind. Irrational thoughts immediately emptied my mind (what if we’re stuck in this cell phone lot forever, should we try to bond with the other people waiting in their cars, did the world end and only the people in this cell phone lot are left but we’re all unaware due to cell phone lot isolation), we turned our attentions from the murderous nurse to Wendi’s fabulous adventures abroad, and didn’t give Charlie Cullen another thought as we zipped away from SFO, human cargo safely in back seat, towards the Bay Bridge.

At least I didn’t, until now. I finally picked up The Good Nurse, as the words of its author, Charles Grabner, made an impression. This isn’t just the story of the “good nurse,” as Cullen claims himself to be at one point in the book. And thank goodness for that, as Cullen’s story is indecipherable at best. We may never know his exact motives, as he probably doesn’t know them himself. The Good Nurse doesn’t waste much time speculating on the psyche of a murderer. Rather, the book sticks to the facts. From the beginning of the story, the start of Cullen’s life, there is an alarming abundance of facts–little red flags dotting Cullen’s history.

Charlie Cullen’s past is littered with the wreckage of constant struggle with oneself, a landfill of evidence illustrating an unsound mind: countless suicide attempts (over 20, with the first at age 9), domestic violence charges, multiple restraining orders, DUIs, and hospitalizations. Cullen struggled with alcohol abuse, and although this isn’t a heavy focus of the book, one imagines it could be, as so many crucial scenes involve a near sober Cullen drinking again, or hiding his drinking, or a Cullen delusional with drink becoming violent towards himself or others. At one point his fearful wife calls the police while a desperate and drunk Cullen tears the pages from his Alcoholics Anonymous texts, throwing them into the fire. When police arrive Cullen promptly takes an overdose and is rushed the hospital. As anyone who has struggled with alcoholism knows, whatever sort of awful things happen when someone drinks, the story always starts with the alcohol. An optimist might wonder what sort of alternative life this man could have found, had he managed to control the more dangerous of his impulses with 12-step programs, therapy, and medication.

But all this help is offered and rejected, and the first part of the book is an almost unbearably dark walk through Cullen’s history. The rote recitation of suicide attempts and sadistic behavior became so difficult to get through at one point I thought about stopping the book, but I trudged on through.

The bizarre behavior comes not only from the sadistic, alcoholic Cullen but from those he works for, as hospitaladministrators begin to notice they have an “odd duck” on their hands and amazingly, offer him time off with pay or a good recommendation as long as he agrees to leave. Hospital bureaucracy allows this man, who tampered with IV bags at his very first job, to leave a long line of in-house investigations or notes in personnel files in his wake, with no actual repercussions. He receives glowing recommendations, finds new jobs quickly, and is always well paid. One job calls him after a hospitalization at a psychiatric facility, where he was an inpatient after a suicide attempt, not to fire him but to see when he can begin working again.

Part Two of the book widens the story’s circle again, not only including the sad, disturbed Cullen and the neglectful, lawsuit-wary hospitals he floats through, but the street smart homicide cops who finally work the case, a pair of characters with dialogue begging for movie adaptation. Somerset Medical Center finally notifies the police about mysterious deaths in its hospital, in the vaguest way possible, when in a meeting with Detective Tim Braun and Detective Danny Baldwin, a lawyer for the hospital vaguely declares “the medical center isn’t reporting a homicide, but has experienced five unexplainable patient incidents. Last Friday, there was a sixth incident.” What?

And this is where the incredible story truly begins, not with the cold character of Cullen or the even more calculated choices made by hospital bureaucracy. But with these two guys, Tim and Danny, who swing by the mall to pick up a medical dictionary after their meeting with hospital. These homicide police are trained to look at a body, usually a body with some gunshot wounds, and instead are presented with a few memos, a few test results, and a ton of obfuscation. Assistance offered by hospitals is sparse and often incorrect, and every institution seems to oppose the detectives as they seek the truth: at times they go against their own supervisors, and they slowly creep towards facts hidden under layers and layers of hospital misinformation.

