Dr Rhona Mahony: Our maternity hospitals are falling down, we can do better for women

“I believe we did not pay enough attention to birth in this country. It was a women’s issue. There’s a tendency to turn off for women’s issues, but here’s the thing: everybody is born and women’s issues matter,” said Dr Rhona Mahony, the first female master of the hospital on Holles Street.

“When you look at it, we have a third the number of doctors we should have, we’re really short on midwives in my hospital, and the Rotunda is the same. And we have these old buildings that have changed very little.”

(Times) >>>

Student notes on Sherwin B Nuland How We Die extract

(by allanj)

First of all, I have chosen to look at the main themes and issues in this chapter. There are two main themes, the first is mortality and the second is the link between aging and death. Mortality is the theme which is constantly present throughout the chapter. The author uses a quote from Francis Quarles to emphasize this, ‘It lies in the power of man either permissively to hasten or actively to shorten, but not to lengthen or extend the limits of his natural life.’ He uses a personal experience to show us that everyone must die, using the example of his grandmother who died from a stroke. He tells us that her death was much the same as a lot of other people’s and ‘hardly unique’. He shows us that death happens to everyone, ‘it carried off James McCarty, it carried off my Bubbeh’.

When he speaks about mortality, there is a lack of sympathy from him. I believe that he uses the example of his grandmother to show us his humanity, because he himself has suffered through the death of someone close to him. I don’t think this attempt was successful however, or sufficient, as he still comes across as very unsympathetic. I researched who James McCarty was, as he is mentioned twice in the piece. I discovered that he was the author’s first patient, a fifty-two year old man who died of a heart attack while beside the author. As he died, he ‘roared’ out to the author, who did nothing, but realised after that McCarty was asking him to desist what was happening. He suggests later in the chapter that we should ‘eschew every bit of McCarty-like behaviour’ which shows his lack of sympathy towards the dying man looking for help and also comes across as quite judgemental of him. It is apparent from the chapter that the author himself is about the same age as James McCarty, if not older, so you would expect him to have a little more sympathy for the man.

He believes that everyone should die and should not try to prevent death. He includes a quote from Thomas Jefferson, ‘There is a ripeness of time for death, regarding others as well as ourselves, when it is reasonable as we should drop off and make room for another growth. When we have lived our generation out, we should not wish to encroach on another.’ His opinion is that it is older people’s duty to die as they should, and allow the younger generations to take over, ‘Old men must die, or the world would grow moldy, would only breed the past again.’ He says that the people who are researching gene therapy or growth hormone are faced with people who are hoping that these break-throughs will result in an extension of life span. ‘The lesson is
never learned-there will always be those who persist in seeking the fountain of youth’. He even goes as far as to say that wishing for a longer life span ‘demeans us’.

The second theme that is very prominent is the link between aging and dying. One quote which illustrates this theme is a quote from ‘a wise old lady’ who said ‘death keeps taking little bits of me’. He believes that death will occur regardless of disease, but with the presence of disease, death comes faster, ‘Aging may be said to be both independent and co-dependent in the sense that it certainly contributes to disease and may in turn be accelerated by it. But disease or no disease, the body continues to get older.’ He also believes that there is very little that can be done for an old person when they come in to a hospital. He asks us what should be done, if an old man presents with cancer. Should we treat him with debilitating chemotherapy only for him to die of something else a year later? Regarding treating old people, he says ‘Hope must always prove to be unjustified.’ In the end, they will die, of something, regardless of what they are in hospital for. This is a very true statement from him, but a negative and irrelevant one. You could also say that about a two month old baby who comes in with a disease, so his argument is unjustified.

