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In what sometimes seems like an increasingly stressful and complicated world, the sage storytelling and wise advice of others—whether they’re in medicine or not—can help inspire more constructive and rewarding ways of practicing and interacting with patients. A good book can also bring respite and a reminder to stay grounded emotionally. For ideas on what to read, and be inspired by, peruse the recommendations below shared by colleagues at the Academy.
The Myth of Normal: Trauma, Illness, and Healing in a Toxic Culture
By Gabor Maté, MD
“If we could begin to see much illness itself not as a cruel twist of fate or some nefarious mystery but rather as an expected and therefore normal consequence of abnormal, unnatural circumstances, it would have revolutionary implications for how we approach everything health related.”
The Myth of Normal, by Gabor Maté, MD, a Hungarian-Canadian family practice physician, is a social critique that delves deeply into the connection between the mind, body, and society. He examines how trauma and stress can lead to disease. In five parts, the book ambitiously covers many topics related to the modern human experience. Part 1 examines the role of trauma and stress in epigenetics and conditions such as autoimmune diseases. Part 2 discusses early human development, including the role of childbirth and early parenting in future mental health. Part 3 considers mental illness as an adaptation to the circumstances of modern human existence. Part 4 explores the effects of the “toxicities” of Western society and culture. Part 5 ends the book with the concept of “pathways to wholeness” and how to undo and heal from the trauma that leads to illness.
Initially, The Myth of Normal allowed me to gain an understanding of how the environment and our modern, self-focused culture play a role in so many diseases that don’t have an etiology. It gave me insight into and compassion for our patients and how they may be suffering from these diseases. As the chapters evolved, I also gained more awareness of how our culture affects me and my physician colleagues personally. So much of our medical training and practice is run on pressure, multitasking, and disconnection of emotion for the pursuit of success. There is almost a pride among physicians who skip lunch or stay late to finish charts or who do not take vacation—working until there is nothing left in the gas tank. Perhaps this pushing forward without an awareness of the need for respite is a cause of physician burnout and the illness that results.
Dr. Maté writes, “In the absence of relief, a young person’s natural response—their only response, really—is to repress and disconnect from the feeling-states associated with suffering. One no longer knows one’s body. Oddly, this self-estrangement can show up later in life in the form of an apparent strength, such as my ability to perform at a high level when hungry or stressed or fatigued, pushing on without awareness of my need for pause, nutrition, or rest.”
According to Dr. Maté, we are all individuals striving to attain private goals. But he suggests this way of living is a “myth” that has been normalized. And the more we believe this myth, the more we move away from communality and the vital aspects of humanity that make us happy and healthy. What we need as humans, according to Dr. Maté, is: belonging, relatedness, or connectedness; autonomy; mastery or competence; genuine self-esteem that is not dependent on achievement; trust; and purpose, meaning, and transcendence.
Dr. Maté ends this complex and beautifully written book with four principles that heal people from modern toxic culture: authenticity, agency, healthy anger, and self-acceptance. He asks the reader questions, including “What did you say yes to that you wanted to say no to this week, and what is the story behind that yes?”
Overall, I found Dr. Maté’s book about the modern human experience deeply illuminating, and in reading it, I have gained more insight into my own life and my interactions with my patients.
—Sahar Bedrood, MD, PhD
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Sahar Bedrood, MD, PhD, is a Glaucoma Specialist at Advanced Vision Care in Los Angeles, and Adjunct Clinical Assistant Professor at University of Southern California Roski Eye Institute, in Los Angeles.
The Four Agreements: A Practical Guide to Personal Freedom
By Don Miguel Ruiz
“Find the courage to ask questions and to express what you really want. Communicate with others as clearly as you can to avoid misunderstandings, sadness, and drama.”
The Four Agreements was recommended to me—it literally showed up unexpectedly on my doorstep—by Hemang K. Pandya, MD, who is the founder and president of the American Retina Forum. It is in a category of book (personal growth) that many people in medicine dismiss as froufrou or hokey. But if they read The Four Agreements, they’ll start to understand.
The premise of the book is that the physical world we live in is a farce—the author calls it a dream—which we agree is the truth because as children, we were not given any choices. Adults told us things—to be perfect, for example—that, over time, we agreed with and accepted as truth. The author says that human society is a dream that is the same as hell (as described in many religions), and people live their lives by fear of this hell, as well as a worse hell that awaits them after life if they do the wrong things in the current life. He says that throughout life, humans search for truth, justice, and beauty because we aren’t able to see that we are already surrounded by these things. “With the agreements and beliefs we have stored in our mind, we have no eyes for this truth,” Mr. Ruiz writes, explaining that we are blinded by our attempt to be “perfect.” Perfect, however, is unattainable, so we reject ourselves and everyone else, he says.
And so, the author recommends that we make “four agreements” in an effort to create a new dream, “your personal dream of Heaven.” They are: Be impeccable with your word, don’t take anything personally, don’t make assumptions, and always do your best.
