Per-Hour Learning Potential / Utility: ★★★★★ (5/7)
Readability: ★★★★★ (5/7)
Challenge Level: 3/5 (Intermediate) | ~320 pages ex-notes (416 official)
Blurb/Description: Pulitzer Prize winning author David Oshinsky tackles three centuries of medical history through the lens of NYC’s Bellevue – the oldest hospital in America.
Summary: Medical history is a fascinating topic. As recently as the era of Lincoln, even the best doctors in the country were more or less quacks. David Oshinsky quotes one observer:A random patient (in the early 1800s), with a random disease, consulting a doctor at random, had no better than a fifty-fifty chance of profiting from the encounter. Click To Tweet
The progress from that era to the medical marvels of today was nonlinear and marked by all the usual human follies. It’s a remarkable and thought-provoking story.
Highlights: On a pure sentence level, Oshinsky’s writing may even be better than in Polio; while this book is fairly information-dense, it’s never dull, dry, or difficult to read. And, of course, there are a lot of fascinating, thought-provoking vignettes on medical history here.
Among them: the development of the ambulance. How debottlenecking of cadavers enabled more medical education. The resistance, then acceptance, of Germ Theory thanks to salience. The curious case of how circumcision came to be an American cultural tradition.
The elevation of nursing and psychiatry to respected fields, and not afterthoughts. The abuse, death, and rebirth of electro-convulsive therapy (ECT – often known as electroshock therapy). The AIDS epidemic and what it reveals about the human side of doctors. The psychological reasons that post-Katrina best practices for infrastructure management were ignored.
These are all good reasons to read the book.
First, Polio was a rip-roaring good story: it had a clear antagonist (polio!) and an ensemble cast of all-star protagonists, ranging from those we rooted and cheered for (Salk, Basil O’Connor, FDR) to those that are eminently hatable (Albert Sabin). Sabin even gets a redemption arc… sort of. (He’s still a terrible person.)
Bellevue, on the other hand, is not a story: it’s more a collection of vignettes that loosely occur around a place (Bellevue), but Bellevue itself does not make for a particularly interesting protagonist or backdrop from a narrative perspective.
Second, this book is a lot more information / fact-dense than Polio, and it’s longer – both of which make it a significantly slower read, and make it somewhat less mental-models-rich per page.
Third and finally, a decent chunk of the book – given Bellevue’s location and inextricable relationship to the development of New York City – touches on New York demographics, history, and politics, topics which I find profoundly and completely uninteresting, since I have no affinity for the city whatsoever. YMMV on this one, but I routinely skimmed the parts relating to NYC politics and demographics.
Mental Model / ART Thinking Points: incentives, n-order impacts, multicausality, culture / status quo bias, salience, sample size, social proof, bottlenecks, overconfidence, precision vs. accuracy, one to many, man with a hammer, a/b testing, intrinsic vs. extrinsic motivation, in-group vs. out-group behavior, trait adaptivity, scientific thinking, hindsight bias, humans vs. econs, opportunity costs
You should buy a copy of Bellevue if: you want a thoughtful, well-written medical history that spans a broad range of intriguing topics.
Reading Tips: Unlike most books, this one actually gets better as it goes on; the first few chapters are not terribly interesting. In my view, the book really picks up with Chapter 5 – “A Hospital in War” – although there are some interesting bits before that (including in Chapter 4). Consider heavily skimming the first three chapters, then paying more attention to the rest of the book.
Reread Value: 3/5 (Medium)
More Detailed Notes + Analysis (SPOILERS BELOW):
IMPORTANT: the below commentary DOES NOT SUBSTITUTE for READING THE BOOK. Full stop. This commentary is NOT a comprehensive summary of the lessons of the book, or intended to be comprehensive. It was primarily created for my own personal reference.
Much of the below will be utterly incomprehensible if you have not read the book, or if you do not have the book on hand to reference. Even if it was comprehensive, you would be depriving yourself of the vast majority of the learning opportunity by only reading the “Cliff Notes.” Do so at your own peril.
