Stories as Diagnosis

By Brian GittisNovember 24, 2015

Internal Medicine by Terrence Holt

LAST YEAR Harper’s published a brilliant essay in which the journalist and novelist Heidi Julavits conducts a kind of literary medical investigation. Convinced she has been misdiagnosed by her doctor, Julavits decides to take matters into her own hands by applying the more supple interpretive skills of a writer or critic to the mystery of a bodily ailment. By the end of the piece, in a sort of intellectual magic show, she has managed to both reveal what her physician missed, and offer her own convincing diagnosis of sclerotic, black-and-white thinking in the medical world.

During the course of her investigation Julavits visits the classroom of Columbia University Medical School professor Rita Charon, who requires her students to study literature, art, or philosophy alongside their medical coursework. Charon teaches doctors to look not just for symptoms, but for narratives. Doctors, her reasoning goes, are interpreters, and developing their “narrative competence” helps them practice medicine with greater insight and empathy.

Author and physician Terrence Holt put it similarly in a 2005 interview with NPR’s Lynn Neary: “The first thing that happens when a patient comes in is they start telling a story, and you try to figure out what it means.”

Holt came to medicine relatively late in life, after teaching creative writing for more than a decade. The horror and sci-fi-tinged tales in his first book, a collection of stories entitled In the Valley of the Kings — though published when Holt was already a doctor at the University of North Carolina — have almost nothing to do with medicine; they do, however, show a keen interest in philosophical questions about narrative. Whether set in small-town New England or a spaceship approaching Jupiter, these stories explore similar themes: the stranger and more mystical properties of language, the ways we use writing both to make sense of and transcend our world, the limits of human knowledge. Holt is particularly good at dramatizing the eerie way language can slip the control of its authors, taking on a mysterious life of its own. In “O Logos!” a word that kills its readers spreads like a microbe from person to person by appearing on the foreheads of the dying. In the collection’s title story, a professor researches an elusive, ancient “word of power” he believes may allow him to transcend death. Shrouded in elegant, austere prose that recalls H.P. Lovecraft, Holt’s astronauts, ghosts, and mummy-cursed Egyptologists lead the reader into cerebral, Borgesian labyrinths.

In his latest book, Internal Medicine, Holt continues to explore questions of narrative — specifically, those with which a patient equips himself for a visit to the physician. Just reissued in paperback by Liveright, Internal Medicine appears to be a memoir of Holt’s medical residency, but its introduction tells us that we are in for something more complicated. Holt’s stated goal is to give “a truthful account” of “what remained mysterious, and often troubling, about the process of becoming a doctor” — but at the same time Holt says he believes it is unethical to publish the stories of real patients, however disguised. Left with only fiction to render his “truthful account,” Holt’s solution is to create a sort of avatar of himself, Dr. Harper, and to send him through fictional cases that crystallize what were, for Holt, the essential dilemmas of residency. These experiences are arranged “according to the logic not of journalism but of parable.” The result is a book explicitly labeled “memoir” that, curiously, also carries that familiar disclaimer on the publication page: “The characters and institutions in these stories are fictional. Any resemblance between them and any actual individual, living or dead, is coincidence.”

What follows the introduction is a collection of what feel at first like fairly straightforward medical case studies. Many begin like your average House episode: a patient whom Dr. Harper has inherited from the overnight shift has an inexplicable, elevated lactate level, for example, or, just as Harper has a pizza delivered, a young woman admitted to the psychiatric ward reports a mysterious abdominal discomfort that gives Harper an uneasy hunch.

Harper is a hardworking and compassionate doctor with the soul of an English major. He sees flashes of Dostoevsky and The Flying Dutchman in medical predicaments and sometimes reflects on his patients as a critic would a text (“She was unusually well-groomed. Her hair was clean, her skin clear […]. All of which was only a setting for the disturbing thing that glimmered in the depths”). Grim circumstances are sometimes rendered with startlingly poetic insight — a terminally ill heart patient is “circling the drain in rings that seemed still, at this point, so wide that the central vortex was only a dimple on the horizon.”

