As I live and breathe: notes of a patient–doctor Jamie Weisman New York: North Point Press; 2002 224 pp. US$23 ISBN 0-86547-602-0
Oh, the patients. They form advocacy and support groups, demand greater autonomy, fraternize, mobilize, and ultimately destabilize traditional physician–patient relations. What once was a position of authority is rapidly becoming a role of deference. Every doctor, whether psychiatrist or surgeon, has been met with canny questions of appraisal: “What are the chances that this treatment will work? Will this test tell us anything we don't already know? Is there an expert to whom you can refer me? I read on the Internet …”
The final frontier for their encroachment is when patients actually become physicians themselves, and this is Jamie Weisman's accomplishment. She is a writer, a doctor and, most important for both, a patient. This book, a series of essays written during medical school and residency, introduces us to her personal experience with misdiagnosis and dabbles in her apprenticeship as a writer. Primarily, however, it recounts her indoctrination in the medical habit.
And oh, the patients with a nebulous symptomatology, those who present time after time with nonspecific ailments, who elude diagnosis and, after a time, raise the medical suspicion of malingering. Weisman was such a patient. It took 11 years of repetitive sicknesses until it was “determined” that she suffered from an obscure immune deficiency. The book begins with Weisman in the infusion room of Mount Sinai Hospital in New York City receiving immunoglobulin. Her writerly talent draws the essential from the pedestrian — in this case, intravenous therapy:
The moment when one's skin is pierced produces a unique vulnerability that has nothing to do with pain. It is fundamentally unnatural to passively allow this insult to the body, and no matter how many times I've had it done to me, I still flinch. It is always when I feel the prick of the needle that the “why me?” thoughts come, as if they were smoke leaking out through the tiny hole in my arm. How did I end up with an aberrant immune system? Which one of my chromosomes misbehaved? Why would one of my cells mess up the intricate process of division, when trillions of other cells in billions of other people manage it just fine, thousands of time every hour? We — my doctors, my family, myself — have no idea where my disorder came from or where it is going. I could develop cancer next year, or I could, like my grandfather, die of old age at ninety while eating a Rice Krispies Treat and complaining about the weather.
Ah, probabilities, the currency of medicine's trade. What doctor has not contemplated a differential diagnosis, moving selections up and down the list over time? All of us have, although only few have qualified for these diagnoses. It's Weisman's lightness of image (a Rice Krispies Treat) in face of the gravitas of illness that makes this book so compelling.
These essays are substantial. Most are dozens of pages long, and all are the product of a mind in equipoise, possessing the tranquility that comes with mortality's constant threat. Suffusing Weisman's prose is a love of life — her own and others — that affirms her chosen vocation. Whether she is taking care of a dying alcoholic patient or is sick herself from sepsis, she writes with the wisdom that is the providence of the doomed. Indeed, Weisman repeatedly mentions the possibility that she will develop lymphoma as a complication of her disease:
With each swollen lymph node, each abnormal biopsy, I am reminded that my body is fragile, more fragile than the bodies of other women my age. I never escape these abnormalities. Every Pap smear I have is suspicious for cancer. I don't see a regular gynecologist for my checkups, I go straight to the cancer specialist. Every new doctor who examines me is alarmed by the size of my lymph nodes and wants to stick a needle in one. Every new pathologist who examines what the needle draws out immediately thinks I have lymphoma … . I know that death — especially death from cancer — often starts from a tiny spark in the body, a twinge in the side, a little headache, a sudden need to nap in the middle of the day. And these small sparks grow, leap up in flames, to finally consume the body. Accepting the reality of this risk, I now realize, is part of the price I pay for being a doctor. In this age I can think of no better candidate for becoming a physician than one who has run the diagnosis gauntlet for over a decade and, in the end, settled into a vague truce with the medical discipline.
Medicine is her career, but it is also her life. Afflicted with “some form of congenital immune deficiency,” she is the poster child for medicine's uncertainty.
Weisman is a doctor, part of our clan, but she's also one of our charges. By writing a book that oozes empathy with every patient that comes under her care, she has done quite a remarkable thing: she's written a book that is sympathetic to our craft despite the fact that the author is immersed in the most difficult and impotent of stages, the trainee period. Her book is an antidote to the cynicism of Samuel Shem's House of God, and should be circulated to all medical residents when jadedness descends.
In short, Weisman's example demonstrates that, despite the failings of doctors — and she dissects these carefully — we're better than we think we are. Reminding the reader of the power of the physician–patient interaction, she instills in her readers, be they patients or physicians, an appreciation of a kind word, of a careful observation and, above all, of giving the benefit of the doubt. The wisdom of being a patient, a resilient survivor, is here. So is the incremental process of becoming a doctor, the acknowledgement that illness is universal and, in the end, triumphant:
But of course we always lose. Death wins eventually, and I, still a medical student … knew that I had chosen a profession doomed to a beautiful, honorable failure.
We should listen to our patients, the spies in the House of God. And Jamie Weisman is a spy perfectly placed. As I Live and Breathe is a testament to Weisman's resolute humanity: as a trainee, she never succumbs to desensitization, the contagion endemic among veteran health professionals. May she continue to survive her physicians' prognostications, for she has yet to write a great many more books.
Shane Neilson Emergency Medicine Resident Dalhousie University Halifax, NS