I provide these notes and analysis for five use cases. First, they may help you decide which books you should put on your shelf, based on a quick review of some of the ideas discussed.
Second, as I discuss in the memory mental model, time-delayed re-encoding strengthens memory, and notes can also serve as a “cue” to enhance recall. However, taking notes is a time consuming process that many busy students and professionals opt out of, so hopefully these notes can serve as a starting point to which you can append your own thoughts, marginalia, insights, etc.
Third, perhaps most importantly of all, I contextualize authors’ points with points from other books that either serve to strengthen, or weaken, the arguments made. I also point out how specific examples tie in to specific mental models, which you are encouraged to read, thereby enriching your understanding and accelerating your learning. Combining two and three, I recommend that you read these notes while the book’s still fresh in your mind – after a few days, perhaps.
Fourth, they will hopefully serve as a “discovery mechanism” for further related reading.
Fifth and finally, they will hopefully serve as an index for you to return to at a future point in time, to identify sections of the book worth rereading to help you better address current challenges and opportunities in your life – or to reinterpret and reimagine elements of the book in a light you didn’t see previously because you weren’t familiar with all the other models or books discussed in the third use case.
Page 1: Bellevue is apparently not only the oldest public hospital in America, but famous in pop culture. Here’s one of the areas where, apparently, TV can help you: I had no clue what it was, but my parents were like, “oh, isn’t that the crazy house?” And I was like, um, not really, but sure, I guess? 😛
Page 3: “Delmore Schwartz arrived in handcuffs following an attempt to strangle a hostile book reviewer.”
*gulps* maybe PAA does not bode well for my life expectancy…
… actually in general, it seems like writers are a sensitive bunch. (I don’t claim to exempt myself.)
Page 4: Oshinsky here notes that Bellevue is more than just the crazy house.
Pages 7 – 8: Bellevue alumni are a “who’s who” of American medical history. Oshinsky notes that two of the most influential figures are William Welch, the “father of modern pathology” and William Halsted, “the era’s most innovative surgeon.”
And a kind of fascinating stat on both Germ Theory and, more generally, the progress of medicine: half of Bellevue patients in 1865 died from post-op surgery; by 1900, it was sub-10%.
As a public hospital, Bellevue didn’t really serve wealthy patients – except when the other hospitals were full, or everyone was broke.
Page 13: Some discussion of whether or not Bellevue or Pennsylvania Hospital was the first. (the latter of which Benjamin Franklin helped along – see ‘The Autobiography of Benjamin Franklin” – ABF review + notes).
I don’t really care about that. What I do care about is this amusing bit: in 1795,
“New York city officials took to rounding up vagrants and prostitutes and paying their transportation out of town.”
Less amusingly, Megan McArdle has an interesting bit in “ The Up Side of Down” ( UpD review + notes) where she explores the counterintuitive idea that providing housing for the homeless might actually be cheaper than not doing so (largely because it reduces their visits to ERs for basic care – a phenomenon that Oshinsky references later in this book.)
Pages 15 – 17: yellow fever is discussed here: as horrifying as Ebola, except it actually killed a bunch of people in New York in the 1790s.
Nobody had a good angle on causation at this point – they were still nattering about miasmas and vapors, it seems – but poverty definitely played a role.
Pages 21 – 23: There are interesting examples of culture throughout this book. One that I find particularly interesting: today, surgeons are quasi-celebrities that often have big egos. See Doctor Strange, or Dr. Atul Gawande’s “The Checklist Manifesto” (TCM review + notes).
Around this time, however – circa 1800 –
“the surgeon played a distinctly inferior role. His was a craft, not a profession, often learned on a naval vessel or a battlefield.”
“in the era before anesthesia and antiseptic medicine, there was not much to recommend him – and a great deal to fear… [amputations or bullet removals were] as likely to kill the victim as save him.”
This drives home Oshinsky’s earlier point about hospitals not doing much, at the time, you couldn’t do at home… of course, there’s a few salient later examples of germ theory (Lincoln, Garfield).
In this era, this was little formal regulation, little certification (thanks in part to populism / egalitarianism), and many doctors were also barbers or some other deal.
