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April 13, 2001/Nisan 20, 5761, Vol. 53, No.28
'Second opinions'
VICKI CABOT
Contributing Editor
Jerome Groopman's highly readable and exceptionally timely, "Second Opinions: Stories of Intuition and Choice in the Changing World of Medicine," (Viking, $24.95 hardcover) provides an incisive road map for navigating today's increasingly mine-filled medical terrain. His carefully drawn collection of eight real-life stories provides an insightful look at the complexities of medical decision-making and the role that both choice and chance can play.
Groopman, a cancer specialist and researcher at Harvard Medical School, is a staff writer in medicine and biology for The New Yorker magazine. As those familiar with his work can vouch, he has a gift for reducing highly technical medical jargon into easily comprehensible writing.
In "Second Opinions," he puts a face on each of the patients he profiles, making the reader feel their pain as they confront life-threatening diagnoses, wrenching choices in medical treatment and the morass of managed care regulations.
He begins with an assessment of the limitations of the practice of medicine.
"I make no pretense of omniscience," writes Groopman in the book's prologue. "Decisions about diagnosis and treatment are complex. There are dark corners to every clinical situation. Knowledge in medicine is imperfect. No diagnostic test is flawless. No drug is without side effects, expected or idiosyncratic. No prognosis is fully predictable."
But he goes on, making a cogent case for the doctor-patient relationship. "A clinical compass is built not only from the doctor's medical knowledge but also from joining his intuition with that of his patients. This melding of minds occurs when the physician probes not only his patient's body but also his spirit..."
His mission, writes Groopman, is to help patients make informed decisions about their medical care.
In the book, readers meet Karen Belz whose mother died from breast cancer and whose sister is currently battling the disease. Belz tested positive for the BRCA1 and BRCA2 genes that indicate the propensity for her, too, to develop the deadly disease. Should she have her ovaries and breasts removed to lessen the likelihood of that possibility? Groopman takes readers through Belz' agonizing thought process.
Readers also meet Peter Emery who has myeloma, a blood cancer characterized by malignancy of a white blood cell that produces an excess of fragments of antibodies. He has been staving off the disease under treatment with a variety of drugs provided by his physician in New Hampshire. When his kidneys begin to malfunction and he develops a bizarre fever pattern, he's referred to Groopman at Harvard. Readers follow the physician's scrupulous investigation and attempt to solve the medical mystery. Groopman offers an inside view of collaboration among medical professionals and the tensions that often surface among family members when making difficult decisions concerning treatment.
Quality of life ultimately determines the choice that Emery's wife, June, and his children make. Groopman is left with replaying his diagnosis and treatment and wondering if more could have been done.
"Although I understood that decisions about life and death had to be made at times without all the anwers, that truth was of little comfort," he writes.
Groopman's humility, and humanity, illuminate each of the stories. His compassion for his own grandfather, Grandpa Max (as he gradually loses his ability to care for himself) and his concern for his mother (who must make the difficult decision to move her father out of his own home) resonate for any families who have had to confront such choices.
Groopman also takes on managed care and the inequities of health care today. Readers meet Marianna Montero, a Cape Cod cleaning woman on the brink of respiratory failure. Physicians at her local HMO insist that she is suffering from a routine case of asthma; when Groopman diagnoses her with leukemia, the HMO refuses to pay for her care. Groopman uses Montero to reflect on the need to create a system where the bottom line is measured in quality and compassionate care, not dollars.
And he throws in the elusive factor of chance in making medical choices. James Leahey, a burly Irishman battling melanoma warned Groopman, "Don't write me off." Yet when denied participation in a new drug trial, even Leahey begins to wonder if his luck is running out. Ultimately, he responds to another medication, but only after Groopman pleads with the pharmaceutical company to provide him the treatment when his insurance company refuses to pay for it.
"I do believe God was good to me," James tells Groopman, reflecting on his remission. "But I don't see why He should've been better to me than to other poor souls who didn't make it."
Why indeed?
Groopman grapples with both profound questions and the distressing dilemmas using his inside view of the practice of medicine to provoke readers to think critically about health care and act responsibly, guided by an underlying respect for the sanctity of life.
"Evaluating medical advice is the greatest challenge for every patient," he writes in the epilogue. "Armed with knowledge, steadied by family and friends, and calling on intuition, we can gain clarity and insight, and are prepared to make the best possible decisions."
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