Daniel Marchalik

Dermatologic Presentations of Orthopedic Pathologies

Dermatologic presentations of orthopedic diseases are commonly encountered in the dermatology clinic. These disorders often necessitate prompt recognition in order to properly refer for definitive treatment as well as to avoid unnecessary diagnostic procedures. As such, the presentations of these diseases as well as the treatments available deserve special attention. This review aims to identify orthopedic diseases with dermatologic presentations and discuss the diagnosis and treatment of these pathologies. In conducting this review, a comprehensive literature search was conducted. Our inquiry was limited to conditions with a unitary orthopedic etiology. By excluding syndromic dysfunctions with both orthopedic and dermatologic manifestations, we were able to create a consistent approach to the review. At the same time, such exclusions created an omission of many important disease processes that require the cooperation of orthopedists and dermatologists. In all, 19 orthopedic disorders and disorder classes with dermatologic findings were identified and carefully examined.The orthopedic pathologies identified require varying diagnostic and therapeutic approaches. While some do not warrant further work-up or referral, the disease course of certain pathologies is drastically altered by timely recognition, cautious diagnostic interrogation, and prompt referral.

Four broad temperament dimensions: description, convergent validation correlations, and comparison with the Big Five

A new temperament construct based on recent brain physiology literature has been investigated using the Fisher Temperament Inventory (FTI). Four collections of behaviors emerged, each associated with a specific neural system: the dopamine, serotonin, testosterone, and estrogen/oxytocin system. These four temperament suites have been designated: (1) Curious/Energetic, (2) Cautious/Social Norm Compliant, (3) Analytical/Tough-minded, and (4) Prosocial/Empathetic temperament dimensions. Two functional magnetic resonance imaging (fMRI) studies have suggested that the FTI can measure the influence of these neural systems. In this paper, to further the behavioral validation and characterization of the four proposed temperament dimensions, we measured correlations with five variables: (1) gender; (2) level of education; (3) religious preference; (4) political orientation; (5) the degree to which an individual regards sex as essential to a successful relationship. Subjects were 39,913 anonymous members of a US Internet dating site and 70,000+ members in six other countries. Correlations with the five variables characterize the FTI and are consistent with mechanisms using the proposed neuromodulators. We also report on an analysis between the FTI and the NEO-Five Factor Inventory, using a college sample (n = 215), which showed convergent validity. The results provide novel correlates not available in other questionnaires: religiosity, political orientation, and attitudes about sex in a relationship. Also, an Eigen analysis replicated the four clusters of co-varying items. The FTI, with its broad systems and non-pathologic factors complements existing personality questionnaires. It provides an index of some brain systems that contribute to temperament, and may be useful in psychotherapy, business, medicine, and the legal community.

