I read Anna DeForest’s debut novel A History of Present Illness in the first month of residency, during a rotation in the intensive care unit. On morning rounds, we presented the medical histories of the patients admitted overnight in a prescribed language and format to match how the supervising doctors expected to hear it. We all began with the “history of present illness,” or HPI, to narrate the story of the patient’s decline. DeForest’s book offers the HPI of a medical education, not to meet our expectations, but to serve as our re-education. Through the path of an unnamed narrator, DeForest examines the space between what we learn in medical training and what dominates the medical experience. It is a lesson enlightening for both clinicians and those seeking a different narrative than expected from the ‘becoming a doctor’ plot of creative non-fiction books such as Henry Marsh’s Do No Harm, Perri Klass’ A Not Entirely Benign Procedure, Paul Kalanithi’s When Breath Becomes Air and the recent All That Moves Us by Jay Wellons. Fiction allows DeForest, a neurologist and palliative care physician in New York City, to explore the territory in a deep, meditative and literate way that brings the insular clinical world alive.
Anna DeForest is a neurologist and palliative care physician in New York City. Her writing has appeared in the Alaska Quarterly Review, the Journal of the American Medical Association, the New England Journal of Medicine, and the Paris Review.
While readers may see DeForest, a Columbia-trained physician, in her narrator, A History of Present Illness is a work of fiction embedded in the bitter reality of modern medical education and American healthcare. DeForest never names the city, the medical school or the river outside the windows of the hospital, but with the latter detail, she situates us at Columbia in Washington Heights. She guides her narrator through palliative care in the ICU as someone who has delivered devastating news to a family and managed healthcare’s perception that hospice means giving up.
The narrator of A History of Present Illness is a young doctor going through the daily initiation of learning her vocation. In the story, the narrator subverts the fabled tradition of medical education through her position as an outsider on the inside. We discover her history in increments: She grew up in an unstable home with a mother who drank too much. In her adolescence, she walks in to see her pregnant mother sitting on the kitchen floor shooting staples into her arm. Financial instability is a way of life, as is self-injury: The narrator cuts lines into the creases of her hands, to manage the suffering and hide her scars.
In these piercing details, DeForest constructs an upbringing that matches the expectation of someone who may see a doctor but not become one. Until she does. But even after the narrator’s matriculation, her wealthy fellow students in the first-year dorm seem to live apart at their expensive parties and retreats. Between these two worlds—of insider and outsider, poor and privileged—the narrator harnesses her dual existence to peel away the veneer medicine uses to cover its racism and classism, emotional dearth and lack of palliation.
The narrator learns that despite medical education’s claim to embrace the socially disadvantaged, clinical snobbery exists. She applies to volunteer for a student-run clinic and is rejected, reflecting, “you aren’t allowed to talk about poverty from the inside.” Her peer who runs the clinic, on the other hand, makes his privilege clear. She watches him shudder as a clinic patient approaches them for a cigarette. When she tells him about a woman who pretended to be her mother to get more food stamps, he responds, “Weren’t you ashamed?” Like many of her classmates, he cannot fathom the needs of those who live in poverty, only the shame associated with it. DeForest presents these interactions to make us understand that no amount of curricular or extracurricular activities can overcome a profession’s exclusive pipeline.
In addition to her upbringing, the narrator channels her fascination with catastrophe to comment on medicine’s emotional coldness. She recounts her own deep-rooted millennial fear as someone who watched Columbine and 9/11 when she was old enough to understand, but not old enough to cope. Her sensitivity sometimes creates a social awkwardness. Early in medical school, during a shift in pre-op, the narrator inquires if a patient is afraid, to which his father responds, “What the hell kind of question is that?” Undaunted, she persists in trying to recalibrate medicine’s emotional neglect. During a meeting with a dean of the school, she wants to know about “terror management,” or how to process the fear of being “primed with death all day” in the hospital. No one offers her answers to these questions because, she learns, fear and the recognition of death do not belong in the hospital. She recognizes how apathy becomes a way to stave off despair in an institution built for mortality.
DeForest also draws on her experience as a palliative care physician to infuse her narrator with an appreciation for the individual and a measured enthusiasm for scientific progress. The narrator describes medicine as a “miracle land,” where lungs or a heart are optional for survival. But the pumping of blood through an otherwise devastated system, the narrator suggests, cannot salvage the damage around it. When she asks a patient in the ICU, bound to his bed with restraints, what he hoped would happen next, he writes “kill me” on a piece of paper. She becomes close with a comatose patient with encephalitis, Ada, and her husband who never leaves her bedside. Every morning the team assesses if Ada will react to pain, applying pressure to her nail beds until they crack and pinches to her skin until it bruises. The narrator’s suspicion of the miracles makes us question end-of-life quandaries: Is this what we would want and are we even the ones who get to decide?
Beyond the provocative content of A History of Present Illness, the structure of the prose itself furthers our re-education. Doctors expect an HPI to adhere to chronological guideposts: The weight loss began six months ago, the dry cough two months ago, and then the blood in handkerchief last week. But DeForest plays with this simple linear structure, moving us between the narrator’s childhood, adolescence and rotations in medical training with thematic cues: The terror of watching planes crash into buildings in middle school runs into the terror of the moments before anesthesia sets in. She refuses to isolate the medical experience, and instead mediates between the inner narrative and medical documentation.
In A History of Present Illness, DeForest presents the HPI of a medical student’s indoctrination in—and confrontation of—medicine’s lore and nobility. Amid the momentum of medical advancement and academic self-importance, the narrator’s honest self-reflection refocuses our attention on the quotidian world of hospitals and healthcare to demonstrate the power of the individual and interpersonal in medicine. She asks why the story of one medical student, one patient in the ICU matters. And she tells us: “It matters most because it happened, if you learn to tell it right.”—Margo A. Peyton
Margo A. Peyton is a resident of the Mass General Brigham Neurology Program. Prior to medical school at Johns Hopkins, she worked in film and television story development for DreamWorks Animation. Her essays and book reviews have appeared in JAMA and the Boston Society of Neurology, Neurosurgery, and Psychiatry.