I found that the author’s tone throughout the chapter was often very gleeful when talking about causes of death. He uses personification of the diseases, which I think gives him the tone of glee. He uses phrases such as ‘marauding power’, ‘of those so betrayed by their cerebral circulation’ and ‘suffocating the tissues of its victim.’ When speaking about pneumonia, he says ‘Pneumonia’s blitzkrieg has yet another way to kill- its putrid headquarters in the lung serves as a focus from which the murderous organisms can enter the bloodstream.’ I think he uses this personification to show us that it would be better to die. There are pages and pages in the chapter in which he simply describes the horrifying diseases and what they do to your body. He always describes the ‘worst case scenario’ making any illness seem horrific, to make us think that it would be preferable to die than to go through any of them ourselves. However, he is so gleeful when describing these diseases, it makes me think he could be exaggerating to emphasize his point, ‘If the stroke is extensive enough or if further complications ensue, such as decreased blood pressure or cardiac output due to failure or arrhythmia, recovery is prevented and the area of ischemia may actually increase. If it becomes large enough, the brain tissue begins to swell. Being compressed in the unyielding confines of the skull, a swollen brain is further damaged by being pushed up against its covering membranes and bony encasement, and part of it may actually be forced down through a fold in those membranes…….’ He always talks about the worst case scenario of all of these diseases, and tells us all the ‘gory’ details, which is why I think he has a gleeful tone.

He speaks quite critically of doctors, and their approach to treating geriatric diseases. He says that in the case of his grandmother, and because she died of two of the most common causes of death; stroke and pneumonia, while doctors read this chapter, ‘they may claim, her mode of death supports their worldview and argues for vigorous intervention to treat the named pathologies in order to prolong life. To me this is more sophistry than science.’ He is criticising even his medical readers, and patronisingly assuming he knows what they are thinking and criticises any who would disagree with him. He is concerned that doctors become ‘absorbed by the riddle of disease’ and want to solve the problem rather than do what is best for the patient and the hospital. However, he contradicts himself by saying, ‘The diagnosis of disease and the quest for overcoming it with his intellect are the challenges that motivate every specialist who is good at what he does.’ If a specialist is good, because he wants to solve the riddle of disease, then does that mean he wants not good doctors treating geriatric patients, because they have no motivation to solve the problem and will let the patients die? However, he then calls the doctors who know when to stop treating older patients ‘wise physicians,’ again contradicting himself.

His writing style at times is quite hard to follow. He jumps from one topic to another, and back again with no warning. For example, he opens talking about strokes and his grandmother. He describes strokes in detail, and the reader believes he has moved on Alzheimer’s disease, when he jumps back to talking about strokes. This happens in several different instances throughout the chapter, making it difficult to find any clear structure in the chapter, and at times, hard to follow his train of thought.

He is also hugely confident in his writing style, almost over confident, nearly forcing his opinions on his readers. He has an entire paragraph of questions beginning with, ‘Can there be any doubt…..?’ regarding to the points he has just made. He uses subtleties of language, such as the word ‘fortunately’ when telling us about the doctors that he agrees with, and ‘unfortunately’ when speaking about people who he disagrees with. There is an air of confidence throughout the whole chapter, leaving you less likely to question his ideas.

There is a small amount of humour throughout the chapter, which I believe he uses to lighten the dark descriptions of debilitating diseases he uses, as well as his pessimism of old age. For example, he tells us that ‘the bets assurance of longevity is to choose the right mother and father.’

Overall, I liked the themes and issues he chose to write about, mortality, aging and death. I disliked the tone with which he wrote about these themes, at times patronising and over confident. I liked hearing his perspective on geriatric doctors and what the right thing to do is involving elderly patients. I would like to read the rest of the piece, but I would read it critically, rather than believing it word for word, due to the apparent joy he takes in other people’s misery and his over confidence.

Student notes on John Berger’s ‘A Fortunate Man’

(lochrins)

This non-fiction extended essay was published in 1967, it was written by John Berger (1972 Man Booker Prize winner) and photographs are taken by Jean Mohr. It is set in rural England in an impoverished and struggling community. Berger and Mohr follow a country doctor, John Sassall, whose career serves as the focus of the essay.

John Sassall, the main character, starts his career thriving on medical emergencies, impatient with non-specific symptoms and the absence of clear-cut physical diagnoses and underlying pathology.

‘That was the happiest time of my life, doing major surgery in the Dodecanese.

He moves gradually towards an empathic listening and companionship with his patients and their families, striving to recognise who they are and the meaning of their illness to them. Physical and psychological intimacy becomes central to his relationship to his patients. Sassall establishes a brotherly relationship with his patients, which was very different to the paternal relationship which existed between most doctors and patients at the time.

‘He began to notice how people develop. A girl whom three years before he had treated for measles got married and came to him for her first confinement. A man who had never been ill shot his brains out.’