We, the animals

2132 www.thelancet.com Vol 386 November 28, 2015 For more on From literature to medicine see Comment Lancet 2015; 386: 1223 and Perspectives Lancet 2015; 386: 1230 and 1618 In 1981, a group of 17 macaques known as the Silver Spring Monkeys became the most famous research animals in the USA when Alex Pacheco, an undercover college student and animal rights activist, infi ltrated the laboratory of psychologist Edward Taub to expose the experiments that took place inside. In his research on neuroplasticity, Taub severed the aff erent ganglia to certain limbs while immobilising the limbs that were neurologically intact in an attempt to train the macaques to use the appendages that lacked neural feedback. While the subsequent legal case against Taub for animal cruelty sparked the expansion of various animal rights organisations in the USA, Taub’s research also gave birth to a valuable therapy for patients with stroke known as constraint-induced movement therapy. The utilitarian and ethical questions of animal research are undoubtedly diffi cult, and this complexity is only one of the many uncertainties explored by Karen Joy Fowler’s We Are All Completely Beside Ourselves (2013). The novel tells the story of Rosemary and her twin sister Fern, told from Rosemary’s point of view as a collection of fragile and elusive memories. For Rosemary, recreating the story of her life is a slow and meditative process, and she asks the reader to consider her life on her terms. That it takes 77 pages for the reader to discover that Fern is a chimpanzee is a choice for which Rosemary off ers no apologies: “I spent the fi rst eighteen years of my life defi ned by this one fact, that I was raised with a chimpanzee...it’s never going to be the fi rst thing I share with someone”. She explains her reluctance to reveal her family history: “Much, much more important, I wanted you to see how it really was. I tell you Fern is a chimp and, already, you aren’t thinking of her as my sister.” Indeed, one of Fowler’s goals is to complicate an anthropocentric stance. When Rosemary finally reveals the secret of Fern’s species, the fact fails to impose order on their story. Instead, it introduces new dimensions to the ideas of identity, self, and other. As the novel advances, Fowler asks the reader to examine some of the toughest questions in animal research. Should experiments in which animals suff er be supported when they have the potential to cure debilitating diseases? Where precisely is the line between acceptable and unacceptable use of animals in medical research? Exactly who can be studied and how? Eventually we learn that the subject of the research project is really Rosemary, not Fern, leading us to wonder why experiments can seem fundamentally more acceptable when they are performed on those “beside ourselves” and who or what falls into that category. Instead of answers, Fowler’s novel invites deliberations. Struggling to make sense of these difficult issues, Rosemary reflects on a series of historical primate experiments. Yet it is the experiment performed on Rosemary that suggests how the price for animal research is also paid by humans. As the fog of her memory clears, we recognise the ruined family left behind in the wreckage of this particular chimp study: Rosemary, her alcoholic father, her depressed mother, and her fugitive criminal, animal-rights-activist brother. Some questions, Fowler’s novel suggests, are best explored in subjective narratives, not objective facts. The most didactic moment in Fowler’s book occurs in a discussion of Thomas More’s Utopia. As Rosemary talks with the professor of a “Religion and Violence” course she is taking, she comments that, “‘Thomas More says that humans learn to be cruel to humans by fi rst being cruel to animals.’” She then offers her own analysis of More’s position: “In point of fact, Thomas More doesn’t advocate doing away with cruelty to animals so much as hiring someone to manage your cruelty for you. His main concern is that the Utopians keep their own hands clean, which has turned out to be pretty much the way we’ve done it, though I don’t think it’s been as benefi cial to our delicate sensibilities as he’d hoped. I don’t think it’s made us better people.” Although Fowler offers no further commentary on this idea, the novel asks the reader to consider that, when it comes to complicated ethical questions, no hands can be completely clean. Medicine is fi lled with diffi cult ethical dilemmas that go beyond questions of research. And although works like Fowler’s cannot offer prescriptive answers, they can serve as reminders that in the end, choices can be diffi cult and they can be morally equivocal, but they should never be unexamined.

Multi-institution analysis of racial disparity among African- American men eligible for prostate cancer active surveillance

There is a significant controversy on whether race should be a factor in considering active surveillance for low-risk prostate cancer. To address this question, we analyzed a multi-institution database to assess racial disparity between African-American and White-American men with low risk prostate cancer who were eligible for active surveillance but underwent radical prostatectomy. A retrospective analysis of prospectively collected clinical, pathologic and oncologic outcomes of men with low-risk prostate cancer from seven tertiary care institutions that underwent radical prostatectomy from 2003–2014 were used to assess potential racial disparity. Of the 333 (14.8%) African-American and 1923 (85.2%) White-American men meeting active surveillance criteria, African-American men were found to be slightly younger (57.5 vs 58.5 years old; p = 0.01) and have higher BMI (29.3 v 27.9; p < 0.01), pre-op PSA (5.2 v 4.7; p < 0.01), and maximum percentage cancer on biopsy (15.1% v 13.6%; p < 0.01) compared to White-American men. Univariate and multivariate analysis demonstrated similar rates of upgrading, upstaging, positive surgical margin, and biochemical recurrence between races. These results suggest that single institution studies recommending more stringent AS enrollment criteria for AA men with a low-risk prostate cancer may not capture the complete oncologic landscape due to institutional variability in cancer outcomes. Since all seven institutions demonstrated no significant racial disparity, current active surveillance eligibility should not be modified based upon race until a prospective study has been completed.