Far from medical malpractice today, doctors then got away with… a lot.
Pages 24 – 25: Two of the most popular treatments were bloodletting and calomel (mercury chloride), which was basically poison.
Doctors basically murdered George Washington by drawing a whole bunch of blood and giving him some calomel.
Pages 29 – 31: The first cadaver was dissected in 1750; for quite a while, doctors who wanted to do dissections were basically graverobbers. Regulations subsequently allowed executed criminals to be used for science… but this wasn’t enough. So on went graverobbing.
Pages 33 – 34: Circa-1800, working at an almshouse infirmary like Bellevue was a prestige position that didn’t even pay. In addition,
“with its endless supply of compliant bodies, the almshouse remained the best place for experimenting with drugs and therapies and matters of the knife.”
Pages 36 – 37: $420K in 1816 ($7MM in today’s dollars) was spent building a big complex including most of NYC’s welfare institutions.
Pages 38 – 39: Interesting background here on the immigrant and trade-driven growth of New York and the Five Points Irish ghetto.
Pages 41 – 43: cholera was a big problem… spread by contaminated water, as British physician John Snow did.
Doctors’ assessments of why it happened – and how they treated it – were all wrong.
Pages 46 – 47: Medicine still sucks at this point – Oshinsky notes that while elite doctors were paid well, they didn’t know what they were doing.
He quotes physician-philosopher Lawrence Henderson:
“A random patient, with a random disease, consulting a doctor at random had no better than a fifty-fifty chance of profiting from the encounter.”
And perhaps even less, given calomel and bloodletting.
Pages 48 – 49: “dispensaries” were like the outpatient clinics of today.
Pages 50 – 52: New York Hospital started a time-honored tradition: shipping the hopeless cases (and the ones viewed as unsavory) to Bellevue. Selection bias probably contributed a great deal to its lower mortality rate than Bellevue.
Page 53: Typhoid apparently routinely killed 10 – 20 – and even sometimes 30% – of passengers on transatlantic “famine ships” from Ireland.
Page 57: Bellevue starts to become more modern around 1850…
Pages 58 – 59: Hospitals were religious at this point; Catholics didn’t like the idea of a Protestant chaplain getting bad ideas into their heads… so St. Vincent’s was formed.
Pages 60 – 61: Social proof: David Oshinsky notes that
“imitation… is precisely what occurred… the example of St. Vincent’s spread to other ethnic groups, including German Americans.”
Oshinsky goes on to discuss how the burgeoning Jewish population also followed suit.
Oshinsky’s written a book about McCarthy… this was a bit before his time, but Oshinsky notes that a lot of German hospitals and street names were renamed circa WWI.
Page 65: Rats have also been an NYC thing.
Pages 66 – 68: Cadaver availability was still a bottleneck for medical training… after the “Bone Bill” passed (by one vote) in 1854, it seems like enrollment expanded meaningfully.
Medical school in this era was still pitiful – Oshinsky cites one modern observer who compares the thesis requirement to “the term paper of a college sophomore” – and there was no laboratory work, nor patient examinations.
Pages 68 – 72: Dr. Valentine Mott was a premier surgeon who apparently was quite good for the time… he started NYU medical school.
Pages 74 – 75: pre-anestheisa surgery is gruesome.
Pages 76 – 78: self-trained New Hampshire physician Samuel Thomson got right that much of that era’s medicine was poison… but it’s not clear he had much else going for him. German doctor Samuel Hahnemann, meanwhile, believed in homeopathy. Another interesting example of culture – this idea, based on really no science, is still around today; Wikipedia notes:
Homeopathy is not a plausible system of treatment, as its dogmas about how drugs, illness, the human body, liquids and solutions operate are contradicted by a wide range of discoveries across biology, psychology, physics and chemistry made in the two centuries since its invention. Although some clinical trials produce positive results, multiple systematic reviews have indicated that this is because of chance, flawed research methods, and reporting bias.
