The Poetry of the Commonplace

In her recent New York Times column, Compelling Stories, If Not Literature, Dr. Abigail Zuger bemoans the recent outpouring of health-related memoirs. “Few of these efforts rise to the level of great literature,” she writes. “None of these books comes close to succeeding according to the usual standards. The language is clumsy and full of clichés; the dialogue is stiff and unreal; the pacing is way off.”

Dr. Zuger also has something to say about doctors who have taken to writing their own stories: “the great majority are sentimental and predictable, and a few manage to be as pedantic, self-important and annoying as, one ventures, their authors must be in person.” Her conclusion? “Most of these books aren’t great literature either.”

Still, Dr. Zuger confides, she has a soft spot in her heart for such books. In the face of all of her prior criticism, you have to ask yourself why. Is Dr. Zuger merely being sentimental? Or does she identify with the sentiments of her patients and colleagues?

In my opinion, what Dr. Zuger fails to recognize is that the patient’s story, no matter how ineptly told, becomes an integral part of the healing process itself.

Medicine’s great 19th century humanitarian physician William Osler remarked that, dealing as he does with poor suffering humanity, a good doctor has to keep his heart soft and tender, lest he develop too great a contempt for his fellow creatures. Osler reflects on what he terms “the poetry of the commonplace”—the ordinary man, the plain, toil-worn woman, their love and their joys, their sorrow and their griefs.

According to Osler, such tales serve to sustain the weary-worn clinician in his daily work. They also serve to sharpen his compassion for his fellow creatures.

My collection of clinical tales in the art of medicine, Patients Are a Virtue, might not be great literature. Few practicing clinicians and fewer patients will ever read it. Most likely it will eventually be relegated to the dustbin of narrative medical writing. And yet I take heart when I receive that occasional communication from cyberspace, such as a brief e-mail from a doctor in rural western Pennsylvania, who wrote that, after reading my book, he felt energized and renewed in his commitment to his patients. He felt so strongly about it that he purchased additional copies for his colleagues and encouraged them read it as well.

Is every patient and practitioner a poet? Dr. Zuger asks. In his consideration of the poetry of the commonplace, I believe that Dr. Osler would answer her rhetorical question in the affirmative.

What’s Wrong, What’s Right?

In a New York Times op-ed piece on the healthcare legislation, The Fight Is Over, the Myths Remain, Brendan Nyhan states:

Studies have shown that people tend to seek out information that is consistent with their views; think of liberal fans of MSNBC and conservative devotees of Fox News. Liberals and conservatives also tend to process the information that they receive with a bias toward their pre-existing opinions, accepting claims that are consistent with their point of view and rejecting those that are not. As a result, information that contradicts their prior attitudes or beliefs is often disregarded, especially if those beliefs are strongly held.

Nyhan addresses the curious tendency we humans have to regard opinion as factual information—in his example, popular myths about the content of the recently passed healthcare bill, now signed into law.  In short, it all comes down to preconceived personal perspective.  Here the old axiom about drawing your curve and then plotting your points is apropos.  We tend to view the world through tinted lenses, all the while assuming that we are the only ones who see objectively.

I was intrigued to read about the former medical student Michael Burry who turned his economic insights into a popular financial blog.  Impressed with his knowledge, Wall Street gurus began to take regular notice of his predictions.  Indeed, many of the financial companies he endorsed turned out to be winners in the market.  Everyone, it seemed, was on the same financial page, until Burry noticed a disturbing trend.  Solid institutions that went on to fail shared one thing in common:  all had invested heavily in subprime mortgage securities.  Eventually, Burry convinced Wall Street to issue credit default swaps through which he bet against the popular tide—and subsequently won big.

This scenario demonstrates Nyhan’s premise:  when faced with the same set of factual data, observers generate wildly different interpretations.  As a consequence of acting on the basis of these observations, the risks are enormous:  you could win big (like Burry), or you could lose big as well.

Which brings me to the role of science in contemporary society.  Just how objective a discipline is science?  When confronted with the same set of facts, how is it that scientists formulate theories with markedly different import?

Global warming:  true or false?

Health care reform:  good or bad?

Wall Street reform:  desirable or undesirable?

In his new book Wrong, science journalist David H. Freedman wonders why scientific pronouncements often turn out to be misleading, exaggerated or entirely off the mark.  Part of the problem, he opines, is that many times scientists are forced to rely upon surrogate measurements, because they cannot get at the things they need to measure directly.  Thus, they have to make inferences from suboptimal data.

