If Medicine Is So High-Tech, Why So Much Illness?

A fine new book by a former emergency doc asks tough questions gently.

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"Early in my ER career I decided I would not press my medical opinions on people who did not request them," writes Robert Martensen in the quietly compelling A Life Worth Living: A Doctor's Reflection on Illness in a High-Tech Era, which will be published next month. Being closemouthed isn't easy for physicians, drilled from the start of their training to absorb, recall, and recite information. The context in the book is a 40-year-old patient named Marguerite. Martensen had tentatively diagnosed inflammatory breast cancer in Marguerite, who had asked to come to his ER because she knew him casually and she wanted him, not an unfamiliar doctor, to check out a tender spot in one breast. His diagnosis subsequently was confirmed, and she was about to enter the hospital for a bilateral mastectomy. "We're going to lick this thing!" her husband, Eduardo, told Martensen.

"I wanted to say and ask many things, but I did not," writes Martensen, who was no longer involved in Marguerite's care. "My job, if I had one, involved being supportive.... To do otherwise, I told myself, to attempt to insert myself into their intimate life, would be disrespectful. The last thing they needed was for me or any outsider to sow doubt."

Why was he tempted to intervene? Because he worried that Marguerite's cancer team had falsely raised her hopes or that the couple had not truly listened to a candid assessment of her chances. Even after her surgery, two malignant nodes could not be removed. That automatically put her in Stage 4, with a 15 percent chance of making it to five years. Probably less. She was only 40 years old, and this is a cancer that tends to be aggressive in younger women.

Then Martensen steps back to tell a larger story, the one reflected in the title: "[D]espite all the effort and hope that patients and their families and doctors have put into breast cancer research and treatment in the past one hundred years, those like Marguerite who present with advanced metastatic cancer probably do not live much longer than their early-20th-century counterparts. It is harder to determine whether they live better."

It oversimplifies the theme of this book, but not by much, to say that it is about medicine as all of us—doctor and patients alike—want to see it in the 21st century as opposed to what it is. "Forty years ago, phrases such as health science campuses, the healthcare industry, and the ubiquitous new dyad of healthcare consumer and healthcare provider did not exist," writes Martensen. "[T]hey signal a deep shift: the commodification of something that resists being turned into a commodity, which is health." Want an example? "[M]ajor transplants...have become the 'financial lifeblood' of academic hospitals," he writes.

Martensen no longer practices emergency medicine. He has a doctorate in history, writes and lectures extensively about the history of medicine, and is now director of the Office of NIH History at the National Institutes of Health.