Internal Medicine
A Doctor's Stories
Terrence Holt
(Liveright Publishing Corporation)
For most physicians, medical training is a long and arduous process. The four years of medical school are characterized by mind-numbing memorization and the need to learn to speak the language of medicine. This is followed for many by another 4 to 6 years or longer of specialty and subspecialty training. It is a marathon that seems to never end. Fortunately for us, there are some physicians who survive this endurance course and then want to write about it, giving us a peek behind the hospital curtains into the humdrum but sometimes catastrophic lives of our fellow citizens. And often, it seems, these physician-writers have an uncanny knack of conveying their experiences in beautifully wrought prose, bringing us close enough to the bedside so we ourselves feel breathless and awed by what we have observed.

For the most part, this is what Terrence Holt achieves in his most recent book Internal Medicine: A Doctor's Stories. This is a volume of nine essays describing in vivid detail some of Holt's experiences over the course of his training as a medical resident in internal medicine in a large hospital and several community settings.

The first story, A Sign of Weakness, which is by far the best, tells the powerful story of his first night on call in a teaching hospital as a new resident. It centers on a middle-aged woman with a rare disease who is slowly dying of respiratory complications while the author is struggling to come alive in his role as a young physician. Although he is over his head in trying to manage her care, he struggles to live up to the unwritten code of his fellow residents not to show any sign of weakness or vulnerability (What a marvelous ethic for a new physician! Don't show weakness or admit mistakes!) At the same time, his valiant patient struggles in her own way against her weakness as she gasps for air but won't give in to using an oxygen mask which might ease her distress and prolong her life. Curiously, the unsung heroes of this story are the nurses and respiratory techs who are mentioned briefly, and never by name, while providing a steady hand and a voice of reassurance without a trace of weakness.

This chapter is a gem of restrained writing and is a masterful example of the dictum: less is more. On finishing this chapter, it seemed that the dust jacket blurb alluding to Holt as Melville and Poe and Borges combined, might actually be an understatement. However, neither of those estimable authors need fear, either singly or in combination, new competition. This is not to say that the remaining eight chapters are not compelling reading --- there is the story of the woman whose face is half eaten away by cancer and another of a woman dying in hospice --- it's simply the fact that they don't sustain the high level of excellence achieved with the opening essay. Perhaps no one could.

Although these stories are meant to reflect the essence of Holt's training years, he is, curiously, not present in the text. Rather, he uses the artifice of fiction and appears disguised as Dr. Harper. Holt seeks to rationalize this approach in the over-long and somewhat convoluted author's introduction.

    In reviewing these stories, I have drawn on what I thought and felt and generally did as a resident. But in re-creating experience as parable I have watched the narrator of these pieces evolve into someone else (i.e. Dr. Harper). He dealt with patients who were of course not the ones I cared for, and did so in ways I never did. He struggles with issues I struggled with, and with which every doctor struggles, but, in the end he learns things that it took me much longer to figure out. In portraying his inner conflicts I've tried to get at what the hospital teaches us. I have tried, more than anything else, to be faithful to the inner life of medicine.

To be faithful to the inner life of medicine. Exactly! Hence, the double entendre title of this collection. Yet this appears to be as much about the inner life of the writer as the hospital, whether we're talking about Terrence Holt himself or his stand-in, Dr. Harper. This results in two unresolved and perplexing questions at the heart of this book: first, why did Holt choose to distance himself from these very powerful and intimate experiences by putting them in the voice of a third person; and second, why does he frame the lessons of these experiences as abstractions, i.e. what the hospital teaches us and to be faithful to the inner life of medicine. It's clear what he means by this last phrase but, for someone who has had the extraordinary privilege of observing firsthand and in minute detail the inner life of patients under the most harrowing of circumstances, it seems a strange way for a writer of his talent and insight to express it.

The final story in this collection, The Grand Inquisitor, with a nod to Dostoyevsky, is another tour de force although not a peer to the first essay. It deals at length with the tragic saga of an immigrant German oncologist who is trying to save lives with toxic but cutting edge therapies which put him at odds with the conservative local community he's trying to serve. It is a compelling, well-crafted drama but the message is ambiguous. In the end, the German physician is shamed by his fellow practitioners and commits suicide out of some sort of guilt. But if we don't have practitioners who are willing to test new treatments, how will medicine ever move forward?

Holt then concludes this chapter and the book with a perplexing and ambiguous apology:

    I know how tedious you find me, now that I'm the one telling pointless stories. I don't mind, there are many mistakes we are doomed to repeat, again and again and again. This is only one of them.

Regardless of the irony of his own judgment, these stories are neither tedious nor pointless.

While this volume of essays may do a splendid job of conveying the rigors and drama of medical training in a modern American institution, it is virtually silent about the larger dramas and life-and-death conflicts being played out on the wider stage of modern American medicine. Life in a teaching hospital as portrayed here resembles something of an isolated cocoon, cut off from the reality of coverage crises, reimbursement schemes and greedy healthcare providers, individuals and institutions alike. Analyzing the health care system in this country was clearly not Holt's intent, yet how can you consider yourself well trained and ready for a competitive market when these issues are not addressed?

--- Lauro Halstead
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