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Book Reviews
We need not go far to find good surgeons. The professionalism of these surgeons is defined by their thoroughness, competence, directness, and talent, says Dr Karl in this slim book of essays, Across the Red Line. The "red line" named in the title refers to the literal demarcation across which only authorized personnel may pass. Nonetheless, a few surgeons--fortunately, very few--behave as bullies; and a few are timid. Many practitioners who inhabit the nether regions of the distribution curve can be professionally successful, in part because of intensive training and in part because work in the operating suite is truly a mutually supportive team effort. One mission of academic surgeons is to train undesirable traits from new surgeons. Surgeons have enough difficult surprises and stresses even when the surgical team includes no technically weak members. Surprises do occur, however, no matter how great the effort to anticipate them; and like the good pilot Dr Karl is, a good surgeon must be able to react quickly and accurately to unforeseen as well as to planned events. These events and considerations, in a nutshell, are what goes on behind the red line. Dr Karl is an accomplished senior academic general surgeon who practices in Florida. In addition to owning the professional attributes he both admires as a professional and wishes for himself as a consumer (sometimes in vain, as the reader will see), Dr Karl is a good storyteller. No, make that a very good storyteller. In 14 essays, he offers anecdotes familiar to surgeons all over the world as well as more personal stories, not all of which describe a surgeon's life in the operating suite but all of which are extracted from Dr Karl's own life. An interesting ethical quandary discussed in the book was faced by the author, who invited a news columnist to observe surgery conducted in the operating suite. Inviting the columnist was solely the author's personal decision and was based on his impatience with what he perceived as the public's remoteness from medicine. As chairman of the surgery department, the author clearly had the authority to make the decision; moreover, a friend in the newspaper business could conceivably shift the tone of an article in Dr Karl's favor regardless of any underlying medical issues or outcomes. However, the decision to invite the journalist was problematic because Dr Karl may not have sought approval from both the hospital's public relations department and an academic ethicist. The author states in his book that he really didn't care about the opinions of these authorities and instead cared only about the legality of the journalist's attendance in the operating suite and whether the patient and the nurses agreed to it. Thus, although red lines exist for a reason, the author's decision clearly was made for nonmedical reasons. Of course, public relations departments and ethicists also have their own guidelines, or "red lines." Other stories in the book resonate even more powerfully. One such story is that of Sal, a woman whose unhappy fate the reader might view as foreordained. A diagnosis of carcinoma of the bile duct was the last thing on earth that Sal, a heavy drinker and cocaine abuser, needed. Her tragic story and the ongoing efforts of clinicians like Dr Karl to help are witnessed every day in hospitals around the world. Whether surgeons or not, all physicians who hate to abandon hope for a patient's recovery will recognize as familiar the author's last introspective examination: Did he try too hard--or for too long--to help the patient? Perhaps the best essay in the book is one of the last ones, improbably titled "The Norwich Classic Car Rally." This essay has nothing whatever to do with surgery per se but examines indirectly the cost of medical care. The reader might wish that this story, about a 22-year-old recipient of a heart-lung operation, were juxtaposed to the earlier piece about the journalist who was invited to observe major surgery on a 77-year-old patient. Affordability of high-tech medical care and rationing of available medical resources are issues raised by these essays. Especially in the context of our aging population, the problem of cost--both in dollars and in personnel--presents decision makers with a dilemma: Can we unerringly decide in every case who should benefit from the best medical technology in the world and who should be denied it? That decision is difficult at best, and we all fumble with it. This book will appeal to laypeople as well as to health care practitioners. The book contains no revelations for the surgeon--nor need it contain any. Across the Red Line provides enjoyable reading about things infrequently discussed, and that's enough reason to pick it up.
Peter N DeSanctis, MD, is a retired Professor of Surgery at Columbia University in NYC. He is now seriously involved in the aquaculture of mollusks.
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