Abstract
Dr. Anna DeForest, Little, Brown and Company, New York, NY, 2022, 176 pages, Cost: $14.19 (Amazon.com).
“All this happened, more or less.” So begins A History of Present Illness, palliative care physician and neurologist Anna DeForest’s stunning debut novel. A History of Present Illness tells the story of an unnamed narrator as she moves through various stages of her medical training. We first meet her on the day of her white coat ceremony, after which she journeys with her class down to the anatomy lab. DeForest takes us into lecture halls, preceptorships, volunteer experiences, and hospital rooms.
The opening line above functions as a sort of disclaimer, casting doubt on the reliability of her narrator. The line also serves as a message to readers who themselves have lived through years of medical training. What we’ll read in the following pages could have happened, to some degree, to any number of us.
Memoirs of and novels about medical training tend to focus on its indignities. In Samuel Shem’s canonical, and admittedly problematic, The House of God, and more recently Sandeep Jauhar’s Intern, we watch as intelligent, dedicated, medical neophytes slowly lose their humanity as they become immersed in a dysfunctional system with perverse incentives and minimal regard for its practitioners’ wellbeing. When I see a new book about medical training, I expect to read about long hours, supervisors whose passion to heal has been stamped out of them, and the pain we feel in making medical errors. Reading these books from within medicine, the stories fail to shock us. Instead, they echo the sufferings and joys we ourselves encountered in our training.
Here DeForest’s book surprised me. The narrator comes from poverty and survives multiple forms of trauma on her way to medical school, a perspective that we see less commonly represented in stories about medical training. DeForest sketches her protagonist slowly, adding depth, and shading through vignettes peppered throughout the narrative. Moving both forward and backward in time, we meet the narrator’s family and bear witness to the hardships they endure across generations—entanglements in welfare scams, emotional, physical, and sexual abuse, feeling trapped in one’s circumstances, and getting out when the opportunity presents itself.
At the same time, we follow the narrator’s journey through her medical training, occasionally aligning with fellow students, mentors, and deans, but never quite fitting in. In one striking example, the narrator joins a dean and students interested in poetry for dinner at a members-only club, the likes of which we often find dotting the perimeter of elite university campuses. The narrator hopes to talk about the proximity she’s feeling to death, but her dinner companions instead “talked the way we were meant to, about schools they had attended, traveling abroad, minor celebrities they all knew in common” (p 20). Later, the dean leaves a poem for her in his office about the perils of arrogance in medicine. She wonders if “this meant him or me” (p 27).
Similar stories move in and out of the book, wrapping around, and layering on top of each other, coming and going without resolution. They give the story a lyricism that feels a half step off the beat, akin to the syncopation we’d hear from a master of avant-garde jazz. DeForest’s narrator doesn’t fit in—she thinks, dresses, and speaks differently than her classmates, and the writing beautifully reflects this pervasive sense of discomfort.
Through her narrator, DeForest sharply criticizes medicine and the people who pursue it as a career. One of her characters runs the student-run free clinic for people experiencing homelessness, yet recoils in fear and disgust when he encounters an unhoused person on the street. Another speaks of taking less and doing more, then takes money from her parents to study Portuguese in Brazil. Written with less skill, these characters risk coming off as caricatures of medical students we’ve often encountered, or even have been ourselves. DeForest, though, sketches them with both detachment and nuance. Readers, then, feel the cringe of recognition without satire’s accompanying chuckle. As a result, DeForest’s criticisms of medicine, and of those who practice it, cut deeper.
These condemnations, though, may not be as they seem. As the novel’s opening line suggests, the narrator is unreliable. She tells stories early in the book, only to rewrite them in subsequent pages. Details change, characters shift. The narrator lays out vignettes about others only to reveal later that they were about herself. Are the supporting characters’ flaws as obvious as the narrator portrays them? Are they memories that have become exaggerated with hindsight? Or are they fictions written by her imagination? This lack of certainty draws us in closer, as if we can only understand the narrator’s world by fully inhabiting it.
Writing this review for the Journal of Palliative Medicine, I would be remiss to avoid mentioning the discussions of serious illness, death, and dying that DeForest weaves throughout A History of Present Illness. As palliative care readers, these moments will stand out not only for their relevance to our practice but also for the freshness of their perspective. Early in the novel, the narrator introduces us to Ada, a young woman slowly dying of a neurological disease. Through Ada, we come to understand how “medicine” thinks about and interacts with serious illness, its failure to name dying directly, and its inability to provide comfort and empathy to devoted family members at bedside, in this case Ada’s husband. DeForest writes:
As the end of things circled around us, I kept waiting for Ada’s husband to erupt with wisdom or clarity. He didn’t. Maybe all the conflict with the staff—every specialist had another opinion, though in private they all agreed she would never leave the hospital—left him too spun and distracted for any dawning truth about the nature of love or anything. He looked more like someone who had survived the crash of an airplane, wrapped in a blanket, stunned and shaking. (p 121).
As she does with so many other tropes, DeForest subtly questions the conventional narrative of growth and knowledge through loss. The novel’s beauty, and its power, lie in its reluctance to give us easy, or expected answers.
A History of Present Illness does function as a critique of medicine and a reflection on palliative care. But to call it these things does it a disservice. It’s a novel that readers, those within and outside of medicine, can appreciate for its economical splendor. At a quick 176 pages, you could certainly read A History of Present Illness in one sitting. But, given DeForest’s prose and characters, you won’t want to.
Conflict of interest: R.E.L. has no conflict of interest that could potentially compromise the objectivity of my review.