Patients and Doctors: Life-Changing Stories from Primary Care (review)

Jeffrey M. Borkan, Shmuel Reis, Jack H. Medalie, and Dov Steinmetz, eds. Patients and Doctors: Life-Changing Stories from Primary Care. Madison: University of Wisconsin Press, 1999. xii + 221 pp. $24.95.

This remarkable collection of medical narratives gives great hope to the strained and unduly restrained medicine of today. Forty-seven family physicians and family therapists write about clinical experiences with individual patients. Clustered into sections with such themes as heroism, secrets, abuse, and suicide, and introduced by perceptive conceptual comments, the stories reflect the intimacy and wonder that can be derived from general practice. The authors write naively and honestly, with a sometimes breathtaking level of self-disclosure, about the germinal events in patients' lives--births, losses, suicides--and about the correspondingly germinal events in the lives of the physicians: mistakes, diagnostic epiphanies, and acts of generosity. There is no restraining the courage, the mournfulness, the rage, and the joy of all involved.

Drawn from physicians' practices in Israel, North America, the United Kingdom, Western Europe, Africa, and Eastern Europe, these short accounts of illness and healing describe a relationship-centered care that ignores neither the person of the patient nor the person of the physician. Woven of the tough fiber of trust, secrets, and reliance that connects doctor to patient, these stories are not only texts of primary care but actual primary texts: they are nonderivative texts strong enough to stand alone. I assigned one of the stories, "Last Day in Omak" by Jon O. Neher, to second-year medical students in a seminar on twentieth-century North American short fiction; it stands up to Alice Munro, Lorrie Moore, and Flannery O'Connor in its savagery and its revelatory lyricism.

This collection suggests more than the commonplace that doctors and patients go through important life events together: it also submits that real medicine requires reflective language. We know not what we have lived until we have written it out--not so much to be disburdened of it (although sometimes this is a blessed dividend), but to see the thing whole, to hear it resonate, to let the story rise. Furthermore, the collection provides evidence that an effective medicine is of necessity an intersubjective enterprise enacted between two authentic selves, an undertaking that embroils both doctor and patient in acts of memory, metaphor, admission, faith, and desire.

Not all the narratives are written in great prose. Some sections (the ones on humor, suicide, and illness in the physician's family) disappointed me. However, enough of the writing succeeds so that the whole gesture becomes a brave claim to courage, a deep call for goodness.

The collection points to some risks of the increasingly prevalent practice of narrative-writing by physicians about their practice. There seem to be some moments of too easily achieved absolution for missteps. Implicitly, these accounts raise questions of informed consent: because no author discusses the sequelae of having shown the patient what was written about him or her, the reader assumes that the subjects of these essays were not given the opportunity to read the texts. Without such disclosure, any physician-author is a potential victim of solipsism, self-promotion, or simply getting the story wrong. We may discover that the real dividends of narrative-writing about medical practice are therapeutic ones, and that only when the patient reads what the physician writes can issues of accuracy, dignity, intent, and outcome be faced.

These complaints, however, do not negate the power of this book. I believe that it will help physicians, medical students, and other health professionals to live up to the requirements of their work. By modeling a kind of actual grace, the collection points the way toward a practice that is not past until brooded on and not completed without personal transformation.

Rita Charon
College of Physicians and Surgeons of Columbia University

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