Pages 79 – 81: Oshinsky references a painting, “The First Operation Under Ether” – by Robert Cutler Hinkley – pictured below:
It was apparently the first procedure under anesthesia. Similar to the earlier cadaver bottleneck, Oshinsky notes that pain was one of the “two biggest obstacles to major surgery.” (The other was sepsis.)
Oshinsky here references that one of the reasons Darwin gave up the idea of being a doctor was the idea of inflicting such pain on others. (The stories here are truly brutal.)
Page 82: Unsusprisingly, medical school was restricted to white males at this time; Elizabeth Blackwell in 1848 was the first woman to become a doctor.
Page 85: Bellevue Hospital Medical College opened in 1861, a time when New York was actually in some senses a Southern city – it was Democratic and much of its economic power came from financing southern plantations and shipping southern cotton (an interesting fact I did not know.)
Page 93 – 95: Occupy Wall Street, 1863 edition: a crowd chanted “down with the rich” and volunteer firemen, sort-of-Fahrenheit-451-style, burned down the building where the conscription lottery was going on. (The Conscription Act allowed the rich to get out of being drafted by paying a fee or hiring a substitute.) It turned into riots and race wars.
Bellevue’s Frank Hamilton made himself busy trying to improve wartime medicine…
Pages 96 – 97: Nobody at this point had whatsoever a clue about Germ Theory.
“It is unfair, of course, to judge someone by the standards of later times.”
Hamilton did invent some useful tools and made the treatment for bone settings more precise, allowing more soldiers to walk without a limp.
Pages 102 – 103: Surgeon General William Hammond realized “there were more lives to be saved beyond the surgical tent than within it – through education, nutrition, and hygiene.” He banned the use of calomel in the army, and required written examinations for regimental surgeons.
Pages 106 – 109: New York was overcrowded and wildly unsanitary – slaughterhouses let blood run into the sewers and entrails rot in the streets; there were no public restrooms and tenement privies were overcrowded… drinking water, obviously, was contaminated.
Pages 112 – 115: the Civil War inspired Edward Dalton to take the ambulance from the battlefield to the city – one to many. Recognizing the important of rapid treatment, having a dedicated fleet of medical transportation wagons was a massive improvement over relying on the kindness of passers-by. Of course, ambulances still weren’t very fast…
And, n-order impacts: “policemen [found] it easier to summon an ambulance than to escort [passed out alcoholics] to the ‘drunk tank.’”
Page 118: More selection bias: reviewing the data in 1900, one city health official noted that other hospitals were “sending the poor, dying patient to Bellevue in order to lessen their [own] death rates.”
Page 121: Portrait photographer Oscar G. Mason helped create the mug shot, by creating the “Wall of the Unknown Dead,” which allowed identification of bodies.
Pages 122 – 123: Photographs made medical education more salient… and perhaps more titillating, too.
Pages 126 – 127: This bit is also fascinating – man with a hammer intersecting with social proofand status quo bias to explain how nonreligious circumcision because a widespread medical practice in the U.S. (I discuss in the culture mental model.)
Pages 129 – 130: Florence Nightingale sighting… stats on British deaths in Crimea: 4,774 to wounds, 16,323 to illness and disease. 3.5:1
Nursing had previously been a not-very-professional profession; Nightingale had a strong focus on cleanliness.
Page 131: Another interesting bit of culture here: an overlooked part of Gawande’s “The Checklist Manifesto” (TCM review + notes) is creating an environment that allows people to point out violations, regardless of their rank.
Oshinsky notes that American doctors at this time were wary of nurses:
“the greatest fear, however, was that trained female nurses might challenge the doctor’s authority – or worse, try to become doctors themselves.”
Pages 131 – 132: Catholic Sisters of Charity became so desired as nurses that a Women’s Nursing Corps was created during the Civil War because there weren’t enough of them.
Page 134: The first nursing school opened in 1873.
Pages 136 – 138: Ignaz Semmelweis didn’t understand germ theory, but he did note that obstetricians – who dissected cadavers – had higher levels of puerperal fever in their patients than did midwives. Semmelweis “urged his colleagues to soak their hands in a chlorine solution before each delivery” – which worked. A/b testing. But he didn’t understand the scientific mechanism; Americans still weren’t really into the idea.
