A medical student -- the joke goes -- is alone in the emergency room when a mother runs in with her son, who has a coin stuck in his throat and is turning blue. The student quickly slaps the child onto a stretcher. It slips and careens down a ramp. The boy's head slams into a wall -- and the coin pops out. The mother clasps the child to her breast. The student is terrified, but he says coolly to her, "Sometimes we have to do that two or three times."
Some are amused by that anecdote; others grimace. For his part, David Black, author of "Medicine Man: A Young Doctor on the Brink of the 21st Century," was disturbed. When he heard a group of medical students laughing over it, he felt betrayed, "the way I do when I accidentally overhear someone making an anti-Semitic remark."
In his graphic, rather bleak account of medical education, Black follows a third-year medical student, Aaron Kenigsberg, through the wards. He claims to be writing about what medicine has become, and what it is becoming. But despite his creditable, even sympathetic, portrayal of young doctors in training, his telltale response to the stretcher joke raises some disturbing questions.
Black so effectively describes the medical students' early attempts to cope with the demands of their new environment that even the knowing insider is left wincing: "Aaron [who is attempting to put an intravenous line into a vein in a woman's neck] tried one angle after another. No matter how he stuck the needle in, no blood came out. He was like a wildcatter in the last week before the bank seized his equipment, drilling one dry well after another, each more frantically than the one before."
By the time, many attempts later, the students left the room, drenched in blood, it should be perfectly clear to anyone that something terribly wrong had happened. Black leaves Kenigsberg pondering, "How else do you learn? Everyone has to have a first time," when he should have been asking where the responsible individual was who should have protected him -- and the unfortunate patient -- from his own egotism. Black reports the details faithfully, but they're not put into a framework in which a reader can tell what is -- and isn't -- acceptable within the training system.
Black explores at length the students' physical gestures -- the subtle nuances of expression, or body language -- that they unconsciously muster in coping with their frightening new environment. He has an excellent eye for these details, but he seldom penetrates the students' feelings sufficiently to make them seem human. Kenigsberg, whom Black knows most intimately, comes off a stiff, posturing boor. Who needs people like that in medical school? Did Black choose poorly, or did his own alienation in a hospital setting prevent his achieving an imaginative intimacy with his subjects?
The text offers clues: In fact, the book may be most interesting as a self-portrait, the initiation of a layman into a fascinating, frightening world, in which what is abnormal and sometimes repugnant is bared to the glaring clinical lights.
A person who knows no medicine is likely to grasp unconsciously at the strength of the individual who is showing him the way. Black, following a student who is as new and green to the wards as he himself, is doubly penalized. His own insecurity is compounded by Kenigsberg's, and the unfortunate consequence is that the much more positive, human side of the training experience simply doesn't come through.
Black's imagination is really fired by the individuals who tell him what medical schools don't teach. To define what medicine is, he juxtaposes Kenigsberg's mainstream training with what mainstream medicine is not: He interviews and discusses the work of philosophers, psychologists and physicians whose approach to medicine is holistic.
He describes unorthodox studies that associate stress with a Pandora's box of diseases, and describes cancer-prone, rheumatoid arthritis-prone and ulcer-prone personalities, among others, as well as the better known Type A personality. (The fun here is to find yourself and then, of course, to worry.) He writes about the relationship of stressful events and illness, and he quotes, among others, a special favorite of mine, Norman Cousins. Cousins, whose ankylosing spondylitis improved dramatically after a self-imposed laughing cure, commented, "I made a very interesting discovery. Ten minutes of solid belly laughter would give me two hours of painfree sleep." Black guesses that the release of endorphins, the natural morphine-like compounds made by the body in relaxed, happy states (as scientists later described them), is what actually relieved Cousins' pain. I'll bet he's right. And I couldn't help but wish that his own book had contained a bit more of that comic relief -- it would have left me feeling better after reading it.