The DO Book Club, May 2022: The English Patient, Flying Blind and Patients at Risk

As Monty Python might say, “And now, for something completely different.” Or better yet, maybe Rod Serling – “Offered up for your consideration …” If you’re young enough, you may have to Google both of those.

For May, I reviewed The English Patient by Michael Ondaatje, Flying Blind: The 737 MAX Tragedy and the Downfall of Boeing by Peter Robison and Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare by Niran Al-Agba, MD, and Rebekah Bernard, MD.

These three books are seemingly disparate, but stay with me here. In its own way, each examines the core of what we do as physicians, what our job is and where our responsibilities lie. One is reaffirming. The other two are at the least, interesting and, at most, frightening.

The English Patient, Michael Ondaatje, Vintage Books (November 1993), 305 pp.

Although thirty years old, this remains a wonderful book. Perhaps more importantly, it remains a wonderful reading experience. If you read it three decades ago, it may read differently to you now. If you’ve never read it, the summer beach reading season is the perfect place to start.

The story is set in the last days of WWII with numerous flashbacks throughout. The title is a nod to what is still one of modern medicine’s worst nightmares and most egregious errors: the misidentified patient. This mistake is not central to the plot but provides one of many narrative intersections.

The story is framed as a bit of a mystery. A badly burned pilot is found in the Sahara Desert; how he came to be there forms the structure of the story. We learn fairly quickly that the English patient is not English after all. Rather, he is a map-making Hungarian aristocrat who is slowly dying from his burns and addicted to the morphine which makes his existence tolerable.

In the early ‘90s, when the book was published, we didn’t scan barcodes to definitively ID patients and we wielded opiates rather promiscuously, convinced we were alleviating suffering. The story has some political and romantic intrigue, but at its heart it’s about the real nature of caregiving and why sharing in a patient’s story remains one of the great rewards in medical practice.

The book has many touches that seem to ring true today – the protagonist is rescued and resuscitated by a nomadic tribe, the equivalent of today’s first responders. His final days are spent in a bombed-out Italian church which would qualify today as a hospice environment. His nurse is a forerunner of today’s palliative care physician.

Although the truly excellent movie adaptation is also worthwhile, experiencing the story on the printed page is something you’ll be glad you did.

Flying Blind: The 737 MAX Tragedy and the Downfall of Boeing, Doubleday (November 2021), 306 pp.

A company run by people who understood and were experienced in its core business and dedicated themselves to the ideals of quality, safety and integrity is taken over by business executives whose goal is profitability at all costs. Those costs turn out to be tragic.

Sound familiar?

This book has nothing to do with medicine. Or, maybe, it has everything to do with medicine. It’s no secret that slightly more than half of all practicing physicians are employed by a health care system or corporation.

Some of these employers are physician-founded and physician-led entities. Many are not. Some are private equity companies with shareholders who have their eye on dividends and top executives with their eye on performance bonuses.

Flying Blind tells the story of what happens when profit becomes the core business and the danger of allowing people with no real experience in the actual core business to run it.

You are probably familiar with the story and the timeline. Two new Boeing 737 MAX airplanes fall out of the sky, killing everyone aboard. Boeing, a company once run by aviation engineers and pilots but now by business executives, blames the foreign air crews.

The truth eventually comes out that an aerodynamics-altering software program installed without pilot knowledge is responsible for the crashes. The story of how this software was incorporated and why pilots were not properly informed or trained forms the basis of the book. It’s a fascinating read.

And a cautionary tale.

Many feel that the practice of medicine is slowly being taken out of the hands of physicians and placed into those of business school graduates who know nothing of the realities of delivering health care. That physicians, like the pilots and engineers at Boeing, can be ignored or overruled by spreadsheets and marginalized by pro formas, mergers and acquisitions.

Imagine that hospital administration MBAs quietly installed an EHR program that, when a “Sepsis Alert” was triggered, immediately started your patient on powerful, hemodynamic-altering infusions without letting you know first. Kinda like that.

I read this book after I retired, but for a number of years in practice I closely watched and gleaned valuable lessons from the airline industry, especially the idea of CRM (Crew Resource Management). An airliner cockpit closely resembles an operating room in terms of personnel, responsibilities, task complexity and decision making.

Your office, clinic or surgery center probably has equivalent similarities. If you feel that corporate business interests might be overtaking patient welfare, I strongly suggest this book.

Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare, Niran Al-Agba, MD & Rebekah Bernard, MD, Universal Publishing (November 2020), 254 pp.

I came across this book by accident, while perusing a listing for another one that was recommended for review. I didn’t even know it was out there and thought perhaps I might not be alone.

As the title suggests, the authors have a point they wish to make. This is not just an objective, data-backed analysis but also an argument in support of a premise. Think of it as a documentary film – it has its particular point of view and what gets presented tends to lead one toward accepting and agreeing to that POV.

As someone who spent my advanced training and career working with and depending on PAs and what at the time were called surgical nurse clinicians, I wasn’t sure what to expect. My personal experience has been positive – but I interacted with and hired well-trained individuals with strong credentials.

As my referring colleagues made more and better use of PAs and NPs, I found them invaluable to running a high-quality program. CRNAs were a staple in my OR. My personal primary care provider is a PA who works with a seasoned DO family physician.

It appears that what the authors really wish to point out is that there is a rise in independent PA and NP practitioners and that not all their degree-granting programs are created equal.

The narrative is framed by the story of a 19-year-old woman whose rural ED care was delivered by an NP with disastrous results. In my reading, the undertrained NP involved was, hopefully unintentionally, pretty much set up to fail. Hard to indict two entire classes of medical professionals on, but it does get your attention right away.

The authors are very good at illustrating the vagaries in training that current NP/PA programs provide and thoroughly debunking the administrative urban legend that NPs/PAs provide equivalent care at lower costs. It is especially worrisome to note the fairly gauzy requirements some programs demand for completion, especially when it comes to academics and real (i.e.: relevant) clinical hours.  

I could not have practiced without the dedicated, talented PAs on my heart team. I suspect most of my colleagues in other specialties feel the same about their PAs and NPs. I have total confidence in my PCP. But I had the luxury of knowing how to peruse education, training, experience and qualifications.  

This book is well researched, its arguments are cogently and linearly presented and backed up with data, and its conclusions are well worth considering. Reading it probably won’t change your opinion, but it certainly will better inform it.

June’s book

For June, Joan Naidorf, DO, will review In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope by Rana Awdish, MD. We encourage all who are interested to read along (this book club can be followed at any pace)! If you are unable to get out to a local library or bookstore, we recommend checking out eBook options.

If you read The English Patient, Flying Blind, Patients at Risk or any previous Book Club selection and want to share your reflections, please leave a comment below or email [email protected].

Related reading:

The DO Book Club, April 2022: Black Man in a White Coat

The DO Book Club, March 2022: Heartsounds, Echoes of Heartsounds, Changing How We Think About Difficult Patients