A psychiatrist's search for resilience

www.thelancet.com Vol 389 April 22, 2017 1599 Christine Montross wrote her first memoir, Body of Work: Meditations on Mortality from the Human Anatomy Lab, when she was still a medical student. In it she described the process of dissecting a cadaver with a poet’s attention to detail and metaphor. When her female cadaver inexplicably lacked an umbilicus, for example, she and her lab partners named her Eve. Anatomy lab became for her, as for many medical students, an initiation into the complicated emotional work of being a doctor. She learned to contain her emotions without becoming indifferent. Montross has now published her second memoir, Falling Into the Fire: A Psychiatrist’s Encounters with the Mind in Crisis, about her residency as an inpatient psychiatrist caring for patients with mental illness in crisis. Each chapter focuses on patients who are “tormented by their ideas about their bodies”— patients with body dysmorphic disorder and body integrity identity disorder. What can she do for people who alleviate mental suffering by harming themselves physically? How should she treat a woman who is repeatedly admitted to hospital for swallowing knives, scissors, light bulbs, and bedsprings? Or a man who undergoes plastic surgery to correct imagined facial flaws? Or a young mother who obsessively imagines killing her child? When Montross discusses these case studies, she is like a detective solving a mystery, searching for the right diagnosis and the best treatment. At the same time, her book is also a meditation on her loss of complete faith in medicine. She expected to emerge from medical school having mastered knowledge of the human body and the methods used to treat illness. But psychiatrists work at the “baffling intersection of the mind and body”, and the uncertainty she confronts every day raises doubts: “If I hold my trust in medicine up to the light, I see that it is full of cracks and seams. In some places it is luminous. In others it is opaque.” “And yet”, she writes, “I practice”. Over time, she has developed a trust in the daily work of talking, treating, and attempting to heal. This description of Falling Into the Fire may suggest that Montross dwells on the less heroic aspects of the profession. Instead of focusing on astounding feats of diagnosis and breakthrough treatments, she chooses to contemplate the daily practice of psychiatry. Throughout her memoir she reveals how she gradually developed new forms of faith and resilience. In residency, she recognised that people who are well “live beneath a veil of invulnerability”, but that “mental illness pierces the veil”. Her role as a psychiatrist, she decides, “is not to try to repair the veil but to strengthen patients so that they can live, so that they can suffer less, so that they can hope”. There is an understated heroism in this work. Learning to cope with the suffering of patients without distancing herself from their pain also teaches her about caring for herself. How can she attend to minds in crisis without falling into the fire herself? How can she resist despair and sustain resilience? Montross answers these questions by closing each chapter with a short personal narrative about life beyond the hospital. These stories often arrive abruptly and they can seem tangential to the topic of mental illness, but they are not at all extraneous. In them, Montross contemplates the relationship of professional resilience to mental health. She locates her own resilience in her family life—in the house by the ocean where she lives with her wife and two children. Using just right metaphor, she says that her family is her mooring—a secure hold in an insecure setting. In the personal sections of the book, Montross often relies on the ocean as a metaphor for beauty, endurance, upheaval, and catastrophe. She finds that, working with patients who are so difficult to diagnose and treat, “you have to be anchored to the shore—to the people and things that are central to your own life”. Knowing this allows Montross to commit to a quiet and often unappreciated form of medical practice: she abides with her patients in the midst of uncertainty.

