Book Reviews

This recently published book gives a semifictional account of the author's internal medicine internship and residency at Harbor-UCLA Medical Center, a county hospital in Los Angeles. The author takes us from the first through the last days of residency but focuses primarily on two events: the first 36 hours of internship and the experience of caring for the author's former residency colleague through the latter's terminal hospitalization. This difficult experience occurred during the author's second year of residency and is presented as the signal event of his training.

The first 36 hours of the author's internship--spent on-call--is described in detail as a descent from being a confident, top medical student to the nadir of medical training: the uncomfortable experience of being a beginning intern who realizes that he knows very little about the real world of caring for sick patients. The types of patients described are familiar; they typify the spectrum of patients seen at a county hospital. The fear, frustration, and sense of being overwhelmed are also familiar to anyone who has been a medical intern at a county facility. Indeed, these feelings brought back quite a few memories to me.

What the author fails to capture, however, is the rascal humor that develops--especially at 2 am--when a night on the ward seems like a scene from Dante's Inferno and the sublime becomes ridiculous. I recall that some of the funniest moments of my life arose from my desperate terror that I might either inadvertently kill a patient through ineptitude or that every illness was so perplexing that no amount of reading Harrison's Principles of Internal Medicine¹ could help delineate the problem. Our only salvation was the laughter shared in the early morning hours with fellow interns and other medical staff. Surviving a three-year ordeal without humor would have been nearly impossible.

In the author's second year of residency, he was faced with the challenge of having to take care of a beloved former resident dying of complications from AIDS. The long, protracted course of the illness is detailed here in a way that brings out the deep and difficult feelings of all physicians in training when they care for a patient who is more than just another admission, one of hundreds seen by residents throughout their training. Medical practice is accurately described, as is the travail experienced by the unfortunate patient, to whom the author feels emotionally attached--a circumstance which adds even more difficulty to the task of providing care.

Because the events of the book are limited primarily to these two major events, little else in the book is available to give the reader a sense of the rhythm and flow of the three-year training process or the experience of working in subspecialty units. Moreover, the main characters in the book are weakly drawn, and we know little of their backgrounds; thus, they seem stiff and difficult to visualize as people to whom we can relate or whom we have known in our own training. The story includes too few of the many anecdotes that we all can remember either as moments of epiphany for us in our developing careers or that made us change our career direction to other fields of medicine. Little is noted about the sexual tension felt by many interns and residents as they interact with other medical and ancillary personnel.

The book offers little description of a major hardship experienced by all county physicians: the chronic shortage of both money and supplies needed for taking care of the sickest patients. Nor does the book mention the medical politics that have engulfed hospitals, especially in the past decade.

In summary, although written earnestly, the book does not adequately depict the experiences it presumes to cover, and it leaves the reader wondering about the training and travails of medical interns and residents working in county hospitals. Reading this book cannot fail to prompt reflection on the vast superiority of another book, the reference standard for this genre: The House of God: A Novel by Samuel Shem, MD, PhD.² County pales in comparison with this superb, fabled story (first published in 1978), and the reader's time would be better spent rereading House of God--even for the umpteenth time.

References

1. Fauci AS, Braunwald E, Isselbacher KJ, et al, editors. Harrison's principles of internal medicine. 14th ed. New York: McGraw-Hill, Health Professions Division; 1998.
2. Shem S. The house of God: a novel. New York: R. Marek Publishers; 1978.

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