Sassall is a highly competent and dedicated physician, ’He sees to it that he stays well informed’. He feels compelled to use his occupational life in a quest to explore basic questions about the nature of human relationships and community. This need drives him to be an exceptionally good physician and to involve himself deeply in the life of his rather insular community. While Sassall is an unusual man and physician, many aspects of his experiences in dealing with patients cast light on doctor-patient relationships in general.

The simple task of turning on the electric blanket on fifteen minutes before a patient arrives shows the deep level of care Sassall has for his patients and it highlights his commitment to making them as comfortable as possible.

The consultation with the sixteen year old girl highlights Sassall’s view of the doctor-patient relationship and it also gives us an insight into his view of the doctor’s role in the community. He is very subtle in the way he address the pregnancy issue and is very quick in getting to the root of the problem.       

‘Do you like working in the laundry?’

His attempt to help the young girl find more enjoyable work is very kind and generous, and though giving her a few days off borders on unprofessional behaviour, it shows the need to be flexible in G.P practice and in medicine in general for the greater good of the patient.

Come up again on Wednesday and I’ll phone the Labour Exchange and we’ll talk about what they say’.                                                                                         

The way he consoles her is almost therapeutic. It highlights Sassall’s role in the community, he plays a key role in looking after the locals’ health, both mental and physical.                                                        

‘The fact that you’re crying means you’ve got imagination. ‘                                                                      

This essay is a reflection on the meaning of ‘good’ doctoring, the naming of illness and the ambiguity of scientific medicine in the context of general practice. Sassall is committed to the fraternal bond that develops over years with his patients. Berger illuminates, through John Sassall, the deep potential of medicine, and particularly general practice, to express solidarity with people as they move through their lives.

‘‘That’s where I live, where you’re putting that needle in.’ ‘I know’ Sassall said, ‘I know what it feels like.’’

The description of Sassall’s qualities as a doctor stand as a guide for all doctors in understanding the doctor-patient relationship and particularly for GPs in seeing their role as more than just scientific and approaching the practice of medicine in a holistic way, acting  as a guide and helper in their communities. Sassall sees the patient as the central character in the practice of medicine.

‘He was straight, not afraid of work, easy to talk to, not stand-offish, kind, understanding, a good listener, always willing to come out when needed, very thorough’

I enjoyed reading this extended essay, it cast a new light on the doctor-patient relationship which has definitely influenced and altered  how I view General Practice, and the way I see medicine’s role in society.

Student notes on Oliver Sacks

(reynaudc)

Oliver Sacks, British neurologist who has practised in the USA for the past 50 years has acquired a great notoriety as a prominent author especially thanks to his book Awakenings published in 1973 which was later made into the Oscar-nominated movie Awakenings by the same name and his book The Man Who Mistook His Wife for a Hat, and Other Clinical Tales. Sacks draws from his experiences as a neurologist to present a unique and insightful look into consciousness, the human mind and brain.

 

The Man Who Mistook His Wife for a Hat, and Other Clinical Tales is a collection of 24 essays relating the cases of patients presenting bizarre and even bewildering neurological conditions. The essays are divided into 4 categories:

  • Losses which presents among others the case of an amnesiac sailor, a “bodiless” woman (who’s lost her sense of proprioception) and the case of Dr. P who can’t recognize objects;
  • Excesses presents the cases where the brain is subject to too much activity as in the cases of Tourette’s syndrome;
  • Transports describes the worlds of visions and hallucinations, in which Sacks includes a personal experience of feeling like a dog whilst under the influence of amphetamines and LSD;
  • The world of the simple presents the cases of people affected by mental retardation but yet enjoy a rich and full life.

 

“Street neurologist with a sense of wonder”: interview with Sandee Brawarsky, the Lancet, 1997

In this interview Sacks is asked about how he came to the USA and how he started writing. When asked how he is seen by other neurologists he is often categorized as “a spokesman” or a sell out to “pop neurology”. It is probably his own view of himself that describes him best. He would like “to be seen as a sort of explorer, driven by, and trying to share, a strong sense of wonder.” a description which seems appropriate and well-fitting upon reading his work. Every case in the book presents a neurological condition whose implications the average reader could never have imagined and makes us wonder at the complexity of the human mind and brain.

