Let’s begin with ‘Iron Maiden’, one of my favourite pieces in Internal Medicine, Terrence Holt’s 2014 short story collection. The narrator, a resident doctor on night duty in a psychiatric hospital, encounters a young woman, an inpatient, who has inserted seven needles into her chest wall, between the ‘cursive sweep of the ribs’. They show up on X-Ray as ‘bright impossibly straight fine lines’ radiating outward ‘as if deep within the body some source of radiation spat out infinitesimal projectiles of energy’.
It’s a powerful image, these straight metallic lines in a place where nothing should be straight; a chilling evocation of psychopathology. In his struggle to understand, the narrator, along with his intern, Joe, confronts the young woman in her hospital bed. ‘The room was dark. On the bed within we saw a shape rigid as a crusader on a tomb. It made no movement as we hung in the doorway. “Miss B?” Joe whispered. Only the head moved, rotating slowly to face us. The eyes were open, wide and sharply focused, giving the impression that she had been lying there, staring into the dark.’
Internal Medicine turns on its head the commonly-held wisdom of power and control in the doctor-patient relationship. Holt’s doctor-narrator is conflicted and questioning, often exhausted and confused. At his calmest he reflects rather than expounds. ‘I wanted to offer a picture of medicine that’s not confused by the traditional triumphalism of the profession,’ Holt says, during our recent interview in Melbourne. His writing aims for something less slick than the sanitised television offerings of medical melodramas, where ‘what entertains usually falsifies.’
Indeed, Holt’s stories are no crisp-white-coat hagiographies. The doctor-narrator expresses much negativity about his role and his inadequate capacity to heal. Death features often: only the means to the end vary. ‘Successes are pretty straightforward,’ Holt says. ‘I wrote about death because I needed to understand it.’ His patients, too, often stand in the way of equanimity and most importantly, a few hours of blissful unbroken sleep. Fear, disgust, anger, dislike: all nakedly expressed. Searing honesty then – gentle reader, beware – but from Holt’s courage and skill in laying it down comes a real understanding of the complexities of the trainee doctor’s experience.
Holt, now a geriatrician at the University of North Carolina (UNC), has reversed the course of most doctor-writers. From a medical family – his father and older brother were doctors, his mother a nurse – Holt, with the characteristic freedom of the youngest child, broke the family mold to become a writer and literary critic. He has a PhD in 19th century English poetry, and has previously published one other highly-praised short story collection, In the Valley of the Kings (2009).
After deciding to study medicine in 2000, ‘a decision not taken lightly’, he told himself he had to give up writing: one career cancelled the other. Or so he thought, until the seminal moment he describes in the introduction to Internal Medicine, a certain day in his intern year when he stood at the crowded nursing station, assaulted by the ‘roar and babble’ of the hospital staff; hungry, footsore and plagued by anxieties about unstable patients. This is not narratable, he thought (and his narrator thinks). And so, writer once more, he set out to narrate it; this cacophony of competing demands that must be constantly reappraised and reprioritised, this ‘mysterious and often troubling… process of becoming a doctor.’
‘Medicine is an art,’ Holt says, ‘in that it is learned through experience and practice.’ Through his career as a writer and literary critic he’s been exposed to good literature, an education which ‘stands in somewhat for the experience of dealing with people’. To this end he’s established an interdisciplinary curriculum at UNC, teaching subjects such as ‘The body’ and ‘Experience of illness’ to students of all disciplines, medicine included. For ten years he’s also been running an autobiography workshop for medical students, ‘Narrative is helpful in understanding.’
Our discussion encompasses much about medical training: the grueling hours of residency that paradoxically place the trainee doctor at risk of harming patients and demonstrate his/her remarkable capacity to endure; the derivation of the word ‘empathy’; the challenges that face the doctor as patient. Holt has Meniere’s disease, and walks with a cane to aid balance. For the first year of his illness he worked with significant vertigo. ‘We learn as trainee doctors that we can do anything. This is not always a helpful belief when you’re actually unwell.’
Holt calls his stories parables, largely to dispense with the notion that these are factual accounts of individual patients, yet the more biblical connotations of this word are reinforced throughout Internal Medicine. God is frequently invoked: by patients and their families, by a group of women from the local church who stalk a dying woman, by the intern Jo in ‘Iron Maiden’ who says of the doctor role: ‘We’re nowhere near as central as we think. But all the same, there is this huge invisible order: but we have access to it only through the grace of God.’ Our narrator, however, remains unconvinced, and through his eyes we see not divine intervention but daily human suffering; the relentless fallibility of the sick and dying body. God is often called upon but seldom found.
In ‘The Grand Inquisitor’, the final story in the collection, the narrator has just begun work as a physician, and an ice-storm – that evocative North American phenomenon – has forced all the on-call doctors to stay overnight in the hospital lounge. A story is told by ‘Hawley, a paediatrician, and by far the oldest in the room.’ Hawley is different from the other medicos, given to ‘a kind of clinical mysticism… No one had ever caught him in a mistake, or reading a journal.’
‘I knew a man,’ Hawley begins, ‘who had a most unhealthy relationship with hope.’ He goes on to spin a campfire tale of medical malpractice so deranged, so evil, that his reluctant audience dismisses it out of hand. With its clever narrating stance and the disturbing questions at its heart – questions about every doctor’s darkest motivations – ‘The Grand Inquisitor’ is a truly remarkable creation, and the stand-out piece of this collection.