I recommend that readers make up their own minds about how the four agreements apply to their lives. The agreement I struggle with the most is number two. I definitely take things personally. The fact that other people don’t have control over our emotions is an insight that is very relevant to my life. When I get my emotions under control, I see that how I respond to external stimulation and provocation is entirely up to me, and the person who lashed out is the one who is suffering. In clinic, we are seeing this more and more every day. Patients complain about wait times, they experience perceived slights, or they are just unreasonable. Patients lashing out at staff is becoming an epidemic and is driving staff and physician unhappiness and stress. When I started to look at these behaviors as manifestations of patients being trapped in their own personal unhappiness (or hell, as the book refers to it), I began to get it.
I can’t fix everyone, but I can control whether someone else’s baggage will affect my day. I highly recommend this book, especially to those who work in health care.
—Mitul Mehta, MD, MS
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Mitul Mehta, MD, MS, is Wellness Czar; Fellowship Director of Vitreoretinal Surgery Health Sciences; and Clinical Associate Professor of Vitreoretinal Diseases and Surgery at Gavin Herbert Eye Institute at the University of California, Irvine.
Better: A Surgeon’s Notes on Performance
By Atul Gawande, MD, MPH
“To live as a doctor is to live so that one’s life is bound up in others’ and in science and in the messy, complicated connection between the two. It is to live a life of responsibility. The question then, is not whether one accepts the responsibility. Just by doing this work, one has. The question is, having accepted the responsibility, how one does such work well.”
Being in practice for several years comes with a sense of comfort. My clinic days are predictable for the most part, with a combination of new and established patients, surgical and medical consults, office-based procedures, lasers, injections, and an occasional emergency or two. Days in the operating room are typical, as well: a steady stream of cataract procedures, minimally invasive glaucoma procedures, lasers, and an occasional trabeculectomy or tube shunt. At times, I find myself on autopilot mode. Have I reached a point in my career where I have plateaued? Where my diagnostic, management, and surgical skills have reached a peak?
We call it practice for a reason. The practice of ophthalmology and of medicine is such that we are never finished with learning. And once we have achieved basic competency, we have two options: continue in a steady state or strive for better performance within our profession.
In Better, Atul Gawande, MD, MPH, a surgeon and regular contributor to The New Yorker, recounts stories of “positive deviants,” people in medicine “whose uncommon but successful behaviors or strategies enable them to find better solutions to a problem than their peers, despite facing similar challenges and having no extra resources.” He discusses what we can learn from the behaviors of these individuals and how to apply these lessons in order to be better in both our professional and personal lives. He says that these improvements do not necessarily derive from genius but from diligence and clarity of purpose.
The book is divided into three sections: diligence, doing right, and ingenuity. Multiple essays about individuals who exemplify positive deviance form the narrative. The diligence of the infectious disease specialist and microbiologist duo who, despite the odds being stacked against them, pushed for the medical community to recognize the importance of hand washing in decreasing infection rates in hospitals. And how a young obstetrical anesthesiologist develops an innovative scoring system to better assess newborns at birth.
Dr. Gawande’s call for all of us to do better had me thinking about what I can do myself, and how I can be more of a positive deviant at this stage in my career. He gives five suggestions:
- Ask an unscripted question. We all have office days where we are running one or two hours behind, the waiting room is full, the phone rings incessantly, and the hour is getting late. In those instances, we just want to take care of the patient’s concern and move on to the next task. But Dr. Gawande encourages us to take a moment to ask an unscripted question: ask the patient about their personal life, family, interests, or passions to help make that human connection. Extend this practice to your staff, technicians, and other office personnel. It goes a long way toward helping patients and colleagues feel cared about.
- Don’t complain. In medicine, we work with human beings daily and deal with circumstances that are only partly under our control. It is natural to want to vent about an issue. Dr. Gawande suggests changing the narrative by offering positive discussions and solutions rather than just reporting the problems.
- Count (or quantify) something you find interesting. In other words, take the measurement of things in order to understand them better. For example, you can learn more about the conditions and diseases you’re treating—what is working and not working—if you measure your patient outcomes.
- Write. Writing provides an opportunity to step back and think about a problem systematically and methodically. It could be as simple as writing a summary of a patient’s drop regimen in order to help them follow it more accurately, or contributing an article to a journal or Academy publication. Either way, writing helps clarify your thoughts on a subject, which can benefit you and others.
- Change. According to Dr. Gawande, in medicine, individuals respond to new ideas in one of three ways: some are early adopters, others are late adopters, and some remain persistent skeptics. He asks that as physicians, we look for opportunities to be early adopters when we can. That does not mean embracing every new trend that comes along but rather being willing to “recognize the inadequacies of what you do and seek out solutions.”
After practicing for nearly a decade, I have found that confidence and comfort can sometimes be accompanied by complacency. If I am managing patients or performing surgery in the exact same way in the future as I am now, that is a disservice to myself and to my patients. Dr. Gawande’s book was a reminder to strive for better.
“Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.”
—Monisha M. Vora, MD
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Dr. Monisha M. Vora, MD, is a Glaucoma and Cataract Surgeon at Kremer Eye Center in the Greater Philadelphia Area.