The interview also raises the question of Dr Sacks’ motivation as a doctor, and his certain guilt in regards to writing about his patients. Does he now practice for the sake of some kind of voyeuristic desire to write his next book or for the patient’s best interest? This is a question often raised when doctors relate their experiences through art.

The Man Who Mistook his Wife for a Hat

The first case in the book is the case of Dr P. a music professor who seems completely unable to recognize objects. He is unable to recognize his students faces but able to see these same faces in water-hydrants and other inanimate objects. Upon developing diabetes and seeing an ophthalmologist he is referred to Dr Sacks. Immediately Dr Sacks is aware that something is not quite right but is unable to determine what it is. It is only upon conducting a routine neurological examination that he starts to grasp what is going wrong. Dr P. is unable to put back his shoe believing that his foot is his shoe. The situation becomes all the more bizarre when Dr P. leaves; he mistakes his wife for his hat and tries to put her on his head. The puzzlement of the narrator is made evident and is easily shared with the reader.

The next day Dr Sacks visits Dr P. at his home and performs a few tests, he first asks him to describe a rose and then a glove. Although Dr P. knows very well what these are, and is perfectly able to describe them he is unable to label them rose and glove. Sacks doesn’t describe the disease with any scientific terminology at any stage during the essay and yet through these two tests he cleverly presents it and reveals to the reader what the problem is. However the simplicity of the situation make us wonder whether or not Sacks has not used some artistic licence in presenting this condition to us in such a neat and effective way.

Other elements hint at the truthfulness of his account (or rather lack of) especially at the beginning when presenting Dr P. “Had he not always had a quirky sense of humour, and been given to Zen-like paradoxes and jests?”.  It is difficult to imagine any doctor knowing his patient so well after only two consultations. Although it seems Sacks may have used some artistic licence (or has an outstanding memory) these anecdotes and details make us relate all the more to the patient.

The essay ends with a somewhat tragic revelation on how the disease has progressed throughout the years when Dr Sacks looks at Dr P.’s paintings. “This wall of paintings was a tragic pathological exhibit, which belonged to neurology, not art.” (Which seems like a strange comment given that many great artists presented some kind of neurological condition or substance abuse which helped them produce their art).

 

I really enjoyed this book as it was easy to read, not burdened with complex scientific explanations and offered interesting insights into the complexity of the human mind whilst making every case more about the patient and his response to the disease rather than about the disease alone.

Student notes on House of God by Samuel Shem

(clearyj3)

Samuel Shem’s ‘The House of God’ follows a young doctor’s internship in the eponymous ‘House of God’ hospital. Following the experiences of Dr. Basch and his colleagues, Shem’s writing ranges between insightful and crass. The satirical often veers into the farcical, while Shem’s own brand of ultra-realism can sometimes come across as exaggerated.

With that being said, there are excellent moments in the text. The sincerity of the main character is endearing and though the humour is probably more miss than hit, there are genuinely funny moments. ‘The Fat Man’, the intern’s first resident who believes that there is no patient ‘whose medical characteristics cannot be listed on a three-by-five index card’, is a prime source of humour.

However, Shem’s attempt to make the novel as realistic as possible can appear more like hyperbole. The seemingly never-ending nicknames and acronyms (GOMER, LOL, NAD…) can be tiresome and the idiomatic speech of some characters, a Chicagoan who speaks nothing but hipster and a foreign patient who shouts ‘go avay’, is simply hackneyed. ‘You dig?’

Though these elements detract from the novel, taken with a grain of salt (or more, as prescribed) ‘House of God’ can be read for what it is, a frank though perhaps exaggerated take on an intern’s story, from a man with real-life experience.

Student notes on extract from Sebastian Barry’s ‘The Secret Scripture’

(by montgodc)

This is a very fascinating novel which for me explores two key themes. The first theme explored is introduced to us very early on in the very first paragraph of the chapter. It is this idea of Mr Grenes where he relates the condition of the building to that of the patients it contains.

“As if the very head and crown of the institution were mirroring the condition of many of the poor inmates beneath.”