Suffering in the digital age

In his 2003 interview with Rolling Stone, Steve Jobs, the co-founder and former CEO of Apple, praised the digital revolution by remarking that technology has “brought the world a lot closer together, and will continue to do that”; but he also warned that, “there are downsides to everything; there are unintended consequences to everything”. In recent decades, technology has transformed medical research, diagnosis, and treatment in extraordinary ways. Amid so many successes, it may seem strange to focus on the “downsides”. Yet on occasion, it is worth casting a critical eye on medicine’s use of technology and the potential unanticipated effects. Adam Johnson’s “Nirvana”, the first of six short stories collected in Fortune Smiles, illustrates these concerns by imagining a not-so-distant future in which technology has increased the isolation of illness. The story chronicles the lives of an unnamed Silicon Valley computer programmer and his wife Charlotte. It opens with the couple awake in separate beds: Charlotte in a medical cot and her husband in their bed nearby. Charlotte is bedbound after Guillain-Barré syndrome has left her almost completely paralysed. Her condition was initially thought to be reversible, but she has made no progress for 9 months. Although in Johnson’s fictional future illnesses like Charlotte’s are no closer to being cured, the world has indeed changed. Cars drive themselves and Charlotte can adjust her bed’s position and open the shutters in her room with spoken commands. At the same time, technology has revolutionised the world of entertainment. When she and her husband need distraction, they can turn to various forms of augmented reality. Although some of these innovations make Charlotte’s life more manageable, there are also less positive consequences: digital experience obviates the need for human interactions. This is one reason the couple’s marriage is unravelling. Charlotte and her husband spend less time talking and have become oblivious to each other’s needs. Charlotte is angry at the medical world and at her body, and she longs for her husband to share that rage. Meanwhile, he worries about a promise he agreed to when his wife’s breathing began to fail from paralysis— “Promise me that when I tell you to make it stop, you’ll make it stop.” The couple falls deeper into their technologically induced isolation as Charlotte spends nights listening to the grunge rock of the late Kurt Cobain’s band Nirvana, while her husband retreats to the garage to converse with an interactive hologram of a recently assassinated US President. Each night, the husband talks with the digital program about topics he cannot broach with his wife, such as her stagnant condition and the end-of-life promise she asked him to make. Staring at his digital companion, the husband searches for answers: “‘Did you and the first lady ever talk about the future, about worst-case scenarios...Did you two make a plan?’” The President seems to respond to these queries but, in reality, everything he says is simply reproduced from old video clips. There is one hint of light when the husband programs a drone so that Charlotte, navigating it with her eyes, can visit her garden. She inspects squash blossoms and tomatoes and, when the drone returns after brushing against her roses, she can even smell their scent. However, this moment also reveals the complex nature of technology. As inventions make the basic tasks of caring for the ill, such as repositioning them in bed or adjusting the shutters in a sick room, easier to manage, human relationships can become displaced. After all, wouldn’t Charlotte have been better served being physically taken to the garden by her husband? Although “Nirvana” appears to be a futuristic fantasy, Johnson’s story expresses genuine concern about our growing reliance on digital technology. Augmented reality has already entered everyday life as Pokémon Go players hunt for digitally generated creatures. When a screen or a hologram comes between us and the world, what is gained and what is lost? The world, as Jobs imagined, has in some ways been brought closer together by technology. But in the world of medicine, where computer screens projecting laboratory results and imaging studies separate patients from providers, technological expansion will come at a price.

The art of transplantation: Mend the Living

For more on From literature to medicine see Comment Lancet 2015; 386: 1223, Perspectives Lancet 2015; 386: 1230, 1618, 2132, Perspectives Lancet 2016; 387: 330, 835, 1365, 1897, 2371, and Lancet 2016; 388: 19, 553, 1874, 2859, Lancet 2017; 389: 147, 897, 1599 Mend the Living begins with the steady beat of 20-year-old Simon Limbeau’s heart as he rouses himself before dawn for a surfing trip with friends. The early pages of this novel by French writer Maylis de Kerangal celebrate Simon’s physical vigour and his emotional exuberance—his heart, both literal and figurative. De Kerangal describes him slipping onto the back of his first wave: he is euphoric, able “to grasp the whole explosion of his own existence, and to conciliate himself with the elements, to integrate himself into the living”. Heading homeward with friends, this integration comes to a violent end. Their van crashes into a pole and Simon is propelled head first through the windshield. De Kerangal then narrates the 24 hours in which Simon’s life hangs, as his surname predicts, in limbo. His brain is dead but his heart continues to beat. Meanwhile the people around him—distraught parents, hospital administrators, doctors, and nurses— navigate a complex process that makes it possible for Simon’s heart, lungs, kidneys, and liver to be transplanted. One might expect a novel about organ transplantation to focus on the donor, the recipient, or both, but de Kerangal comes at the story from a different perspective. She is interested in the human element of the intricate medical and bureaucratic process. She describes the tightly choreographed actions of all the people who make donation and transplant possible— from the nurse who catheterises Simon when he arrives at the organ donation unit in Le Havre, to the administrator who arranges for the distribution of organs, to the man who cleans Simon’s corpse after his organs have been harvested. De Kerangal reveals how the healthcare workers involved in Simon’s case never let their work become routine and mechanical. Thomas Remige, a nurse specialist in the organ donation unit, “knows the steps and the milestones of the process”, but “he also knows to what extent it differs from a well-oiled mechanism, a chain of set phrases and diagonal checkmarks on a checklist”. Any single case, he observes, “is terra incognita”. Who can predict, for instance, how parents will respond to the request for organ donation in the hours after their child’s sudden death? One of the pleasures of Mend the Living is how de Kerangal depicts the individual members of the ensemble cast as they take turns at the forefront of the story. Each one is uniquely insightful about the meaning of his or her work. Alice Harfang, for example, is a medical intern and the scion of a famous medical family. She rem embers looking, as a child, at Rembrandt’s painting, The Anatomy Lesson of Dr Nicolaes Tulp, in which dissection signifies both scientific progress and the body’s violation. As Harfang watches the surgeon remove Simon’s heart, she recognises that, at this moment, she occupies a space where there is no separation between the living and the dead. The “absolute matter” of the body has transformed into “a substance of incredible potentiality”. After Simon’s organs have been removed, Remige becomes similarly reflective. He transforms the routine task of preparing a body to be moved from the operating room to the morgue into a sacred ritual by singing a “song of a good death”. This private performance over Simon’s body is “not an elevation, the sacrificial offertory, not an exaltation of the soul...but an edification: this song reconstructs the singularity of Simon Limbeau”. De Kerangal’s account of the medical, legal, ethical, and existential complexity of organ transplantation has been praised by physicians for its accuracy, and the novel recently won the 2017 Wellcome Book Prize. There are, it should be noted, two quite different English translations. The more lyrical British version by Canadian translator Jennifer Moore won the Wellcome prize and is quoted in this review. The crisper American translation by Sam Taylor bears a different title, The Heart. Mend the Living fittingly concludes not by shifting attention to the woman who received Simon’s heart, but by maintaining its focus on the people who made the transplant possible. With lyrical descriptions of ritual and routine, de Kerangal depicts doctors and nurses re-emerging from limbo to rejoin the living. They clean the operating theatre and tally the instruments. They wash up, discard their scrubs, and put on their street clothes. They pause to flirt or they catch a homeward train. After mending the living, they mend themselves.

