Monday, August 1, 2016

Internal Medicine

Internal Medicine: A Doctor's Stories
Terrence Holt (Liveright, 2015)

Terrence Holt conceived of his account of internship and residency not as a memoir, but as a series of parables, "seeking to capture the essence of something too complex to be understood any other way." Not only are the patients composites of his imagination, the narrator is a transformation of Dr. Holt. "He struggles differently from the way I did, but in the end he learns things that it took me much longer to figure out." This narrator is good company. He sheds light on the uncertainty of the enterprise, both from a medical point of view – the same few symptoms apply to so many conditions – and on an interpersonal level: How do you keep listening to the patient who's been labeled a whiner, or whom you just don't like?

Part of the goal of training is to teach the young doctors how to appear confident even when they' are, inevitably, uncertain. "During those years, I always felt that I knew nothing. And no matter how much you did know, there was always more you didn't. In that vast desert of ignorance always lurked that one detail waiting to kill somebody." He's in a teaching hospital, so he is often without the complete medical record, because patients are being admitted by the house staff rather than their own doctors. Much can go amiss in this process; the history may be too complicated for the patient to remember or explain; she may be confused, demented, in shock or unconscious.

Or she may be lying, concealing something she's done, like the girl who swallowed a handful of Tylenol and damaged her liver. To assume she is lying leads to a certain cynicism that may lead directly to hardness of heart. It's always a breakthrough when the young doctor looks up from his lab results and sees a human being, but if they thought about that all the time, they'd be unable to do the work. "There is so much death and suffering and grief, and in the midst of it we still need to fill out forms, subject the sick to indignities and pain, try to eat and sleep and keep all these needy people at some kind of distance."

Dr. Holt has a chapter about some of the neediest, the patients in a mental hospital. He works a rotation in intensive care, where matters are somewhat simplified: keep the patients alive, with oxygen and antibiotics. (Or is it, kill them slowly?) And he goes out on hospice calls, where the patients are on the far side of need. But the families need something, and a doctor actually arriving with the nurse gives them a strange sort of comfort.

Three out of three people die, it's been said. Surrounded by family or alone, dimmed by morphine or amid the turmoil by a Code Blue, "in the middle of a scene with all the dignity of a food fight in a high school cafeteria. We can't cure everybody, but I think most of us treasure as a small consolation that at least we can afford people some kind of dignity at the end, something quiet and solemn in which whatever meaning resides in all of this may be – if we watch and listen carefully – perceptible."

If we watch and listen carefully. Here's hoping we can.

Any Good Books
August 1, 2016

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