Barry uses very vivid imagery to allow us to depict in our minds a very large unwelcoming building. Dr Grene does not resist the idea of a new building but he is not welcome to it. He feels that the building has almost become the heart of this mental asylum, both patients and workers alike have become a part of this building through the history shared in it. It is interesting however in the way in which he portrays this idea in relation to patients and workers, he imagines that the patients have become part of the actual solid construction of the building.

“How can we prise many of the patients out of here, when their very DNA has probably melded with the mortar of the building?”

Yet when he talks about the workers they appear to be more of the inhabitants in the building not the building itself

“Similarly the attendants and nurses have become as much part of the building as the bats in the roof and rats in the cellars.”

For me one of the most powerful parts of the story is when the hospital is referred to as the ‘lost ground of Roscommon’ this really sums up the stories of the people inside, despite the knew plan of reassessing the patients and releasing those who are found to have been held for unjust reasons the overwhelming feeling is that society had forgotten about them and by society demanding there release now it is too late for them, they are to old they have been interned for too long.

“I am not so great a fool as to think that all the ‘lunatics’ in here are mad, or evere were, or were before they came here and learned a sort of viral madness”

The introduction of Mrs Mcnulty brings into the story a character who we are told is very old, yet it is her realism that propels the story forward. She does not come across as a person who should be in a mental hospital and this helps us to then accept when her history is brought into question. For me she is a person who has just grown to accept her position and what she has.

“There will always be mice”

When she says the beauty of Dr Grene is that he is entirely humourless you are left wondering does she feel this because it allows her to read him more easily and know exactly where she stands or is it because after over 50 years in the asylum she has lost her ability to enjoy humour and so Dr Grenes lack of humour she finds refreshing and easier to deal with.

On a whole I really enjoyed reading this book it out of all the books we have read so far this one is the one I have most wanted to carry on reading and to see how it turns out. The story was well written building up an excellent basis for the story and out lining to very different yet both fascinating characters while not revealing to much committing the reader to wanting to read more.

Student notes on ‘Angel of Mercy’ by Joyce Carol Oates

(by moriartn)

This gothic short story portrays two nurses, who at the outset seem extremely different, but who by the end have intertwined to become intimately similar. One, Agnes, or the Angel of Mercy who worked in the “city of the damned” in the 1950’s is followed 8 years into her career, when she has already began to question her values as a nurse in terms of her definition of care and how far it should go. The other, Nurse R- who remains unnamed throughout the story works in the hospital almost 50 years later, but we follow the beginning of her career, when she is trying to remain true to the values of her profession unquestionably. We follow R- as she begins to move in to the realm of where we begin to follow Agnes, and we follow Agnes herself further from society and deeper into her own world of beliefs and morals.

 

Both characters develop a distinct idea of mercy throughout the story, and this idea of how far Mercy should go, is a prevalent theme throughout, as is the characters development which plays a key role in the telling of this story. Nurse R- is staunch in her beliefs and understanding of where her duty is in helping someone at the beginning of the story, what society believes and what she has been taught is absolute. There is no question of what her duty of care involves, and where the line is that she must not cross for a patient. As the story progresses she begins to doubt this, and the first signs of this are after her encounter with B-, when she observes her arm and the marks he has made, almost as though she wishes there was more she could do for him. Then as Marcus Roper is introduced we see her resilience being tested as she tries to maintain her boundaries and stick to her rules. As the story develops she falls further and further away from her initial ideals and turns more towards the views of the Angel of Mercy. Agnes on the other hand is described at the beginning described as a “smiling and eager” young graduate nurse, excited at the prospect of her new career. Clean, and well turned out, the “perfect nurse”. She begins her serial killings in her 8th year of service, which is where her narrative begins in this story, and notes them in her journal. It seems that Agnes is in the place that nurse R- is moving towards, while we have skipped over Agnes’ journey that R- is currently making. She has moved from the beliefs of her peers of mercy and how far her care should go. Although her killings stem from a wish to help her patients and end their suffering, she seems to develop an Angel complex, from her time at the city of the damned. This, and the running theme of the damned Vs the non- damned is highlighted by her journal entries, where she writes God’s name in a mode that is between both, writing G-D instead of God or just G-. She seems to believe that god has abandoned the patients of the “city of the Damned” and so has chosen to complete what she believes to be God’s work herself. She also seems to develop a sick enjoyment of what she does, as is portrayed at the end, where the killing becomes a compulsion; she must do it, despite the fact that the patient is not at deaths door, like her other victims and fights back with a strength that surprises her. Rather than stop she fights her victim, quite literally to the death.