Pages 139 – 140: Hand-washing was mandated… nurses’ role continued to become greater and more respected.
And here’s the bit on culture: circa-1983, former NYU Medical School Dean Lewis Thomas “could only marvel that so many of his male colleagues still viewed their nurses as glorified ‘ward administrators and technicians.’”
Pages 141 – 142: Incentives – students seemed to basically bribe professors, since it was so competitive…
Pages 145 – 146: Joseph Lister’s experiments with carbolic acid – another example of a/b testing – found a 3x lower rate of deaths post-amputation. Admittedly a small sample size (35 and 40 respectively), but still.
Page 148: How did audiences react to Lister’s presentation on Germ Theory in 1876?
“Few minds were changed… mostly, there was bewilderment that anyone should listen to an Englishman spouting the theories of a Frenchman about the dangers of particles too small for anyone to see.”
One exception: Robert Wood Johnson, who started selling sterile bandages under the name Johnson & Johnson…
Page 149: In fairness, there were some advocates of Germ Theory…
Page 151: … but seriously though. “Frank Hamilton viewed Smith’s methods as “demented.”” Oshinsky notes that some doctors would say things like “there’s a bacillus, catch him!” Germ Theory was widely mocked.
Pages 152 – 156: Garfield did more for Germ Theory than statistics ever could. Salience.
Page 162: Interesting bit here on incentives and intrinsic vs. extrinsic motivation that I need to come back to.
Pages 163 – 165: I previously referenced Dr. Matthew Walker, in “Why We Sleep” (Sleep review + notes), citing cocaine addict William Halsted as the source of the medical profession’s anti- sleep culture. Oshinsky here provides some interesting color on Halsted, who was clearly influential…
Page 167: Cleveland had Garfield to thank for his life: a cancer removal surgery included plenty of antiseptic.
Pages 168 – 169: “Reputations can be remarkably immune to change.” More status quo bias. Bellevue was viewed as the home of the unwashed masses.
Bellevue’s operating budget was stretched quite thin… cost per patient per day was 50 cents, although in reality it was probably even lower because the staff were plundering the alcohol supply.
Page 172: Pulitzer was a muckraker. Added to the list of “things I did not know.”
Page 180: “Gotham” comes from Washington Irving, and not Batman, apparently.
Page 186: in-group vs. out-group behavior shows up throughout this book… everyone likes “othering” the immigrants and viewing them as “purveyors of disease.” (In fairness, they were, to some extent, although certainly it wasn’t science driving people’s opinion.)
Pages 188 – 189: Bellevue starts treating private patients… Oshinsky also notes that in 1910, unlike 1880, hospitals now had science and technology: germ theory, x-rays, labs for blood/tissue examination, etc.
Page 192!: Oshinsky here notes that “The Flexner Report” is considered a “watershed document” that “changed the course of medical education in North America.” He notes that it was part of reformers in “the Progressive Era” – which might be worth reading about. (1910s?)
Pages 195 – 196: On African-Americans in medicine: the first African-American doctor at Bellevue was circa-1917… one of these early African-American doctors, Maynard, saved the life of Martin Luther King, Jr.
Interesting trait adaptivity bit here: I’m very fond of the (well-understood) fact that Germany’s anti-Semitism caused it to lose its brain trust. Similarly, and especially given that many doctors at this time – and even later – weren’t great (see Groopman on “gentlemens’ Cs”), clearly we were worse off – purely practically – from excluding African-Americans from the profession.
Page 198: Oshinsky here notes that NYU Medical School didn’t have a quota system, so it was highly Jewish. He notes that Jonas Salk came here – see Oshinsky’s wonderful, wonderful “Polio: An American Story” (PaaS review + notes), which touches on this.
Page 199: The Great Influenza killed 50 – 80 million lives; one in four Americans contracted it and 700,000 died. In 1918, life expectancy dropped 12 years (?!)