The surgical theatre

The art of medicine has always involved a bit of artifi ce. The Hippocratic Corpus, the original medical code, warned physicians not to reveal poor prognoses to their patients lest they extinguish their hope. Although medical care has continued to advance, the palimpsest of the Hippocratic mandate has remained visible in professional rules of conduct. Thomas Percival, credited with drafting the fi rst code of medical ethics (1803), believed in benevolent lying as a way to instil optimism in patients. His doctrine served as a backbone of the American Medical Association’s first Code of Medical Ethics (1847), which instructed physicians “not...to make gloomy prognostications...for, the physician should be the minister of hope and comfort to the sick [and] that, by such cordials to the drooping spirit, he may smooth the bed of death”. Yet this code also reminded physicians that they “ought not to abandon a patient because a case is deemed incurable”. The space where futility meets a desperate need for hope is the focus of Richard Flanagan’s The Narrow Road to the Deep North. The novel centres around Dorrigo Evans, an ageing surgeon in search of his fl eeting memories, tracing his life from a childhood in Tasmania, to an aff air with his uncle’s wife, to his life as a surgeon and a prisoner of war (POW). Dorrigo’s career begins when, after graduating from medical school in Australia at the dawn of World War 2, he joins an Allied army battalion that is quickly captured by the Japanese army. Flanagan chronicles his life as a POW working on the Burma–Thailand Railway—an eff ort that claimed the lives of more than 12 000 Allied prisoners. Having no experience as an officer or a surgeon, Dorrigo nevertheless becomes a leader in the camp and the sole medical provider for over 1000 captured soldiers. Committed to depicting a relentlessly realistic portrayal of war, Flanagan devotes dozens of pages to describing the horrors of prison life—random beatings, food shortages, unending exhaustion, and rampant cholera. Yet Flanagan maintains an element of romanticism in his narrative, simultaneously exploring the inherent human need for hope and the power it has in healing. Indeed, Dorrigo, who “was not a good surgeon, [and] not a good doctor”, succeeds as a POW physician because he tends to the non-physical aspects of illness through performance. When prisoners lack food and sleep, he off ers hope by enacting the rituals of medical care. As the camp succumbs to malnutrition and cholera, Dorrigo enacts the public routine of “morning rounds” even though he does not have the resources to provide medical remedies:

Kazuo Ishiguro's uncanny science.