Although the story is about the personal journeys of the nurses rather than the development of themes, although some main ideas or run throughout. These included:

  • The idea of “mercy” as shown by both main characters, in contrast with the somewhat restrained view of society.
  • The damned, before and after they become so, highlighted by the use of some names and not others, the damned being named and those who have not yet been damned who remain anonymous. Nurse R- remains anonymous only because she is on the journey towards the damned during the story.
  • The Angel complex of Agnes, which is prevalent in her diary entries, where she claims that G-D has abandoned the city of the damned, taking it upon herself to relieve the suffering of the abandonees.
  • Depression. The hospital is portrayed as a dismal place to say the least, and using description, the town although remaining fairly anonymous is portrayed as a mortal Hades, with the burning river Styx, and the “city of the damned” in the hospital. It is also depression among other things that drives both nurses to their killings.

In an interesting twist, I found that it was a difficult piece to read, but well written. Although it was well written, especially the descriptions and developments of the two characters, the phrasing was often difficult to understand, syntactically it made it difficult to breeze through, a clever tool, as it made you think about the story more as you tried to decipher what was going on and the meanings. I felt that interlocking the two stories rather than telling them both together in a chronological fashion was a good tool for the author as it made the journeys more comparable, so that the similarities and differences were both highlighted.

 

In conclusion the two central characters and their journeys highlight a number of issues. The younger nurse R- becomes hardened and cynical; exactly what she said she would not “R- vows she will not. She will not become hard, cynical depressed like the others”, while Agnes gives up steadily and moves further and further into her world and her ideas and further away from societal beliefs of mercy right and wrong. She develops a distinctly unnerving enjoyment and rush of pleasure when she acts as the “angel of mercy”.  Their development as characters highlights just how fragile human morals and “sanity” can be.

 

Student Notes on Rachel Cusk’s ‘Forty Weeks’ from A Life’s Work

(jmclaugh)

One of the main themes throughout this piece was pain. The mother to be, spoke regularly about her fear of pain and her dread of a painful labour. This fear seemed to stem from an early childhood experience of hospitals. She also complained about a lack of information and literature on the actual process of giving birth. Any literature she did read was mostly unhelpful or too simplistic. This made her feel isolated and alone in her experience. She found it difficult to interact with other pregnant women. This was highlighted when she attended the yoga class and spoke very little to the other women, making an excuse and leaving early while everybody else stayed for tea. Cusk purposely fails to mention the fact that the pregnant lady is not alone. We learn in the last paragraph that the father of the child is present and more than likely, has been throughout the whole pregnancy.

The whole theme of pregnancy is shed in a very negative light. Never once does the mother display joy or excitement about her future child. This is very uncharacteristic of most texts relating to pregnancy and is an important point that Cusk tries to make. The narrator mocks the National Health Service’s information leaflet entitled “Emma’s Diary”, a fictional character’s week-by-week diary account of her pregnancy. Emma’s account of pregnancy is too normal and ‘perfect’ for the narrators liking.

In conclusion, I felt that the text was very purposely written and Cusk chose her words and images carefully. Although it may not have been very enjoyable or uplifting it still hit on some important issues regarding how pregnancy is portrayed in literature.

Student notes on an extract from Stephen A. Hoffman’s Under the Ether Dome

CGreene

“You hardly realize you are being changed and yet you are.”

‘Under The Ether Dome’ reveals many different issues that the author personally experienced in his journey to becoming an intern at Massachusetts General Hospital. Hoffmann highlights how internship, for him, began the moment he entered into medical school. He emphasizes the ‘changes’ that occur, most importantly in attitudes and beliefs to each student beginning their first medical year.

As a first year medical student myself, Hoffmann’s first chapter both amused and surprised me. He describes how the “transformation had already begun” as he sat down for his first lecture in the large amphitheatre at Harvard University. He reveals how he believed “med school, I was sure, would be a grind.” Yet, as the year progressed he highlights how he also found that “it was also remarkably enjoyable.” When I sat down for my first lecture in Medicine at Trinity College Dublin, it really wasn’t what I had expected either. One month on, and I still don’t feel “transformed” as Hoffmann described, yet then again, he highlights how it is “more felt than seen, and it progresses almost imperceptibly.”

