AYESHA RASCOE, HOST:
Existential thoughts on what it means to live and die and the inequities of the medical system - these questions nag at the narrator of a new novel, a young, unnamed woman who starts her medical training healing others only to uncover wounds in herself.
ANNA DEFOREST: (Reading) All this happened more or less. I've seen a beating heart in a wide-open chest. This place has been a miracle land. No one even dies until we let them.
RASCOE: That's Anna DeForest with a line from her new novel, her first, called "A History Of Present Illness." She's a neurologist and palliative care physician in addition to being an author, and she joins us now. Welcome.
DEFOREST: Thank you so much. I'm so happy to be here.
RASCOE: I wanted to ask you about this unnamed narrator. She's trying to treat people, but she's also struggling with not just the long hours and the hard work, but with the very nature of the medical profession.
DEFOREST: The early aspects of medical training - it's funny, but they really are an indoctrination. You're not just learning science. You're learning a different way of being a person. The way that you're learning is in this system that is phenomenal, necessary and good, which, at the same time, is a really toxic environment. Anyone who's been in a hospital can tell you it's not the best place in the world when it comes to being treated like a human being.
RASCOE: Almost to be a human being would be to try - to, like, run away from suffering, I think, is very human. But to run towards suffering - that's kind of not what I think of as a regular human aspect. Is that, like, a key thing here?
DEFOREST: That is. That's - and it's so well put because I see the book - it's ostensibly about a kind of occupational training. But what it's really about to me is suffering and about, how do we attend to suffering? To look away is the most natural thing in the world. But it's an impulse that we all have to overcome if we want to make the world less awful. The heart of this book is the question, what if you didn't?
RASCOE: I feel like part of what this book is is she's going through dealing with these patients. Some of them are very hopeless. And so how do you acknowledge or do that in a way that could ever be satisfactory?
DEFOREST: For me, before I ever thought about going into medicine, I had an almost pathological preoccupation with the frailty of the body. I was terrified of dying. And because I had this preoccupation, then the best thing to do - it's counterphobic, right? - is to just get closer to it. And that's what medical training came to be for me, a way of showing myself or, like, teaching my body that death is OK. So there are a lot of deaths that aren't. But the fact that we die is OK is something I wanted to learn, and I'm starting to.
RASCOE: Is that what the narrator is also coming to terms with? Like, the narrator does not come from a privileged life. Her mother's an alcoholic. It was a very unstable home. There's a scene where there are twins born by caesarean section, and she doesn't seem to know or really seem to care if they lived or died. Was it a result of her trauma or is it medical training to be dispassionate? Do you have to become disconnected?
DEFOREST: The question of how disconnected do you need to be to perform the job of a physician is one that really presses on me. A lot of older physicians will tell people considering medical school, don't go into this profession. It's impossibly difficult - not the science, but the daily workload and the difficulty of being presented with this volume of suffering in this bureaucratic system of American health care. That's kind of separately a nightmare. And then those of us who do anyway, we're here and trying to figure out, can I suffer with the suffering and still be their doctor? And it's a hard line to find. But we swing very far in the direction of being cold, I think, because we feel like we have to or we're afraid of what will happen to us if we don't.
I had the privilege of being a fellow in hospice and palliative medicine the past year - I just finished in June - where in our training, it's so embedded that we learn to recognize and process the emotional experiences that we have. And so we carry a large volume of patients who have really serious illnesses and many of whom die in our care. Learning to handle your feelings over time, I think, is so much easier than trying to avoid your feelings.
RASCOE: You started writing this novel your third year in Columbia medical school. That's a big deal, being in Columbia. Then you entered your residency. What did you think of it when you went back to it?
DEFOREST: I wrote out a draft, and I put it away. I thought, this is, like - this is unpublishable is how I thought of it because it was so dark. It was so sad. And the question - like, what is the meaning of all of this suffering? I did not answer it. I still have not answered it. But by the time I was done with residency, I couldn't feel these things anymore, partially because I was getting a little bit hardened inside and didn't have the time to. But you also - you just acclimate. It's an amazing thing that human beings do.
We would have this experience sometimes in the neurology wards, the in-patient neurology service. Many of our patients are very, very confused. They have brain injuries or they've had strokes, and they get out of bed a lot. So what we do is we tie them to their beds. And when the med students would rotate on our service, they would be horrified. And you - when you saw them see it, you would remember that of course it's horrifying.
And so when I came back to this manuscript, it was like getting a letter from yourself through time. And it made me remember what it was like to feel those ways and to feel them again. And it was really almost medicinal to have that experience. Like, I became a hybrid of my past and present selves.
RASCOE: Is it possible that you can have, like, a system of medicine and it feel compassionate?
DEFOREST: Yeah. The system hurts a lot, and it hurts a lot of people a lot. There's people who think about this on a systems-level way, and I admire them deeply. My interventions tend to occur on the level of the individual. So you have two questions - can you make doctors see their patients as humans, and can you give them the tools to know what to do with that information? The answer, I think, is, yes, you can do it. And the ways that it's being done now - there's plenty of schools that work very hard to recruit nontraditional students into medicine.
But we sometimes encounter things in American medicine where doctors have been driving medical care plans right up to the edge of what's possible. And then they have a case where a patient is certainly going to die, and then they lay out these options for the family to choose from in times when it's almost cruel to make a family choose that. The question is like, do you want us to extubate him today and he'll die? Or we can keep him on a ventilator through a hole in his neck for a couple of more weeks, and then he'll die. There are times when we abscond our responsibility to help.
RASCOE: I want to go back to the line that you read about feeling like you're in control. Like, I mean, if you've seen a beating heart in a wide-open chest, you know, no one even dies until we let them, until you name it. How do you become a doctor without getting, like, a bit of a God complex?
DEFOREST: It's really interesting about power. When I was a child in that environment, it was so disempowering. And even, like, being a 20-something who is adjuncting (ph) and trying to publish short stories - so disempowering. And when I got into medical school, my life really changed. And it continued to change as I succeeded through all the different hoops they made me jump through. And now, done with my training, I realize something about power, which is that it's not a feeling. It's the absence of obstacles. It doesn't even occur to you. You don't even notice how powerful you are when you're truly powerful. It's just as though the world rolls out in front of you.
Once I realized that, I was really horrified because if it's not a sensation, like, how do we teach people who have power that they have to be cautious in how they wield it, that they don't deserve it, that disempowered people deserve what they have? And it's a mystery why some people get and some people don't. It just takes a lot of humility. It's a humbling work, medicine.
RASCOE: That's Dr. Anna DeForest. Her new novel is "A History Of Present Illness." Thank you so very much.
DEFOREST: Thank you.
(SOUNDBITE OF RAY BARBEE'S "THERE'S A PROPER TIME AND PROCEDURE FOR EVERY MATTER") Transcript provided by NPR, Copyright NPR.