At every turn in Cullen’s past, individual people chose to not get involved, or to not rock the boat; all those individual people allowed Charlie Cullen to continue killing for years, across hospitals. He doesn’t even remember how many people he might have killed. The story of these two detectives, and eventually the informant who works with them, is a brilliant, shining example of the truth bubbling to the surface. The brutal weight of sadness surrounding this story is made a little more bearable knowing that in the end, the bad guy and even the bad corporations were no match for two good guys determined to know the truth.

Further reading:

• Pretending To Be A ‘Good Nurse,’ Serial Killer Targeted Patients (npr.org)
• The Tainted Kidney (nymag.com)
• DEATH ON THE NIGHT SHIFT: 16 Years, Dozens of Bodies; Through Gaps in System, Nurse Left Trail of Grief (nytimes.com)

After last year’s English translation of Herman Koch’s internationally acclaimed The Dinner, an agonizing story of the anger and violence dragging under the surface at the dinner table, we know to except something searing and intimate from this master of the slow burn. I expected a car crash of a tale from Summer House with Swimming Pool, vehicles flipped and burned, while I’m left staring and braking as I pass by, unable to speed up and get going and leave the wreckage in my rear view.

I wasn’t disappointed. Koch seems to choose the most mundane names for these books, which drastically juxtapose with their messy and dark guts: a dinner, a summer house, a swimming pool. Simple things. The books, however, take on the most private and tragic of subjects–those around you turning violent and pedophiliac, nights where too much drink goes from fun to bad to irreparable too quickly, choosing to seek revenge on those who have wronged you or your family, allowing revenge to be taken while you sit back and watch the clock.

Summer House with Swimming Pool starts with Dr. Marc Schlosser, general practitioner, revealing to the reader his odd view of his craft and his patients. He seems almost maniacal as he rants of the artists who drink too much and then hide their vices from him, their doctor. He practices medicine with a careless abandon, spending twenty minutes with each patient to ensure they feel attended to while really dismissing most concerns outright. This part of the book, the lead up to the actual meat of the thing, seems to be the weakest, as the Schlosser’s character seems bordering on insanity, unbelievability.

But then, we get past Schlosser’s introduction to his private practice as he recounts what can only be called a tragedy, one of those awkward and beautifully rendered modern family portraits executed so startlingly well by Jonathan Franzen and A.M. Homes in the past. Schlosser and his wife and two kids go camping, and meet up with a patient of Schlosser’s. An actor, with a house. A summer house, with a swimming pool. The booze is flowing and from the beginning things are not quite right–motives are unclear, and Schlosser’s wife wants to leave this new gang of friends. As with so many things, enough small warning signs are ignored, enough unusual events made usual, enough heads turned in the wrong direction, that everything is okay until it all has suddenly, horribly spun out of control. Someone is hurt, and revenge is taken.

I just can’t say too much about this book without giving something or other away, as this is one of those books that illustrates so well our inability to ever truly know those around us, especially those closest to us. Clear your schedule if you pick this book up–I read it in a day or two, unable to stop until I knew what was truly going on, until I’d followed every paranoid twist and desperate turn to the final conclusion.

Summer House with Swimming Pool, just as The Dinner before it, reminds us that every individual has a uniquely intimate private life, swirling with their own motives and fears, their own lies and truths. Koch’s writing deals with, as some of the best writing does, these monstrosities we keep within ourselves or place onto others: the unknowable within us, the rage we hold inside or are unable to hold inside any longer, desires filled or unfulfilled, beliefs rightly or wrongly held. One of the gifts of literature is that we are able to read what other people are thinking, but books like this remind us that we are luckily unable to know what those around us are thinking in everyday life.

Summer House with Swimming Pool by Herman Koch on Amazon.com/Powell’s.com/Indiebound.org

If you like Herman Koch’s writing, try these books:

• Lost Memory of Skin by Russell Banks
• May We Be Forgiven by A.M. Homes
• Dissident Gardens by Jonathan Lethem

Related links:

• Good With the Scalpel, but Lacks People Skills (nytimes.com)
• Herman Koch talks about his new bestseller, Summer House with Swimming Pool (youtube.com)
• Interview with Herman Koch (goodreads.com)