Economists, for example, rely on economic indicators extracted from bits of data to identify trends and forecast the economic outlook. Unfortunately, most research papers published in economic journals don’t conclusively prove anything one way or the other.  Freedman wonders:  “If tests of the exact same idea routinely generate differing, even opposite, results, then what are we supposed to believe?”

Freedman highlights the work of Dr. John Ioannidis, an M.D. with an undergraduate degree in mathematics, originally published in JAMA (John P.A. Ioannidis, “Contradicted and Initially Stronger Effects in Highly Cited Clinical Research,” Journal of the American Medical Association Vol. 294, No. 2 (2005): 218-28).

According to Ioannidis, “most medical treatment simply isn’t backed up by good, quantitative evidence.”

The whole point of carrying out a study is to rigorously examine a question using tools and techniques that would yield solid data, allowing a careful and conclusive analysis that would replace the conjecture, assumptions, and sloppy assessments that had preceded it. The data are supposed to be the path to truth. And yet these studies, and most types of studies Ioannidis looked at, were far more often than not driving to wrong answers.

Ioannidis felt he was confronting a mystery that spoke to the very foundation of medical wisdom. How can the research community claim to know what it’s doing, and to be making significant progress, if it can’t bring out studies in its top journals that correctly prove anything, or lead to better patient care?

The largest source of wrongness in scientific studies is publication bias.  Prestigious medical journals eagerly publish studies that demonstrate novel or unanticipated results.  Witness Andrew Wakefield’s bogus study published in the Lancet that purported to link the administration of the MMR vaccine to autism.  This problem is compounded further by the mainstream media, which is only too quick to disseminate such conclusions to the public at large.  Such misperceptions have a tendency to persist for years.

In his classic treatise on The Structure of Scientific Revolutions, Thomas Kuhn argued that “professionalization” leads to “an immense restriction of the scientist’s vision and to a considerable resistance to paradigm change.” He opines that scientists become captives to a paradigm “like the typical character of Orwell’s 1984, the victim of a history rewritten by the powers that be.”

Perhaps scientists themselves possess their own set of preconceived notions, which in turn dictate how they interpret the data they measure.  I suppose that it all depends on which side of the emotional aisle you happen to take your seat.

As Mr. Nyhan writes: “People seem to argue so vehemently against the corrective information that they end up strengthening the misperception in their own minds.”

“Pediatric Primary Care Case Studies” published

Pediatric Primary Care Case Studies, a collection of pediatric case studies that addresses common health problems of well, acutely ill and chronically ill children, has been published by Jones and Bartlett Publishers, Sudbury, MA.

Author Brian T. Maurer contributed an original chapter on a toddler with language and social delays, in which he reviews the diagnostic criteria and current management of children with autism.

These case studies are designed to help students develop critical thinking and diagnostic reasoning skills as they work through common patient scenarios encountered in general pediatric practice.  Guidelines and evidence-based research support current care recommendations.

Maurer was one of three Physician Assistant contributors selected for their expertise and experience in caring for infants, children and adolescents by editors Catherine Burns, Beth Richardson and Margaret Brady.

Ordering information is available on the web here.

Traditional publishing? Perish the thought

When the news came that John Brown was about to be executed for his seditious raid on the federal garrison at Harper’s Ferry, Henry David Thoreau rang the village bell in Concord, Massachusetts, to call his townsmen together. When a neighbor asked him what prompted this action, Thoreau replied: “I have something to say.”

Throughout human history, many of us have had something to say. The problem was that, up until fairly recently, there was no venue readily available for the dissemination of the thoughts and ideas of the common person. That, of course, was before the Internet exploded upon the scene.

Traditionally, most would-be writers had to submit their work to countless publishers before getting anyone to consider it. And if any editor did bother to peruse the manuscript, the upshot was most likely a letter of rejection. Because name recognition goes a long way toward mounting a successful book marketing campaign, many editors and agents preferred to work with previously published authors. This left the unknown writer in a bind. How to get recognized by a publisher without an agent? How to secure an agent without having name recognition?

Traditional publishing houses are not necessarily in the business of bringing new literary talent to the reading public. First and foremost, traditional publishing houses are in business to make money. They search for marketable writers with name recognition, those who craft good stories that will sell to a large audience. Authors take their traditional 15 percent cut and royalties, leaving the publishing house with the bulk of the proceeds from book sales.

