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Book Reviews
I am not sure why, but there just aren't many great novels about what it means to be a doctor. One such gem is The Citadel, by AJ Cronin. This book was published almost 70 years ago at a time when medical practice involved hardly any laboratory tests, x-ray films, or specialists. The vivid characters, dramatic plot, and moral lessons presented in Cronin's novel make it as timely and readable today as it must have been in the 1930s. The Citadel is particularly pertinent to us in Kaiser Permanente because Cronin's protagonist begins his career in a health care system similar to our own but which existed in Wales at the beginning of the 20th century. The challenges Dr Andrew Manson faces and the ethical issues Cronin presents are essentially the same ones each of us in medicine faces today. As this semiautobiographical novel begins, a young physician arrives in a small, Welsh mining town to take his first job. Fresh out of medical school and up to his neck in debt, Manson is hired by a coal company to be one of the four doctors employed by a prepaid plan that provides care for miners and their families. As the only recently trained practitioner in town, Manson meets stiff resistance from patients as well as from other doctors who are used to their old ways of doing things. Despite his youth and inexperience, Manson questions medical dogma. He tries to apply current scientific knowledge to the problems his patients bring to the clinic. His diligence, intelligence, and decency soon pay off. Patients begin to respect him and choose him over his outmoded colleagues. Young Manson has many admirable qualities. He judges people (patients as well as medical colleagues) by their actions--not by their wealth or power. He constantly strives to improve his clinical skills, and he bristles at the incompetence and unethical behavior of colleagues. However, he is not a saint. He isn't always tactful, and he has trouble choosing which battles are worth fighting. Luckily for Manson, a young, female schoolteacher in town finds his brashness endearing. When Manson abruptly quits his job over what he feels is his unfair compensation agreement, Christine accepts his precipitous proposal of marriage and accompanies him on his next professional challenge in a larger mining town. In their new situation, Manson and his wife establish a trusting relationship, which provides a strong foundation for the doctor's increasingly demanding practice. Cronin describes many great clinical cases in which Manson's curiosity and hard work lead to good patient outcomes. One of the most exciting vignettes is an emergency amputation Manson performs by candlelight, lying on his stomach in a narrow, dank mineshaft to save the life of a miner trapped by a partial roof collapse. Manson observes a connection between coal dust exposure and lung disease in certain of his patients. He embarks on a research project to prove that such occupational exposure can cause disease--a fact that was unrecognized at the time. Christine assists Manson in his research and helps him study for a postdoctoral examination. Her unstinting support enables Manson to travel to London, successfully defend his research paper, and qualify for the advanced degree--an amazing set of accomplishments for a graduate of an undistinguished medical school, practicing in a small town. In The Citadel, Cronin preaches many lessons: hard work, conscientious patient care, and intellectual curiosity are the keys to success in medicine; knowledge and integrity count for much more in life than money; doctors need continuing education to remain current and to serve their patients well. In each of Manson's professional endeavors, he befriends a colorful colleague whose lack of material success belies a keen intellect and great personal integrity. These "diamonds in the rough" reemerge later in Manson's life to help him through professional and personal difficulties. Again in
his second position, Manson clashes with the powers that be. He resigns
his provincial post and takes Christine off to London, where he hopes
to become a specialist in lung disease and become an attending physician
at a respected London hospital. He first takes a position with the occupational
health ministry but quickly becomes disillusioned by the bureaucracy.
He leaves to establish a small private practice. Although Christine and
Manson struggle financially, they support each other, build a successful
practice, and learn to enjoy the cultural offerings of the big city. Manson's
patients are working-class people, his income is modest, and his success
is based on integrity and clinical acumen. Later, however, he meets affluent
doctors with offices in prime locations for catering to the carriage trade.
When Manson is offered, through their schemes,
Throughout The Citadel, Cronin explores issues that are still unresolved in today's health care environment. He shows the ways in which reimbursement patterns can affect physician behavior. He demonstrates the insidious effect drug and equipment companies can have on a physician's judgment. He argues for establishment of integrated, multispecialty group practices and suggests the power of clinical research to improve public health. He vividly portrays the difficulty sometimes experienced by busy physicians in balancing professional responsibilities with their personal lives. None of these is a new problem. All these themes make The Citadel as relevant today as it was in the 1930s, and The Citadel is still a "great read." Much has changed in the practice of medicine since this wonderful novel was originally published; however, what will never change are Cronin's most basic points: that medicine is not merely a business whose goal is to enrich its practitioners materially; and that the essence of being a doctor is the use of one's senses, knowledge, and experience to reduce suffering and improve people's lives.
Seth Kivnick, MD, is a surgeon at the SCPMG West Los Angeles Medical Center. E-mail: seth.kivnick@kp.org.
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