- Mike begins the book by observing that two plus two doesn't always equal four. To what is he referring?
- Many readers have been struck by the relationship Mike has with his fellow construction workers. They seem able to kid each other about their ethnicity with neither the rancor of the bigot nor the insipid pretentiousness of the politically correct. Do you find this believable? What characteristics might these workers have that much of our society seems to lack? What lessons might we learn from them?
- The strength Mike draws from his large family is never acknowledged, but is almost palpable nevertheless. Are we given any clues as to what made his family tick?
- When Mike has his interview for med school he asks the dean of admissions to consider more than just grades. How realistic is that? How realistic do we want it to be? As health care consumers, would we rather have a doctor who spent his entire college career studying diligently to prepare for medical school or someone who worked construction and drove cabs?
- Mike wonders, at one point, why they never talk about moral issues in medical school. "People are going to look to us someday for help in deciding important issues like abortion, infanticide, the death penalty, assisted suicide and euthanasia," he says. "Why do we spend weeks on lysosomes, membrane channels and protein synthesis and not one day on the definition of life?" Do we want our doctors to advise us on such things? Or is their proper role to stick to the purely physical?
- At one point Mike expresses dismay that he and his fellow medical students are never encouraged to think some of the deeper lessons of life and medicine. "There seems to be an assumption that medical students should be taught the mechanics of medicine, but the spirit of medicine they should learn on their own." What does this say about our system of medical education? Is this, perhaps, why many of us find our doctors cold and unsympathetic? Have sympathy and sensibility been bred out of them?
- Medical students need to learn. Mike describes how they learn to draw blood by practicing on each other. But what about other times (doing rectal exams, performing surgery)? Is anyone troubled by the morality of students learning from and practicing on real patients? Would you let a medical student practice on you?
- "There is so much to learn and so little room for failure," Mike comments about medicine. How much room for failure should we allow our doctors? Is every mistake a doctor makes malpractice? Should they be sued every time they don't make the correct diagnosis? every time a surgery isn't entirely successful?
- We want our doctors to be human, to sympathize with us. But doctors in training are often told that they must stay detached in order to retain their objectivity. "I want doctors to be intimately and deeply involved with every patient," Mike says. "I want them to feel her pain, to walk in her shoes, to laugh and cry with her. But I also want them to be able to be objective, to be analytical, to be always prepared to make the difficult decisions. And that isn't all. Despite their having poured their heart and soul into the care of their patient, I want them to be able to go home and put all that stuff in a different place and be able to have a normal home life, to retain the capacity to laugh and love with their family, and not be drained emotionally." Collins seems to come to the conclusion that this isn't realistic. Do you agree?
- Both Mike and his wife Patti, looking back, have said their first few years of marriage, when they had nothing, were among the happiest of their lives. Why might that be? Is there ever a time when it is a blessing not to have a lot of material possessions?
- Mike has said elsewhere that starting the IV on the burned infant, Heather (described in chapter 20) was the most disturbing and painful thing he has ever had to do in his medical career. He is tormented by the notion that he and the other residents were "practicing" on Heather. And yet he, and all of us, realize that, as Mike says, "The Chief of Surgery can't start every IV, can't change every dressing, can't perform every surgery." How do we reconcile this?
- In chapter 21, Mike is made to function as an intern because the real intern has committed suicide. Doctors commit suicide at a rate far greater than the normal population. Why might that be?
- Mike is concerned about the little baby in the ICU with the brain damage. His resident tells him to forget about the child. "He's a veg," the resident says. But Mike can't let it go. "If I... ignore this child it means I have accepted something I don't want to accept. It seems an abandonment of my principles. If you love enough, if you care enough, if you try enough, shouldn't you be able to overcome the obstacles life puts in your way? If I ignore this child, am I not acknowledging that there some fights better left unfought, some dreams better left undreamt?" Ultimately he decides that yes, there are. Do you agree?
- How do you feel about the resident who makes Mike learn to insert a subclavian line on the patient who had just died? Do you accept the resident's justification that "This guy's dead... But the next one won't be. And maybe the next one will be your father or my father. And maybe he will die if Collins doesn't know how to put in a subclavian."?
- In the chapter about the woman who dies of metastatic breast cancer, Mike describes the "well intentioned path" of her treatment. Each step seems reasonable enough, but ultimately the patient finds that her treatment is prolonging her death, not her life. Did, in fact, her doctors go wrong somewhere? What might they have done differently?
- In the Afterword Mike presents his vision of the facts, the story and the truth. Do you find his assessment accurate? In light of recent revelations of memoirists who have fabricated significant parts of their memoir, how closely do you think a memoirist must stick to the absolute, literal truth? Mike implies that readers won't mind that he calls the construction company he worked for "Scalese" instead of "Scapone." Is this true? Do you mind? Should any latitude be afforded a memoirist in telling his story?