But despite the occasional poetic image, Internal Medicine reads more like a collection of personal essays than short stories. Gone is the stylized, darkly intoxicating prose of In the Valley of the Kings; Internal Medicine is sober and earnest — so much so, it’s easy to forget that the work is, in fact, fiction — which points to a liability in this book’s form. The danger of true-ish stories is that they can end up possessing neither the artfulness of fiction nor the sobering shock (or voyeuristic intrigue) of stranger-than-fiction facts. Part of what usually makes medical stories interesting is that frisson of looking behind the curtain. When we read a medical story that defies belief — such as when x-rays reveal that the woman in the psych ward was experiencing mysterious abdominal discomfort because she had intentionally driven a dozen needles between her ribs — we have to reconcile its strange events with the world we live in, and that can be thrilling or destabilizing or enlightening. Because Internal Medicine feels like nonfiction, it conjures these sorts of feelings in us — but they lose some of their immediacy when we remember that nothing in this book really happened. Holt seems to be offering us tantalizing, privileged access to something with one hand and obscuring it with the other. We are ushered behind the curtain only to find another curtain.

But Holt is not simply out to satisfy our voyeuristic curiosity about hospitals. In Internal Medicine, he wants to afford us glimpses of things beyond the realm of medicine or even of reason itself — the moments when extreme medical situations seem to cross into more numinous or spiritual terrain. While medical stories usually follow a trail of reasoning to a solution, Internal Medicine more often leaves the reader with more questions than answers. In “The Perfect Code,” a routine resuscitation suddenly appears otherworldly when Harper is unexpectedly struck by its sublime perfection — the room’s “eerie calm,” the nurses’ “surreal economy of gesture,” the flawless interlocking of everyone’s simple, discreet tasks. In “Iron Maiden,” two routine examinations in the psych ward lead Harper to an unsolvable paradox in the relationship between mind and body. In “Orphan,” Harper’s investigation of a young woman’s stomach ache produces in him a sensation in which she appears to him “suspended between life and death […] seeming to occupy both states at once.”

In the book’s closing story, “The Grand Inquisitor,” Holt addresses the mystery in the act of storytelling itself. One snowbound night at the hospital, Dr. Hawley, a veteran doctor known for boring younger staff with old yarns, tells a vividly affecting hospital story that turns out to be made up. In other words, Dr. Hawley does to Harper what Harper (or Holt) has been doing to readers throughout Internal Medicine. Harper finds himself puzzling over why the story was told, what function it might serve, not just for the edification of Hawley’s young charges, but for Hawley himself. This leads Harper to an odd conclusion about his own habit of telling stories — that far from being a tool at his disposal, storytelling might instead be more of a “mistake” he is “doomed to repeat again and again.” So after opening Internal Medicine with a certain confidence that stories might help him make sense of his residency, Holt closes by suggesting his habit of creating them is driven by some darker and stranger force. It’s an unsettling note on which to end a book that began with such a clear, positive sense of purpose.

And so we find ourselves, once again, in the territory of In the Valley of the Kings. Our storyteller believes he is in command of his narratives until they slip out of his control. In that first collection’s superb ghost story, “Eurydike,” a man in a spaceship awakens after an unknown trauma, with amnesia. In an effort to gain some foothold in reality, he sits down at a computer and begins to write. As he puts into order his scattered impressions of who he might be and why he might be there, the story he’s telling seems to take on a life of its own, revealing the narrator’s circumstances to him in an almost supernatural fashion. Harper/Holt, several million miles away in his hospital, is not so different — both begin narrative-making in order to make sense of their worlds, but in the process find themselves conduits to larger forces that contain more than they find possible to grasp.

Presumably the idea behind helping medical students to cultivate “narrative competence” is that stories can be useful to doctors as rational, analytical, and organizational tools. They help us make sense of things. But it’s Holt’s great sensitivity to, and curiosity about the times that they don’t — and more generally the times that reason fails us — that give Internal Medicine a more unusual flavor than the conventional medical memoirs it resembles. Like plenty of its cousins in the genre, it is an engrossing, compassionate, and at times powerfully moving book. But, less commonly — and perhaps despite its author’s initial intentions — it is a haunting one as well.


Brian Gittis’s writing has appeared in The Paris Review Daily, Bookforum, and The New York Times.

LARB Contributor

Brian Gittis’s writing has appeared in The Paris Review Daily, Bookforum, and The New York Times.


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