The author shows the impact that Harvard University’s prestige and fame had on him. He highlights how “the shadow of history” lay heavily upon both himself and his classmates. The many famous physicians such as Walter B. Cannon and William Best that also began their careers in Harvard created a sense of intimidation within Hoffmann, I believe, that he was challenged to live up to these men.

“Would we do justice to the long line of distinguished doctors who preceded us?”

Like Hoffmann, I too feel the intimidation and pressure of being a medical student in a prestigious college. When I accepted my place in Medicine in Trinity College Dublin, I knew it was going to be nothing less than life-changing for me. The honour of being taught by some of the most highly regarded lecturers in the world, as well as having state of the art anatomy and physiology laboratories to learn in has a huge impact on each student in Medicine here in Trinity I believe.

Hoffmann highlights the challenge he felt of following in the footsteps of Walter B. Cannon in Harvard University, whereas I feel there is a challenge within many medical students I know to also be as accomplished as some of Trinity’s most famous alumni. I believe the author’s first impressions of medical school are endearing and interesting to read as they can be felt by the reader, particularly a first year medical student, that reads his first chapter.

Hoffmann’s honesty is what I believe I relate to the most. His use of symbols to highlight the enormity of what his first medical year entailed for him appeals to me greatly. He describes how the “panoramic view was breathtaking” as he discusses the first year curriculum that he studied. His “panoramic view” highlights how he is not just living his dream but also enjoying the diversity of the subject as well as how “breathtaking” the workload of his first medical year was.

Personally, I enjoyed Hoffmann’s humour and comic relief throughout his opening chapter. “We also took anatomy lab. On the first day, our instructor fainted. Apparently he had never taught the course before.” The author’s account of his first anatomy lab reveals how this comical occasion, and the many other anatomy labs to follow, were his way of enjoying the “breathtaking” workload of anatomy. He shows how each student felt the tension ease in these labs as “the fine points of dissection eluded almost all of us.” I admire Hoffmann’s honesty in describing the “hopelessly comic” scene of events that occurred in anatomy even though the impact of what each lab entailed was always felt too.

“Once we began the abdominal dissection, we discovered our cadaver was flawed.”

Hoffmann’s account of the anatomy lab also creates a sense that the immensity of his career fell upon him when he discovered the many tumours that his cadaver had. He uses the gentle word “flawed” even though the impact of this experience was huge for him as he describes how it had taken him “beyond the realm of the abstract”.

Another aspect of Hoffmann’s first chapter that surprised me was his thoughts on his Medicine and Literature course. He reveals how he thought it “sounded unlikely indeed for a medical school curriculum,” which was surprising as this was how I also felt as I tried to pick my Humanities module this year. Like the author, the title ‘Medicine and Literature’ also lured me into choosing the module, I was unsure of what to expect yet my curiosity of what this broad module entailed made me choose it. “There was no overarching thesis to the course, no critical perspective imposed on us.” The author reveals how he was enthralled by the contrasting nature of this course in comparison to his lectures in anatomy and physiology.

“Literature celebrated this uncertainty, while medicine often seemed to abhor it.”

The author’s opinions throughout the chapter are both insightful and unexpected. Hoffmann reveals how he believes “physicians are always at risk of taking themselves too seriously.” This generalisation provides the reader with a view which is then contrasted with Hoffmann’s own experience in the OR for the first time. The author’s enthusiasm is endearing in his account of the events that took place that morning. He wanted to be professional, confident, careful and most of all, he wanted to feel a sense of belonging within the OR medical team, yet he couldn’t. ““Contaminated myself, didn’t I?”” As the author “hoped to avoid wrongdoing” during the operation, Hoffmann’s feelings of irritation, humility and inadequacy are clearly felt in this scene.

Yet, as Hoffmann goes on to recount his experiences of his second medical year, the mood of the chapter, I believe, changes. Hoffmann reveals how it was the “most intense segment of our medical school career.” I believe his sense of adequacy and feelings of belonging are felt more in his second year than his first year. “Running gave me an invaluable sense of continuity and belonging.” Hoffmann’s language also reveals his more positive outlook in second year. He uses words such as “wonderful” a number of times throughout the chapter, for example “wonderful runs” and “enjoyed remarkable successes.”