In his 2015 New Yorker article, “Gene Hackers”, science writer Michael Specter described the mixture of excitement and uncertainty that followed the successful cloning of Dolly the sheep in 1997: “scores of journalists (including me) descended on Edinburgh, and wrote that the achievement, while wondrous, also carried the ominous implication that scientists had finally pried open Pandora’s box”. In Greek mythology, of course, Pandora raised the lid of a jar she was told not to open and released death and other evils into the world. By the time she was able to close the lid, only hope remained inside. In 1997, what was released into the world was the possibility of human cloning. Less than a decade after Dolly was cloned, Kazuo Ishiguro published Never Let Me Go (2005), an alternative history of the recent past that imagines an England in which human cloning is widespread. Told from the perspective of a 31-year-old “carer” named Kathy H and set in the 1990s, the novel recounts the lives of a group of children at Hailsham, a boarding school in the English countryside. At fi rst, Kathy and her friends seem entirely normal, preoccupied with friendship, crushes, and rivalries; much of Kathy’s story centres on her tumultuous relationship with her best friend, Ruth, and her private affection for a volatile boy, Tommy. But, as the readers gradually learn, Kathy and the other students are human clones, brought into being and raised to adulthood for the sole purpose of being organ “donors”, a word that obscures the absence of choice. The Hailsham “students”— another euphemism that conceals their true purpose—are biologically human, but socially and culturally lessthan-human. As one school guardian explains, the students might look and feel like other children, but their ultimate purpose is to sacrifice their organs to preserve the lives of uncloned humans: For more on From literature to medicine see Comment Lancet 2015; 386: 1223 and Perspectives Lancet 2015; 386: 1230, 1618, 2132 and Lancet 2016; 387: 330, 835

Breathing lessons: Paul Kalanithi's When Breath Becomes Air

At the beginning of Paul Kalanithi’s memoir, When Breath Becomes Air, he appears to be a doctor at work, scrolling through CT scan images on a hospital computer: “the diagnosis was obvious: the lungs were matted with innumerable tumors, the spine deformed, a full lobe of the liver obliterated”. The story takes an unexpected turn when he adds, “This scan was diff erent: it was my own”. 15 months before the end of his neurosurgery residency, Kalanithi was diagnosed with lung cancer. He died less than 2 years later. When Breath Becomes Air is Kalanithi’s fi rst and only book. So many books and essays have been written about the shock doctors experience upon becoming patients, and about patients who learn to live when they face death, that it may seem there is nothing more to say. Kalanithi’s memoir is special, however, because it off ers a portrait not only of a young surgeon facing tragic circumstances, but also of a deeply refl ective man who wants to understand what it means to be a doctor, a father, and a mortal being. In the fi rst half of the book, in which Kalanithi describes his education and residency, it becomes clear that his habit of refl ection long preceded his diagnosis. Even before medical school, he studied literature and philosophy. As a medical student, he contemplated the relationship of the brain and mind and asked questions about the quality of life versus its quantity. Later as a young neurosurgeon, he described his work as “a manipulation of the substance of our selves”. He wanted his patients to understand that they might emerge from surgery with changed capacities, so he spent time discussing what kind of lives they felt were worth living. Since Kalanithi was so reflective about identity and medical practice before he learned he had cancer, his insights into illness and mortality are richer than those off ered in many illness memoirs. Being a patient unmoored him from his planned future and altered his experience of time. His refl ections on time are some of the most striking passages in his book. Medical training, he observes, is “relentlessly future oriented”, a decade of delayed gratification. But after his diagnosis, long-term plans no longer matter. Because no one could say how long he might live, Kalanithi was uncertain how to make the best use of his remaining days: “Tell me three months, I’d spend time with family. Tell me one year, I’d write a book. Give me ten years, I’d get back to treating diseases.” Time for him became “a perpetual present”. Kalanithi returned briefly to his work as a surgeon and, due to his changed relationship to time and its effects on his sense of self, he gained a new understanding of the kind of doctor he wished he had been. Illness led him to an understanding of practice “not found in Hippocrates, Maimonides, or Osler”: “The physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and a family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.” Treating a physical ailment is a physician’s fi rst priority, but that is not where the job ends. Morbidities remain, emotional as well as physical, Kalanithi argues, and medicine’s commitment should extend to helping a patient and family build new and meaningful lives and identities. He is an idealist, certainly, but an idealist who understands very real unmet needs. Although some of Kalanithi’s insights about medicine and living in the present may seem familiar, the value of reading this book is in seeing how he handles suff ering and death with such elegant thought and writing. Among the many insights Kalanithi’s memoir offers is how much the practice of refl ection can enrich one’s work and one’s life. Taking the time to be thoughtful is, for him, an essential part of caring for himself. This element of Kalanithi’s story can be seen as a challenge to the medical profession. If the young doctor’s education in literature and philosophy and his refl ective habits of mind prepared him to be such a perceptive and astute physician and writer, how might the profession seek to cultivate such refl ectiveness in its ranks—for the sake of both patients and doctors?