Although described as memoir, it quickly becomes clear that the boundaries between fiction and nonfiction in Terrence Holt’s “Internal Medicine: A Doctor’s Stories’’ will be murky. On the third page of the introduction, Holt refers to his stories as parables of life in a hospital and the making of doctors (himself in particular); by the fourth, he explains that the patients in the book are not “based upon specific individuals . . . They aren’t ‘facts.’ ”
Furthermore, despite having drawn upon his experiences as an internal-medicine resident for the content of the stories, told mostly in the first person, he writes that their narrator evolved “into someone else [who] dealt with patients different from the ones I cared for, and . . . in ways I never did.”
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As the nine linked stories in the book unfolded, however, Holt’s technique began to make sense. By choosing to untether himself from an exacting chronicle of his personal experiences, he gained the freedom, the distance to describe unflinchingly the disconnect between the patients and himself (as well as his colleagues), an admission which might otherwise have been cause for great shame.
The lack of empathy and basic compassion demonstrated by these exhausted, overworked, and under-experienced doctors constitutes the common thread in these tales. In one, for example, the narrator — in this case, an intern coming on call — is briefed thusly by a weary colleague on a patient with advanced lung disease: “Don’t get too excited about anything she says . . . basically, she’s a whiner.”
As the night progresses, the patient’s condition worsens, and she becomes claustrophobic, unable to tolerate her oxygen face mask. Her efforts to remove it almost trigger a physical altercation between them until he is able to overcome her resistance, forcing the oxygen back on her face. “I thought we were about to struggle over it, but then she stopped, and her hand fell away.”
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Arising from the narrator being focused on treating his patient’s disease rather than on treating her, this situation is evocative of the short story “Brute’’ by the writer and surgeon Richard Selzer. In it, a doctor struggling to suture a head laceration of a drunk man who won’t hold still stitches the man’s earlobes to the mattress to keep him from moving so that he can complete his task. Reflecting back on this later, the surgeon is haunted by then having looked the man straight in the eye and grinning at him with “the cruelest grin of my life. Torturers must grin like that.”
Unfortunately, introspection of this kind is mostly absent in the physicians whose stories Holt tells, and the detached, even antagonistic relationships between them and their patients is the antithesis of what we would wish for ourselves or our loved ones from those to whom we would turn for help when needed.
Holt, who also holds a master’s in fiction writing and a PhD in literature, is an excellent story teller, to be sure. A portion of one story, “The Perfect Code,’’ describing the unsuccessful resuscitation of a patient found slumped over in bed, can make a reader feel as though he were physically present at the bedside. Told in the second-person voice, it is a gem.
While the portrait Holt offers is artful, unfailingly human, and understandable, it is also troubling. One hopes that the reality Holt traces is no longer reflective of most physician-patient interactions in the internal medicine wards of our hospitals today. Good relationships and communication between doctors and patient based upon empathy, compassion, respect, and competence are vital to providing better quality care. Recognizing and acting upon this within the different branches of our health-care system is critical if we wish to avoid experiencing the very troubling dysfunction that Holt presents in his book.
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Dennis Rosen is a pediatric pulmonologist practicing in Boston, and author of “Vital Conversations: Improving Communication Between Doctors And Patients.’’