Mad Dog admits it, right at the starting line: He reads the New Yorker regularly, and listens to The New Yorker Radio Hour podcast. Mad Dog is a fan. Sort of. Well, mostly. Well, not really.
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| Discoverers of Insulin: How Much Good |
Remnick begins his interview with Atul Gawande with the sentence: "It's hard to calculate all the good Atul Gawande has done in the world."
And therein is contained a bias to which Mr. Remnick is assuredly blind: Dr. Gawande may have done good in the world, and it may be incalculable, but if Dr. Gawande had been a graduate of Cornell University Medical College, at least until the advent of the 21st century, faculty there would have looked at his career and you would have seen a lot of heads shaking in disappointment.
Gawande trained as a surgeon, and he once did some surgery.
And he told a wonderful story about being called to the Emergency Room for a woman with an abdominal aortic aneurysm, which he thought would surely kill her, but she refused surgical intervention, and he sadly watched her son take her home to certain death, only to learn, a year later she was still alive, which taught him a valuable lesson, and he used it to great effect with his audiences, that doctors are not always correct. Of course, ask a vascular surgeon and he will look at you quizzically, and say, "Rupture of any large abdominal aortic aneurysm, and the decision to try to fix it is always a risk versus benefit thing--there is a certain percentage of aneurysms which do not rupture. You are always talking about risk, not certainty."
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| Paul Offit, MD |
Dr. Gawande gave up surgery for a job with Amazon medicine, with much fanfare about how he would change the medical care delivery system for the entire country, and when that didn't work out, he took a government job with the Agency for International Development.
And he wrote two books, one of which extolled the virtues of surgeons stopping before beginning a procedure to run through a check list, as airline pilots do, which was a reasonable suggestion, if not revolutionary, but he got a book out of it.
And he wrote a famous New Yorker article which got a lot of attention in the Obama White House, about how doctors often change their practice to skew toward more profit, gaming the insurance system. And he wrote about how nice it is when doctors can directly communicate with each other, the way doctors at the Mayo Clinic can do, because they are all in the same building.
And he wrote about a famous doctor who ran a famous clinic for cystic fibrosis patients, with a little vignette about a doctor who asks a patient, "What have you done this week to make this the best C.F. Clinic in the world?"-- as if the most important thing to this patients ought to be the clinic's success rating.
Of course, this famous clinic could offer nothing to really help these patients. Pulmonary toilet in CF is just a band aide on a wound. It may get a patient 5 more years of life. You can really appreciate how inept a therapy is only when a truly effective therapy emerges: in CF, that is gene therapy and CRISPER technology which may promise patients a normal lifespan and a normal life. This clinic, though famous, had nothing more to offer its patients than Elliot Joslin, who was treating type 1 diabetes with a diet of dubious benefit, before the discovery of Insulin.
Famous, but useless. That's a thing in medicine. Sort of the Dr. Oz phenomenon.
Gawande was not, in Cornell speak, a "real surgeon." A real surgeon, on a gorgeous Spring day would want to be in the operating room, doing a lovely dissection.
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| Semmelweiss |
But that world of dedicated physicians and surgeons has receded into the mist: the world of doctors for whom medicine was a calling, the highest and most rewarding pursuit in the world.
Dr. Gawande, those ancient physicians would say, "Went Hollywood." That is, he sought personal fame and fortune, doing stuff that was not really surgery or medicine. But for Mr. Remnick, the fame was the thing.
If you want to talk about doctors who did incalculable good in the world, you might consider Dr. Frederick Banting and Charles Best, his graduate student, who discovered the molecule insulin one hot Toronto summer, sweltering in a lab, dissecting dogs. They sold the patent rights to their discovery for $1. They had wards filled with children dying from type 1 diabetes. They did not want any delay over patent rights to delay treatment. Those are real heroes. Not famous. Not a single student at Winnacunnet High School in Hampton can tell you who Frederick Banting or Charles Best are. But these doctors did incalculable good for the world. They just don't make the pages of school textbooks, or popular magazines.
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| Before Insulin |
Giving up bedside medicine does not mean you have lost the faith. Tony Fauci was a Cornell product and he left bedside medicine, for the most part, for a job in the government which was mostly administrative, although he did cleave to bedside medicine for may years after most of his colleagues had stopped making rounds on real patients.
Of course now, even at the Cornell Medical College reunions, the alumni who are celebrated are those who got famous: a guy who became famous as the orthopedic surgeon for the New York Rangers and the New York Knicks.
Did that famous orthopedic surgeon do more good in the world than some other orthopedist who labored away in obscurity for 40 years, fixing up high school students in Fergus Falls, Minnesota, or the guy replacing hips in Portsmouth, New Hampshire? Did he affect medicine as broadly as the Cornell graduate who became the chief of radiology at Duke for 35 years, who trained hundreds of radiologists, whose textbooks of radiology trained thousands others?
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| Lynching: American South Berserkdom |
David Remnick is a man whose career has to do with mass communications, and he has drunk the Kool Aide that the celebrated, the famous, the folks at places like the Hoover Institution, or the Harvard faculty, are the people who are important, who know more, and who have more impact in the world.
So, when he interviews some guy from the Hoover Institution, whose critical insight into our current fix with the Trump mob is that America has always been "berserk," Remnick finds that notion profound, important and something which, if only he could get out there, might save the world, or will, at least, make millions feel much relief.
And yet...anyone who reads enough American history has known, America is berserk and has been since its inception. Read "The Guarded Gate," by Daniel Okrent, or "A Peoples History of the United States" by Howard Zinn or "The Untold History of the United States," by Oliver Stone or "White Trash" or "Fallen Founder" by Nancy Isenberg or "The Best and the Brightest," by David Halberstam, anyone who has drunk from these founts of knowledge knows just how vile, wonderful, nasty, superlative, corrupt, pure, and checkered the USA has always been.
Or, you could simply read Huckleberry Finn.
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