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To Do No Harm: A Journey Through Medical School.

Under the Ether Dome: A Physician's Apprenticeship at Massachusetts General Hospital

"The metamorphosis" of medical student into physician, writes Stephen A. Hoffmann in Under the Ether Dome, "is a process that is haphazard more than deliberate, more felt than seen, and it progresses almost imperceptibly" (p. 7). This process is the central theme of both books reviewed here. In To Do No Harm, in fact, Philip Reilly states pointedly in his preface, "I wanted to watch these attitudes take shape in myself" (p. xiii).

One characteristic of the metamorphosis from student to physician, readily apparent after reading only a few of today's numerous medical autobiographies, is the uniformity of that social and emotional process. Maintaining one's individuality within the tradition of medical education poses formidable challenges for the would-be physician. It is, however, doubly difficult to experience and to examine the experience by writing of it. Although as writers Hoffmann and Reilly both falter at times, as humanely self-conscious physicians they succeed more often than not.

The two books could almost be said to offer a developmental study of medical education. Issues of truthtelling and informed consent, for example, are first raised with student Reilly's discomfort at being introduced as a doctor, but subsequent dilemmas become even more complex. At one time, he inwardly questions a physician's assertion that a patient understands the treatment he is about to receive. Later, Reilly feels uncomfortable when a patient turns to him for information either overlooked or withheld by the physician.

Reilly usually writes--as is his intent--about the dilemmas facing the unempowered medical student. This is perhaps why his accounts are often prsented without resolution, taking the narrator only to the moment of conflict. Hoffman, on the other hand, considers the dilemmas of the (seemingly) empowered physician. He tends to be more abstract and discursive, usually offering solutions he has reached himself rather than writing only of the confusion he experienced initially.

The developmental approach can also be seen when the two writers talk about their experiences with dying patients. Reilly observes that during the first week of his medical clerkship he "became familiar with death" (p. 111). Six months later, he sees death as "an icon...brilliant and relentless" (p. 183). He decides, in a rather curiously calculating way, to visit Mrs. Landi, a dying patient, daily. For all his deliberateness, however, Reilly soon finds himself in "one of the most intimate relationships I have ever known" (p. 186), and he is frequently torn between his roles as friend and "physician."

Hoffmann, on the other hand, is not unfamiliar with death: "Although death was no stranger to me when I started in the [ICU]...I did not yet know what it meant to brush up against morality so intimately and so regularly" (p. 112). He learns this lesson in the ICU, where "[c]oming to terms with death is one of the hidden agendas of the...rotation" (p. 112).

In both instances, Reilly and Hoffmann find themselves struggling with the problem of whether or how to distance themselves from--not exactly the pain of their patients--but the pain they experience in being so close to another person's suffering.

One factor that helps both is the love they develop for their patients. When Reilly, for example, discovers that he has come to love Mrs. Landi, he finds the courage to stay with her through the horrible process of her dying. For Hoffman, as armor of indifference created by weeks in the ICU crumbles when he recognizes h is love for Mr. Franco: "How could I push on the chest or make crude stabs for a vein of a man I had almost begun to, yes, love. I hadn't realized until then how close I would come to feel toward a patient" (p. 199).

In such passages both writers successfully portray their emotional development (metamoprhosis, if you will) as they move from initiate to to initiated in the mysteries of medicine. With Reilly, his first emotion is fear. Futtingly, his book's epigraph is from The Red Badge of Courage. By the end of his four years of medical school, however, much of the fear vanishes, and he chafes under the restrictions imposed on a medical student.

Hoffman's early descriptions of himself evoke an image of a wide- (at times wild-) eyed zeal, but this ingenuous enthusiasm fades during his year of internship and is replaced by his growing realization of his powerlessness to cure many of his patients. One can imagine Reilly's book ending on the threshold of Hoffmann's and wonder if Reilly, too, will complete his "metamorphosis" with Hoffmann's realization that "I no longer see myself as infinitely hardworking or infinitely caring. I have my limits, and I am more tolerant and forgiving of myself" (p. 300).

However they portray themselves, both Hoffman and Reilly have the valuable ability to recreate the details and tensions of their "metamorphoses" vividly. But when either writer moves out of a narrative mode, his story often falters. The article in both titles (A Physician's Apprenticeship and A Journey) implies a personal rather than a generic accounting. In Hoffmann's case, this expectation of a personal, anecdotal accounts is heightened by his epigraph from The Autobiography of William Carlos Williams about the endless opportunities for "[m]utual recognition" between patient and physician that are "likely to flare up at a moment's notice." The kind of writing necessary to convey these kinds of moments is almost pure narrative--"immediate"--and usually nondiscursive. Hoffmann's "moments" actually are quite successful, but, less than a third of the way into his book, these narratives become embedded in increasingly long sections of exposition, where "I" becomes "we" and Hoffmann speaks, seemingly, on behalf of interns and all physicians.

Reilly presents a different kind of narrative dissonance. Again, certain expectations are set in the book's introductory sections. Both the forward by Margery W. Shaw and Reilly's own preface refer to his diary, which "he has successfully refrained from retrospective[ly] editing" (Shaw, p. vii). The book, however, contains a substantial amount of what can only be retrospective commentary.

Retrospective in itself is not bad, but it is confusing when Reilly does not differentiate between the voices of the early diarist and the retrospective physician. For example, in one anecdote the voice of the older physician begins: "One of the milestones in the life of medical students...." (p. 119). Reilly then describes a patient whom, because he speaks so unendingly about his pain, Reilly calls "an unpleasant little man" whining "like a spoiled child" and asking for help with "a simpering plea" (pp. 119-120). Such an unempathetic description could well be the way Mr. Bodmer was perceived and originally portrayed in the diary of the irritated student Reilly, but it jars when put into the context of an event remembered by an older-but-wiser Dr. Reilly.

The problem seems to lie in Reilly's narrative inexperience. Although the has written extensively, the intricacies of literary voice and narrative construction are subtle and not easily learned. I would hope, however, that both authors continue to study and practice these narrative methods. Their stories are, on the whole, worth telling, and the process of preserving and recording them is valuable not only to the reader but to the writer as well. Writing, for many medical autobiographers, becomes a way to keep oneself in touch, not only with past events but also with past ideals, fears, and rewards. Hoffmann and Reilly are to be commended for valuing that past, both its pains and its joys.

Philip Reilly, MD. Dover, MA: Auburn Publishing Company, 1987. XV + 292 pp. $24.95; $16.95 paper.
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Author:Poirier, Suzanne
Publication:The Hastings Center Report
Article Type:Book Review
Date:Oct 1, 1988
Words:1270
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