Hippocrates' Shadow Paperback – September 15, 2009

This book offers a critical assessment of the contemporary practice of medicine, and its credibility is strengthened by the fact that the author, David Newman, MD, is an ER physician, so we get an insider's perspective. Newman identifies many areas where medical practice comes up short, and he illustrates them with apt case studies as well as incisive reviews of clinical research studies. At the same time, he does recognize where medical practice is often successful, and he remains optimistic that medical practice can and will continue to improve overall.The following are my notes on key points from the book:(1) The rise of science and technology in medicine, though beneficial in many respects, has resulted in narrow specialization, as well as costly and sometimes misleading overuse of testing. Indeed, many doctors and patients have forgotten that medicine is about health outcomes, not "science." A general result is that doctors often no longer treat whole patients, so communication between doctors and patients has greatly suffered. This is especially unfortunate because the quality of doctor-patient communication has been found to be a significant factor in patient outcomes for a variety of medical conditions. In fact, such communication is a contributor to placebo effects, which are biologically real and are related to the ways in which the mind ascribes meaning.(2) Medical knowledge is still quite limited in many areas, and the more we know, the more we find out we don't know. Medical "facts" are thus tentative understandings which often need to be revised or discarded, sometimes within a decade or so after becoming widely accepted. Disagreement among doctors regarding diagnosis and treatment is an indication of the limitations of medical knowledge. Moreover, the paradigm of modern medicine generally includes many fallacies, ineffective treatments, and poor practices which remain entrenched for a long time even in the face of abundant contrary evidence. In the same vein, different medical specialties and institutions often have different practices for treatment of even the same conditions. And yet doctors often hide their ignorance and patients often incorrectly presume that medical knowledge is complete. One result is that "where alternative and complementary medicine has flourished, it's nearly always a sign of modern allopathic medicine's failure ..."(3) The overall effectiveness of particular medical treatments varies from very high to zero, depending on the medical condition. This effectiveness can usefully be quantified by measuring the number of patients which need to be treated in order for a single patient to benefit from a particular treatment (NNT). The NNT thus varies from one (always effective) to infinity (never effective). However, it must be remembered that the NNT is a statistical measure applicable to populations, and thus doesn't specifically predict how an individual patient will respond to a treatment. Also, any potential benefits of treatments must also be weighed against potential adverse effects, especially considering that roughly 100,000 people die each year in the US due to medical error.(4) Health care spending per capita in the US is, by far, more than any other country, yet US health care outcomes are near the bottom among industrialized countries in nearly every category. In particular, "... health-care spending in the final year of life (and predominantly in the final one to two months of life) now represents nearly a third of our system's total health expenditures." Part of the problem is that our system is biased towards generating profits, rather than solely focused on (cost-effectively) improving health outcomes, and it's noteworthy that research funded by pharmaceutical companies has (unsurprisingly) been found to be biased. Also, behavioral issues such as alcohol misuse, smoking, poor diet, and physical inactivity account for about 40% of annual US mortality.One area where I somewhat disagree with Newman is in relating the Heisenberg uncertainty principle and Godel's theorems to medical practice. Both of these have precise technical meanings which don't have much relevance to medicine, so these are at most metaphors, and possibly misleading as metaphors.But overall, other than the exception noted above, I think this is an excellent and eye-opening book, and I recommend it to anyone who wants to realistically understand medical practice and how to more effectively utilize the services of doctors. And indeed several doctors have reviewed the book and indicated that they learned a lot from it, so I suppose the book can be recommended to doctors also.As further reading, I suggest the following, in order of increasing sophistication: How Doctors Think  by Jerome Groopman How Doctors Think: Clinical Judgment and the Practice of Medicine  by Kathryn Montgomery The Logic of Medicine  by Edmond Murphy

I read a NYT editorial the author wrote on the ineffectiveness of mammograms* so I got this book out of curiosity. I'm glad I did- out of the hundred or so non-fiction books I've read, it's easily one of the best and also one of the most disturbing.In this deeply insightful and philosophical book, the author reveals how modern medicine really works- that doctors pretend to know far more than they really do and that some treatments (CPR, cough syrup, back surgery, antibiotics for viruses, etc.) are actually ineffective and may cause more harm than good. And yet, these practices persist due to tradition and because of our blind faith in technology and because doctor-patient communication is completely dysfunctional.But patients are equally at fault too. Doctors are regarded as all-knowing - just like medicine men in primitive societies were regarded as having magical powers. We can't accept that many conditions can't be treated effectively or at all. So we demand "something be done" and we willfully ignore the limitations of modern medicine. Vast amounts of money are spent during the final months of a patient's life- in vain- rather than simply accepting the inevitable.The author prescribes a paradigm shift among doctors and patients to fix the problem, which wastes hundreds of billions of dollars annually in the US alone. He doesn't believe a fix can be legislated. (I'd been on the fence re: Obamacare- but perhaps a drastic change like that is needed instead to improve the system, which hasn't been fixed by market forces alone. The free market has made the problem worse because pharmaceuticals heavily promote expensive new drugs which are no better- and sometimes even worse (e.g. Vioxx) than cheap generics.)This is must-reading for every doctor and for anyone who will see a doctor, which is everyone, of course. Highly recommended.*Note: The case of mammograms is extremely controversial- but study after study reaffirms their overall ineffectiveness: there are many false positives which means a great deal of unnecessary distress and surgery; some tumors are benign and don't require treatment; and the radiation can actually cause cancer in a few cases. (Self-examination for lumps is far more effective.)

Unlike several of the earlier reviewers, I am not a medical professional; I'm a patient. I found Hippocrates' Shadow to be among the very best medical writing for laymen. Dr. Newman's ability to explain complicated medical concepts in simple terms, without condescending to the reader, is exceptional. It is obvious that his life experiences inform his writing as well as his medicine. From his time riding an ambulance as a paramedic to his Army service in Iraq, the book is full of interesting anecdotes, but not in service of his ego. Rather, the stories support the central point of each chapter.If you've ever wondered what your doctor is thinking, or how he makes his decisions, or even just wondered why he can't talk to you a little better, you should read this book.As for the footnotes, skip them. Unless you're a scientist, they're of little interest. They are necessary, though, to demonstrate that Dr. Newman didn't just make this stuff up. He shows you the facts upon which his conclusions are based. That's a direct and open communication with the reader. Direct and open communication is what doctors should have with their patients; it's the central point of the book. Dr. Newman walks his own line.I look forward to reading his next book.

It's a "must read" for all of us!