The Internet has proven to be a great equalizer, giving voice to the average person who has something to say. Witness the explosion of personal blogs on sites like MySpace and Facebook. The latest leveling on the literary playing field has come in the form of self-publishing sites. Would-be authors no longer have to pursue literary agents or beg editors to peruse their work.

For a small fee, these online publishing firms will transform an author’s manuscript into a bound book, complete with glossy cover and ISBN barcode. Because these enterprises function by print-on-demand, initial financial outlays are kept to a minimum.

The current recession is impacting book sales nationally. Everyone in the bookmaking business is suffering—traditional publishing houses, book sellers, editors, literary agents—except the print-on-demand entrepreneur, who stands ready to give the little guy who has something to say a venue for his voice.

Humane Medicine column debuts in JAAPA

Author Brian T. Maurer is pleased to announce the debut of the Humane Medicine section in the October 2008 issue of the Journal of the American Academy of Physician Assistants with the publication of his essay “The practice of medicine: moving beyond the science”.

JAAPA, the official journal of the American Academy of Physician Assistants, currently plans to run a series of articles relating to humane medical practice over the next year. Maurer will serve as section editor for Humane Medicine.

Announcing the publication of “Village Voices”

Brian T. Maurer is pleased to announce the publication of his latest book, Village Voices. In this new collection of tales, Maurer captures life in a New England village, where everybody has a story to tell.

“Old Bill, who made a living trapping muskrat and beaver along the river, and Miss Pritchard, who worked her way up to a management position at the Connecticut Mutual Life Insurance Company, are gone now, along with a host of other folks from that era—but their stories remain. I’ve added some of them to the pot, stirring them in with my own, and let them simmer over the years before serving them up for my readers to savor.”

“Some of us are on the move; some of us stay put. Some are just starting out, trying their wings, while others are on their last legs, coming home to say good-bye. The birds still sing every spring down along the forest path that runs by the river, where it meanders through the hairpin curve on its way down through the gorge, eventually becoming one with the sound and the sea beyond.”

Interested readers can view a brief description of the work, peruse a preview of the text, and order a copy online here.

Birthing a Book

Last fall, news of the arrival of the first child of Angelina Jolie and Brad Pitt flashed around the world. Everyone was happy for the couple, even overjoyed after hearing the announcement of this new little life recently added to the global register of live human births.

I suppose if Angelina had birthed a book, it would have shot immediately to the top of the best-seller lists. Within a week we would have been reading stunning reviews in the New York Review of Books and the New Yorker magazine. Conceivably, it could have made the top ten in the rankings.

Yet what of all those other babies born that same day; what of all those other books birthed after months of mental gestation? Is each one less significant? Are they inherently of less value? These questions are apropos for an author who also happens to practice pediatric medicine.

“How many a man has dated a new era in his life from the reading of a book?” Thoreau wrote in the pages of his masterpiece, Walden. Indeed, how many a person has dated such an era through the writing of one?

After several years of persistence, burning the midnight oil; writing, editing, rewriting, polishing the manuscript; periodically emboldened, like Mr. Thoreau, by some degree of success in quiet hours, I finally got a glimpse of my first literary creation.

I remember the day that I found the proof copy of my book resting comfortably inside a brown corrugated cardboard UPS package on my back porch when I returned home from work.

I slit the plastic packing tape with my penknife and pulled the book out, looking rather dumbfounded as I held it in my hands, like a father staring in disbelief at his first-born son.

I paged through it, amazed at how perfect the type looked; each page appeared just as I had painstakingly formatted it. It actually brought a tear to my eye (from the dust, you understand).

I turned on the A/C and the upstairs fan to cool the house off a bit, and then sat down to read through it. I discovered a few minor errors that were easily fixed. I marked them with a highlighter and later made the corrections in the manuscript document on my computer.

Back then, it seemed to me for all the world like a dream come true—something I had wanted to do my entire life. After fathering four children, I’d finally birthed a book of my own. Your fifties may be a fertile period after all.

What does a man do after writing a book? He hems and haws, not knowing exactly whom to share the news with; ponders and postulates, comes to a decision, only to retract it … then, in the end, he takes the leap and elects to publish it to the world.

In 1853, faced with a four-year record of poor sales even after receiving wide notice and favorable reviews of his first book, A Week on the Concord and Merrimack Rivers, Thoreau wrote in his journal: “I have now a library of nearly nine hundred volumes, over seven hundred of which I wrote myself.”

Too bad for Mr. Thoreau that wasn’t online in 1849.