Page 203: Prohibition had lots of n-order impacts… one of which was fueling forensic medicine.
Pages 204 – 207: The Examiner’s Office was like Ducky… Norris and Gettler came up with a lot of cool stuff… great examples of scientific thinking and control groups / a/b tests here.
Pages 208 – 209: I liked this, too:
“That is why Gettler kept the captain’s remains in plain sight until the day he retired: not as a reminder of failure, but of the work that lay ahead.”
Pages 210 – 213: More on the n-order impacts of Prohibition: lots of deaths…
Pages 215 – 216: In the early 1900s, Dr. Menas Gregory wanted to put psychiatry “on par with other specialties in training medical students and interns.” Oshinsky notes that close to half of Bellevue’s patient count had some sort of mental condition.
Pages 229 – 231, 234, 237: Shock therapy, lobotomies, and so on are discussed here… this section was really fascinating.
I’ve noted elsewhere how genetic engineering still has a really bad rap in part because people feel the need to apologize for Hitler’s perversion of genetics. Similarly, it’s pretty clear here that ECT (electroconvulsive therapy) went way too far (to the point of child abuse) – and it took a long time for it to lose that stigma; it’s now being used again in limited (far more humane) conditions because it turns out that under some circumstances, it’s actually effective.
Page 241: Cardiac catheterization served to take away a bottleneck, allowing more accurate measurement of various phenomena.
Page 242: Tuberculosis did infect some doctors…
Page 244: nice bit on multicausality here – multi-drug therapy was more effective than streptomycin alone.
Page 246: Physically speaking, Bellevue in the 1950s was a wreck.
Page 251: The AMA hated Medicare… until they realized, as Oshinsky notes,
“Medicare… provided reimbursement for ‘reasonable costs,’ which, as one student put it, ‘were whatever hospitals and physicians said they were.’
Pages 260 – 261: AIDS was originally called “GRID” – gay-related immune disease.
Again in an example of hindsight bias – now it’s obvious how and why AIDS was more prevalent among gay men – Oshinsky cites one doctor who notes that she “began to take sexual histories, something nobody ever taught me in medical school.”
Of course, these are now routine form questions…
Page 262, 266: Another interesting example of culture: to the extent that it seems like anti-LGBT discrimination is still an issue today, it was a hell of a lot worse 30 years ago. Oshinsky notes that in all of NYC, merely fifty private-practice doctors could be found willing to put their names on a referral list for AIDS patients… dentists, similarly, did not want to treat someone with the disease.
This, at least, had some underlying rationale: dentists were worried about contracting it via saliva. It’s now known that’s probably not a risk, but again in fairness, that’s with hindsight bias. Meanwhile, doctors could very well contract it via needle sticks.
Here, Oshinsky gives one example: Dr. Roger Wetherbee, NYU’s director of infection control, circa 1985:
“I’ll tell you very frankly that I’ve managed, either accidentally or somehow intentionally, to not care for more than one or two [AIDS] patients at any one point in time.”
“Witnessing your own generation dying off is not for the faint of heart.”
Page 269: A nice contrast of the AIDS epidemic in San Francisco vs. NYC, and the cultural/demographic reasons San Francisco was much more friendly…
Page 271: … at Bellevue, on the other hand, it wasn’t so much gay men, but a lot of drug abusers.
Pages 273 – 274: Really interesting discussion here of the “right to die” and quality vs. quantity of life. See also Gawande’s “Being Mortal” – which I started a long time ago but never finished (and want to, soon).
Pages 275 – 276: The “slow code” bit is intriguing. Again in multicausality, the multidrug therapy seemd to work.
Pages 283 – 285: “deinstitutionalization” did not work, and Bellevue needed more security…
Pages 294 – 296: Bellevue saw surprisingly few cases post-9/11..because tehre was no middle zone (gravely injured). People got out a lie, or perished.
Page 314: Also a great bit on Ebola.
First Read: summer 2018
Last Read: summer 2018
Number of Times Read: 1
Planning to Read Again?: probably
Review Date: summer 2018
Notes Date: summer 2018