I also feel that Hoffmann gained a sense of freedom as he continued throughout his second year where he reveals how “finally we were turned loose.” Again, Hoffmann’s humorous encounters provide the reader with a sense of how the author’s eagerness to do his best for his patients and live up to the prestige of Harvard impacted on him as a medical student. I enjoyed the author’s account of his consultation with the patient from Boston that had “hat disease.” The tutor’s reaction was also even more amusing. ““Did you ask him where he ‘paks his cah’?” the tutor asked. “It’s heart disease, not hat disease he has!””
In Hoffmann’s final two years of medical school, I believe the themes revealed throughout the beginning of the chapter in first and second year are again interestingly repeated in quite a similar way.

“Almost overnight we went from onlookers to participants in the workup of patients.”

I believe Hoffmann’s honest account of his experiences on the wards of the hospital are what makes his first chapter so enthralling to read. Again, just like the first time he walked into the OR in first year, he felt daunted and nervous carrying out his first ever suture on a patient. The feeling of inadequacy and humility underlies his experience of suturing his patient’s head wound.

Hoffmann also continues to ask both the reader and himself many questions, just as he did in first year as he questioned the many equations of physiology that he had memorized by heart. “What was I doing violating their trust?” I believe this line highlights how strongly he feels the patient’s needs must be considered above his own need to learn how to correctly suture a wound. He bombards the reader with ethical questions that are very difficult to answer. “Was I prepared to commit errors in the quest to become a capable physician?” These questions are an important aspect to the opening chapter in my opinion. They highlight how he questions not only the reader’s beliefs but also his own character and ability to be a good doctor.

I also feel that it is important to highlight the comparison in attitudes that the intern in the suture scene and the OR resident that he encountered in first year had towards him as a medical student. The intern gave him a look that was “confident and sad,” “as if he were trying to say, go ahead everything will be all right.” In contrast, the OR resident he met “bellowed” at him. He made Hoffmann feel humiliated in front of the OR team by asking him ““What are you doing?” “Get up here!””

I believe that Hoffmann’s first suture was a major landmark in his medical career. He reveals this by saying “I was now in the pilot seat, a doctor.” Yet, although Hoffmann was nervous, he was also clearly elated to be given the opportunity to further his medical experience- “bit by bit my confidence grew.”

The similarity of his experiences in both his first and final years of medical school continue as he reveals the more serious side to his time on the wards. He reveals his thoughts on how “medicine is not a game. We were no longer in the realm of the textbook.” It is clear from this line that the comical antics that occurred in the anatomy labs in first year contrast greatly to the extent of maturity that he has gained since then.

Hoffmann highlights how in his final years they “were under tremendous pressure to perform,” just like they were when they first started in medical school. In first year, Hoffmann was expected to live up to the prestige of Harvard whereas now, in his final years, he was expected to rise to any challenge that was brought before him along the wards of the hospital. Yet, in contrast to his feelings of doubt and fear in first year, Hoffmann reveals how he felt more capable and confident in his final years. “I came to feel more like a doctor.”

Hoffmann’s first chapter gives the reader an outlet to consider the many ethical dilemmas that a medical student encounters throughout their time at medical school. I liked how Hoffmann provided the reader with a very personal view of his own experience of ethical issues and his beliefs. His gratitude and respect towards his patients makes him an extremely likeable character in my opinion. “Our learning to be physicians ultimately derives from the charity of patients.”
The honesty displayed throughout the opening chapter of ‘Under the Ether Dome’ is what made me want to read Hoffmann’s other chapters. The language and changing moods expressed as he moved from one medical year to the next was insightful for me as a first year medical student. I believe Hoffmann’s book not only appeals to medical students, but also to every healthcare professional. Hoffmann makes his readers reflect on their own beliefs on diverse ethical issues that most affect their relationship with the patient. Yet in saying this, the author does not impose his own opinions on the reader, he instead effectively provides an outlet of reflection to any reader that has had similar experiences to him.

“My life seemed like an early series of beginnings and leave–takings.”