About the Book by Anna DeForest titled “A History of Present Illness”

From a New York Times review by Ellen Barry of the book by Anna DeForest titled “A History of Present Illness”:

In the opening pages of “A History of Present Illness,” Anna DeForest’s novel about medical training, the unnamed narrator finds herself with two groups of people — her colleagues, who are future doctors, and the cadavers they are assigned to dissect.

Her sympathies, it is fair to say, lie with the cadavers. The residents are rich kids, for the most part, raised with ski trips and country houses, who brag about the financial sacrifice they are making by going into medicine instead of finance or consulting.

Most of the residents, our narrator reports, have never held a real job, though “sometimes had a brief employ as a barback or a clerk in a dessert shop, each role a kind of ruse or joke, the visors and poly-blend polos some sort of poor-kid disguise.”

Our narrator is not one of them, having grown up on intimate terms with addiction and poverty. This makes her less like the doctors and more like the patients they are caring for, and it is what allows her to describe the social structure of the hospital with such merciless clarity, like a spy who has sneaked into the temple.

Our health care system, she reports, can feel like a conspiracy of the powerful against the powerless. The surgeons, she writes, “mock the patients they put under (for their belly fat, their scars, their low-class tattoos), mock their students for sweating or shaking or having attended public school.”

When panicked young women came into the emergency room with vaginal bleeding, the young physicians giving them pelvic exams “would joke to each other that girls like these — unspecified, technically, but poor and Black and brown in context — should be sterilized by age 13.”

The worst thing the doctors do is not even their fault, though: Powerful machines and powerful incentives drive them to prolong life artificially, when it serves only to draw out suffering. DeForest’s young doctor shows us these patients, strapped to their beds with padded shackles to keep them from tearing out their IVs and breathing tubes.

“Kill me,” an old man scrawls to her on a piece of paper, but the surgeons — who, it is rumored, are graded on the percentage of patients who survive 30 days after an operation — persuade his son not to listen to the hospice doctors. So they rouse the old man and he dies like that, tied down, awaiting another surgery.

DeForest, a practicing neurologist and palliative care physician, at times seems to waver between the goals of imaginative fiction and bearing witness. “A History of Present Illness” offers us the perspective of a doctor who feels everything. Her writing is dreamlike and fragmentary, a sequence of vivid scenes that the reader must piece together, like a puzzle, to understand who exactly is telling us this story. The answer, tucked in the book’s last pages, is a revelation.

But what she has written is also prosecutorial, documenting life inside a system that is closed to most of us. To anyone caring for someone near the end of life, “A History of Present Illness” provides a powerful argument to push back against the juggernaut of the hospital, to wrest control of the process. At times I wished she had written something as straight and clear as an indictment.

The problem is not so much that doctors are desensitized — the nature of their training practically guarantees that. It’s that they have so much power to decide when death is allowed to come.

The narrator confesses her own error, with a young patient she calls Ada, who is dying slowly of encephalitis. That night, Ada is “brain-dead,” irretrievable; at the same time, her death will be engraved in the life of her family. So the narrator grants them time before disconnecting the tubes, keeping Ada on the ventilator for one last night. She believes it to be a final kindness.

Then she goes home, exhausted, and Ada’s survivors turn on one another viciously, uncertain whether she is alive or dead.

At the end, the husband, battered and heartbroken, stops the future doctor in the hallway. “Stay honest if you can,” he tells her, by way of farewell, and his words linger in the air between them. He, too, has gotten to know the hospital from the inside, and he doesn’t sound very hopeful.

Ellen Barry covers mental health for The Times.

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