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Book Review: Monday Mornings

Book Review: Monday Mornings

I started Sanjay Gupta‘s novel Monday Mornings very excited to read some realistic and exciting stories of compelling and interesting characters working on exciting cases.  However, in a lot of ways I was disappointed.  It was an okay medical novel, but felt a bit like I was reading the novelization of an okay medical show.  It felt a bit like Gupta has watched some medical dramas and then wrote a novel based on tropes and themes he considered popular.  Instead of using his unique and special perspective as both a practicing neurosurgeon at a major research center and an expert on health policy, he has written the plot for just another TV medical drama mini-series.   This is especially unfortunate given the popularity of realistic views of the activities and personalities in real emergency departments and operating rooms, as demonstrated by Terence Wrong’s series Hopkins, Boston Med, and NY Med.

I understand the need to make things extra dramatic (although there is likely no dearth of real drama he could draw from) and to simplify things for lay readers; however, I don’t think he needs to make things so unrealistic.  One of the main characters is a very young neurosurgery attending who has 15 New England Journal of Medicine publications and who (until the novel) has never made a surgical mistake.  Now, to put the first part in perspective, the chair of neurosurgery at Stanford has 2 NEJM publications (out of over 200 total publications) and the neurosurgery chief at Harvard/MGH has one review on Neurofibromatosis and is quoted in a few Case Reports of the Massachusetts General in NEJM.  Practicing surgeons just don’t typically do the kind of research that gets into NEJM, and even if they worked full time doing clinical research, I know of many mostly full time research, full professors of internal medicine who have maybe 4 NEJM publications.

Ignoring the outstanding publication record of the young surgeon, he also is renowned for never making any mistakes.  That doesn’t even make any sense in the context of the novel which is about the hospital’s Morbidity and Mortality meetings on Monday mornings.   The reason these meetings are held is that surgeons make a lot of mistakes and they need to review and discuss these mistakes in order to become better at their jobs.   If you look into any of the work on expertise, be it Atul Gawande’s writings, Outliers, or even go to the source such as the research of K. Anders Ericsson, the only way to become an expert is to make a ton of mistakes along the way.  To quote Niels Bohr, “An expert is a man who has made all the mistakes which can be made, in a narrow field.”   Another way to look at a perfect record is that a string of successes invites a failure, not because of any kind of universal karma, but simply because of regression to the mean.   Even the greatest perfectionists make mistakes along the way, that is how they get better.  The character in the novel is a bit like a caricature of character like Perry Mason (from the 1950’s) who has never lost a case.

In a weird juxtaposition with hypercompetence attributed to the medical staff of the world class medical center (Chelsea Hosptial), the mistakes they do make are either rookie mistakes or things which are a bit outdated and counter to current practice.  An example is an argument in the book about counting sponges, and the search for a missing one in a patient or the trash bag.  A world class medical center should have very clear guidelines and a protocol for what to do when a count is off, and yet it is surprising that there is so much resistance to following this in the book.  It’s a well known problem.  What would have maybe been more realistic and interesting is if the hospital were to be prototyping a new system to deal with this problem (like the bar code scanners being used at some places on a trial basis).  I don’t think the medical public is surprised about the existence of common medical errors or surprised that physicians feel really badly when they make them, both a mix of feeling terrible for their patients but also professional shame amongst their peers.  Those are common stories in medical dramas, and there isn’t really much a new twist in this novel.

Gupta goes to so far as to insert the incredibly common and totally unrealistic trope of TV and film medical dramas of having the team “shock a flatline“.   In chapter 28 of the novel, a patient during bowel surgery suddenly, without warning, completely flatlines (with a monotonous, continuous beep tone that alerts the team).  They shock the heart once, add some medication in a few tense moments of activity and then use the defibrillator again, restarting the heart.  What?  That’s straight out General Hospital or something.  There has been ton written online about why it doesn’t make sense to defibrillate asystole, and why it would typically be counter productive or injurious.  It’s really like he pulled this scene from a bad TV show.  This would be a great opportunity for him to have a more realistic adverse event happening, using his medical knowledge and experiences to come up with something good.

The way that neurosurgical training is done also seemed to be very outdated.  The novel made it sound like the traineess all did a full general surgery residency and then a neurosurgery residency on top of that.  This is a very outdated model, as everyone now goes right into neurosurgery residency.  As of 2009, trainees are no longer even required to have a general surgery intern year.  Even the procedures described as being revolutionary and exceptionally challenging, such as endoscopic endonasal approachesdeep brain stimulation or 3D guided stereotactic surgery should be relatively standard fare at the world class hospital Chelsea is supposed to be.  Given they have such prolific researchers publishing so much, maybe they are a little behind on recent clinical advances or something.  To be really compelling and fun, why not add some patient supplied music.  There was just a lot of the book that made it sound like it was from an earlier era.

There is also an important scene where the hospital staff (physicians and nurses) do a terrible job taking care of a scumbag patient.   In one part, the nurses are refusing to give care to a murderer with swastika tattoos.   I am sure many nurses would find this depiction offensive.  At a major medical center with an active emergency department, they have all sorts of unsavory characters, including many perpetrators of horrible crimes (rapes, murders, assaults) coming in that they provide care for.  It’s their job and something they have to get used to.  Having one physician provide a low level of care because of his own revulsion is a realistic exception, having a whole group of providers requiring a rousing pep talk from management before they will act just seems very unrealistic.   This is an important part of medicine, but it seems like the issues healthcare providers face when dealing with reprehensible patients could have been dealt with using a lot more complexity.

These are just a few examples of things taken from the novel that seem more like medical stereotypes or fables.  How is it just as a novel?  Again, the writing didn’t stand out as exceptional and for some reason the characters were not that compelling, which is unfortunate.  It makes a novel a lot more fun when you really root for some of the people, but most of the characters came off as so self-absorbed that it was hard to really like them very much.

Overall, it’s not a bad novel, but I can’t help but feel like it is a missed opportunity to be something really exceptional and revolutionary in terms of medical fiction.  I hope Gupta keeps writing novels, as practice and trial and era are what lead to improved work, the key message of the Monday Mornings of the title.

 

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