Book Review

The Midnight Meal and Other Essays about Doctors, Patients, and Medicine

N Engl J Med 1997; 337:1638November 27, 1997

Article

The Midnight Meal and Other Essays about Doctors, Patients, and Medicine
By Jerome Lowenstein. 128 pp. New Haven, Conn., Yale University Press, 1997. $17.50. ISBN: 0-300-06816-6

Attending physicians who think they enliven rounds with house staff and students by recounting the days of the giants — how things were when they were in training — often find that their bleary-eyed auditors have little interest in ancient history. They are too worn out to stand with Newton on the shoulders of giants and too busy for another recital of how wonderful it was back then. The chorus of their beepers is a shrill reminder that today's residents and medical students believe that they are living in the days of the giants and that you, the professor, are from the Stone Age. With ample justification, they believe the medicine they practice is one of the technological marvels of our millennium. Indeed, we are long past the era of midnight meals in the doctors' dining room and unhurried consultations — when there were no MRI scans, angioplasties, or bone marrow transplants and when HMOs and evidence-based medicine were unimaginable. But as the new centurions begin to take command there is justification, too, for remembering that technological marvels do not necessarily give rise to giants. Rather often they merely hatch technicians.

These thoughts — and many like them — sprang to mind while I was reading Lowenstein's collection of short essays on the way things were, and ought to be, in medicine. The entire book can be read in just two hours, but it lingers in the mind, summoning nostalgia and recognition. Lowenstein, a nephrologist and professor of medicine at New York University Medical Center, meets regularly with small groups of students and house officers to talk about humanistic aspects of medicine. He values words and explores how they reveal attitudes about patients. He hates dehumanizing and judgmental jargon and deplores the psychic numbing of overworked residents. When Lowenstein asks if compassion can be taught, an intern answers, “I don't know if you can teach compassion, but you can surely teach the opposite!” He teaches by example, learns from patients, values the physical examination, and doubts — profoundly doubts — the utility of outcomes research. Lowenstein finds evidence-based medicine disturbing, frightening, and anti-intellectual. And he sees the promoters of alternative medicine as not only disingenuous but also lacking any fresh ideas. I was moved by Lowenstein's admiring sketch of Daniel Laszlo, who was an oncologist at Montefiore Hospital in New York City long before oncology became a recognized specialty. Not the least of Laszlo's many gifts was his remarkable ability to comfort a dying patient by a simple gesture of solidarity. The story of Laszlo taking the time from rounds to remove the dentures of an old woman dying of breast cancer rings true. I was also lucky enough to fall under Laszlo's spell during my formative years in medicine.

The Midnight Meal is a tasting menu of Lowenstein's thoughts about medicine. It is served up in easily digested and rapidly absorbed morsels. Highly recommended for readers who hunger for reassurance that they are not alone.

Robert S. Schwartz, M.D.