The Art and Science of Compassion, A Primer: Reflections of a Physician- Chaplain
By Agnes M.F. Wong, MD, PhD, FRCSC
“It’s not the length of life, but the depth.”
In the preface to The Art and Science of Compassion, the author, Agnes M.F. Wong, MD, PhD, FRCSC, an internationally renowned neuro-ophthalmologist and strabismus specialist, describes how her experience with a medical condition led her to examine her life—both internally and externally. That examination prompted her to pause her scientific and clinical activities to pursue chaplaincy training and study compassion. A result is this eminently readable 200-page volume.
The short, well-referenced chapters consider compassion from physiological, psychological, and spiritual perspectives. The author discusses obstacles to being more compassionate with ourselves and others. She suggests approaches to cultivating it—drawing on a balance of theory, evidence, and practical advice. Her perspective as a physician makes the material accessible and relevant to ophthalmologists. It is presented in a straightforward and elegant style that will be familiar to anyone lucky enough to have benefited from Dr. Wong’s clinical or scientific instruction.
Dr. Wong emphasizes that, rather than being a draining force, compassion is a source of resilience. She provides concrete physical and behavioral suggestions for exercising compassion during challenging interactions with difficult patients, disengaged trainees, and those in our personal lives. This book gave me a framework for thinking about the amorphous idea of compassion as well as the tools to be more compassionate toward myself. The simple, implementable solutions for self-compassion are directly applicable to addressing physician burnout.
In 2021, Dr. Wong joined our women in neuro-ophthalmology book club to discuss her book. In that same year, we were thrilled to host Dr. Wong at Stanford when she presented on this topic in ophthalmology grand rounds. The material was particularly relevant as we navigated the second year of COVID-19 restrictions, and it remains important today, even though the public health emergency has officially ended.
For those who are intrigued but not quite ready to tackle the material in written form, I highly recommend Dr. Wong’s under-30-minute YouTube lecture (https://youtu.be/smasyeI5cRY) as an introduction to the key ideas. It is perfect listening during a commute or when the OR is delayed.
—Heather E. Moss, MD, PhD
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Heather E. Moss, MD, PhD, is Associate Professor of Ophthalmology, Neurology & Neurological Sciences; Director of the Neuro-Ophthalmology Fellowship; Director of Ophthalmology Clinical Research; and Director of the SURGE-C course in the Department of Ophthalmology at Stanford.
The Invisible Kingdom: Reimagining Chronic Illness
By Meghan O’Rourke
“The actual encounter was always confusing, eleven minutes of liminal contact in which I tried to conduct myself in a way that would make the doctor like me, in the hope they would take some true interest in my plight.”
Meghan O’Rourke chronicles her journey from being a relatively healthy young woman to developing a rash one summer at the beach and the cascade of health problems that followed in its wake. She describes chronic fatigue and brain fog and other symptoms that progress and severely impair her ability to perform normal, everyday activities. When small tasks, like cleaning and cooking, start to require Herculean strength, Ms. O’Rourke begins questioning her sense of self and she grapples with her new identity—someone living with chronic illness. Ms. O’Rourke pulls back the curtain on her experiences as a patient as she describes her journey toward diagnosis and treatment for Hashimoto thyroiditis, chronic Lyme disease, hypermobile Ehlers-Danlos syndrome, and dysautonomia, which led to postural orthostatic tachycardic syndrome.
She is poignant as she discusses a subject that physicians often feel uncomfortable with—un-certainty. Having pursued careers in science, physicians are often accustomed to correct answers. In medicine, we diagnose and treat. However, the author points out, this paradigm begins to falter when the diagnosis is unclear. Herein lies Ms. O’Rourke’s most important point: in medicine, when the physician is unable to treat the disease, treat the patient. Wandering from specialist to specialist, from chiropractor to nutritionist, she writes that the people who often had the biggest impact on her, at least on an emotional level, were those who saw past her symptoms and saw her as the person sitting in front of them searching for connection.
Ms. O’Rourke also discusses her sense of loneliness despite being surrounded by caring friends, family, and her husband. She seeks out nontraditional healers, sociologists, and poets, hoping to find someone who can put words to her feelings and make meaning of her experiences. Ultimately, this is when a diagnosis arises. While a diagnosis does not ease her symptoms, putting a name to her illness connects her with other patients who help her find a path forward toward treatment.
At times, Ms. O’Rourke seems to digress, switching from a critic looking through a scientific lens to a disgruntled patient trying to understand why she was wronged. For example, she juxtaposes quotations from scientific articles and expert interviews with philosophical essays and Facebook message posts. But the message of the memoir is: the medical profession thinks patients come to experts for answers, but more importantly, patients come to us for reassurance and community.
—Douglas Brown, MD, and Lisa S. Schocket, MD
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Douglas Brown, MD, is a Resident and Lisa S. Schocket, MD, is Interim Chair and Associate Professor, Vice Chair for Clinical Affairs, and Chief of Vitreoretinal Surgery. Both are in the Department of Ophthalmology and Visual Sciences at the University of Maryland School of Medicine, Baltimore.
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More reviews. For books that have shaped the way your colleagues work, see “From Page to Practice,” in the October 2019 EyeNet.