Saturday, July 27, 2013

Open Wound by Karlawish - A Wonderful Read



I wanted to alert the Geripal community about a wonderful and interesting book written by one of our colleagues: Open Wound, The Tragic Obsession of William Beaumont by Jason Karlawish form the University of Pennsylvania.

Most people will enjoy the historical fiction (based solidly on actual events) following a young physician (Beaumont) who saves the life of a French fur trapper (Alexis) in a northern Michigan military outpost in 1822. Alexis suffered a gunshot wound and was going to die until Beaumont intervened and treated his wound. Unfortunately, he was left with a fistula, a hole leading directly into his stomach. This hole provided a window into the world of digestion and over the course of the next several years, Beaumont performed numerous experiments on the gastric juice that he collected. These experiments largely proved that digestion is a chemical process rather than a mechanical one.

I'm not necessarily a history buff, and I might have missed this book if it had not been a friend and colleague who had written it. However, I'm so glad I did.

For me, the book was personal. As a medical researcher, the amount that I identified with Beaumont was frightening. I identified with the endless hours of work, the travel, the unresponsive government funder, the criticism from fellow researchers, the constant self-criticism, the exasperated spouse, the children wanting to see more of me, the difficulty in finding happiness, the ambition...

Indeed, the ambition is what caused the most introspection for me. While it is quite clear that Beaumont's intentions at the beginning of the book were to help a patient and to advance science, those intentions became quite muddy over the years. It made me think about my research and my patients. I often have the experience where a patient I am seeing might also be eligible for a study that I'm conducting. When that is the case, I generally ask that patient if they wish to be in the study. All of the work that I do is approved by our research ethics review board and most of the studies I do don't involve invasive interventions or long time commitments. I always stress the voluntary nature of my request as well as my fidelity to our relationship. I haven't been too concerned with people feeling coerced by direct recruitment.

Like Alexis to Beaumont though, I wonder how easy it is for my patients to say no to such a request. While my clinical relationship is supposed to protect the patient, how will I know when my ambition to complete a study gets in the way of protecting a patient for whom a research study isn't the best idea? Ambition causing unethical research was recently highlighted by two UC Davis neurosurgeons who experimentedon injecting gastrointestinal bacteria into humans with brain tumors - an experiment that was apparently meant to be done only on rats.

I strongly recommend this book to potential researchers and potential research subjects - that's basically everyone. One reason we learn about history is so that we can avoid repeating it. Like all good histories, this is indeed the value of Dr. Open Wound. Nice work Jason - I look forward to your next book!

by: Dan Matlock, MD, MPH

1 comment:

Alex Smith said...

Thanks Dan - I thought this was a terrific read as well, and wanted to review it, but couldn't think of a good GeriPal connection - I like the researcher introspection tie in.

I've avoided recruiting my own patients for studies for just that reason. I've been fortunate that the primary data studies I've conducted have been of common conditions. For rare diseases or conditions for which the physician is the only specialist and researcher, this presents a sticky dual loyalty that is explored to devastating effect in Jason's book.

Having grown up in Michigan, some of my favorite parts of the book were the historical scenes of early Fort Mackinaw island, a place where I vacationed frequently as a child. My memories are filled with riding around the island on a rented bike, and chocolate fudge.

How fascinating to read of Mackinaw as it was nearly 200 years ago - a frontier outpost, Voyagers, the crude conditions, the sense of isolation, and beauty.

The book is very well written. You can picture the heat of a hot day in Michigan:

"The summer grew unusually hot. By August, the heat was so intense and unremitting it drove families to sleep outdoors beneath canopies of bug netting. Work slowed, and people lingered under the trees along the lakeshore, fanning themselves. The women wrapped their skirts about their hips and waded into the lake and splashed water over their heads. Some gave up all pretension and walked out into the lake far enough that their skirts rose up about them as though their torsos were at the center of great blossoms. Some men simply sat in the water. Others wandered out as deep as their shoulders. Ramsay Crooks was seen floating upon his back, a great berg dressed in trousers and a cotton blouse." (p 72)

Full disclosure- Jason Karlawish is a geriatrician, bioethicists, and a friend of mine too. But I don't think that colored my thinking about the book. Check out the Amazon page - rave reviews from places like the New York Times, Wall Street Journal, NPR.