Danielle Ofri

The Women's Review of Books, June 2003

"Spanish, Tagalog, Bengali and English elbowed for air space as did the smells of coffee, curry and homelessness. The doorways were littered with gum wrappers and cigarette butts. Windblown scraps of the New York Post and -New York Times tangled in trampling feet that pressed forward every morning." (p. 6)

If you think this describes the sensory assault experienced when descending the subway stairs, you would be metaphorically correct. But the doorways here are the entries to New York City's Bellevue Hospital, the setting for Danielle Ofri's memoir of her seven years of clinical medical education.

Ofri's account is a reminder that preparation for the healing arts is no different from acquiring a trade. The novice moves from trainee to helper, from apprentice to skilled worker. In Ofri's words, medical knowledge "came in erratic bits like splattering raindrops." Her Candide-like adventures as she advances from third-year medical student to resident are harrowing, poetic, and, well, somewhat alarming from a patient's perspective, especially the intern's apparent credo: "when in doubt, pretend." Yet the more clinically competent she becomes, the less certain she is that illness can be approached with technique and book knowledge alone. Her clinical education teaches her humility.

Singular Intimacies receives its title from that unique moment when strangers-patient and physician-"collided and combined" their personal histories into one intense, emotionally bonding moment. Many of the singular intimacies in this collection of 15 essays occur when Ofri's assigned patients are on the precipice of death; she yanks them back or loses them. In the process, she always learns something about herself, medicine, and humanity.

There's a great deal here of the "poor little me" syndrome-the lowly med student, the overworked intern, the resident denied autonomy by preening attending physicians. Earning an MD and a PhD in biochemistry simultaneously, Ofri could have been arrogant rather than eager. Thankfully, she makes nothing of being a woman and a doctor, surely no longer unusual anyway. But would a male doctor weep in, front of his colleagues when a patient dies? Probably not.

Each of Ofri's stories could have blossomed from the imagination of a talented fiction writer, and many of the stories in this collection have been published elsewhere. What she chooses to recall about her patients and their families, her colleagues, and the often amusing details of her training coax a reader to reflect on life's precariousness. Ofri's writing is about the revelation of the "person with- in the patient."

When she begins her first clinical stint, as a third-year medical student, Ofri trusts her own admirable openness with the patients whose care she is following. She takes a liking to an elderly man whose life-saving emergency surgery she observed "uneasily at the edge of the crowd, squinting in the glare of clinical medicine." She visits him frequently while he recovers in his hospital bed. They chat enthusiastically. Then, during one visit, the man pulls at her comforting hand, draws her down, and plants a prolonged kiss on her lips. Ofri is shocked and repulsed-her first lesson about intimacy sought, obtained, and abused when one walks among the vulnerable. Did this patient mistake her friendliness for something other than it was, as Ofri believes? Or was he asserting his own life force in the aftermath of his near-death emergency?

As a new first year intern, Ofri attends a terminally ill, 90-year-old Hispanic woman who is surrounded by her loving extended family, including her adult grandson, a nurse whom Ofri allows to stay with his grandmother while Ofri performs a digital rectal exam. In the middle of Ofri's examination, the grandson observes that his grandmother is dead. In a serio-comic description of her desire to respect the family but fullfill her legal and medical responsibilities to determine if the patient is actually dead, Ofri engages in an inner, metaphysical monologue:

"I'd never had a lecture in medical school on how to tell if someone is dead. I guess it was assumed to, be pretty obvious-dead is dead', and if you're not dead then you're alive, right?... Pulse, that's it. Dead people for sure don't have a pulse... Of course, the only way you know you've found the pulse is when you find the pulse. How do you know when you haven't found one? How do you document the absence of something when its presence is defined by hunting until you've found it?" (p. 84)

Her efforts to stick EKG attachments to the dead woman's chest are foiled by her inexperience and performance nerves as the woman's family "looked at me, their eyes gathered in a single longing stare, waiting for an answer." Each EKG attachment pops off as another is planted. Ofri realizes that it is useless, even cruel, to throw so much technology at what is so obvious to everyone.

Ofri has similar philosophical problems when she attempts to draw blood from a patient's vein:

"When T was sure that I'd captured regular pulsations beneath my finger, I jabbed the needle in. Nothing. Maybe those pulsations were just the pulse of my own fingers. My boundaries were beginning to tremble. Was this my pulse or his pulse?" (p. 105)

The art of drawing blood is clearly a kind of clinical gold standard and unfortunately, acquisition of this skill requires practicing on hapless human beings. A chronic injection drug abuser with veins impossible to tap is hospital-savvy enough to demand, loudly, the "IV Team" whenever the inexperienced Ofri comes near him. Apparently, mastering this procedure provides its own rush: "No matter how dire or depressing a patient's situation is, it can never take away that momentary delicious feeling of blood flashing into the syringe."

In an early clinical experience as a medical student, Ofri incurs a needle stick as her hand rests on the surgical table during a midnight hysterectomy. This is the early 1990s, when AIDS still means a certain, early death. She becomes obsessed with the HIV status of the patient. She reads the patient's record: She was a nurse at a Bronx public hospital. Ofri is nearly paralyzed with the possibility of compounded exposure. This patient must have had her own share of needle sticks. "Her history could now become my history. Her blood my blood. Her story mine."

Ofri visits the recovering woman the next morning. The patient, Mrs. Burton is delighted to have a staff visitor, and talks enthusiastically about her grandchild, her diabetes, the outcome of surgery. Finally, the good-natured woman notices Ofri's quivering lips and asks, "You okay, honey? You took a little peaked... Sit. Come sit down. What's up, honey? You look like something's got you." Ofri, hesitantly describes the needlestick and "those diseases... like AIDS and stuff." Mrs. Burton gets it right off. "It's okay. I know what you're saying.. You don't have to worry about me, honey... I was a nurse's aide. I didn't handle no needles or nothing...." She embraces the sobbing, relieved Ofri, patting her back and smoothing her hair.

When an apparently robust, very young, single mother of two small children finally acknowledges the meaning of her HIV-positive blood tests-without ever saying the word-Ofri, the young woman and her aunt all stand together in the outpatient clinic, weeping. In a stunning expression of how one arrives at compassion, Ofri writes "And then there was the strange harmony of three people crying, each caught in a private dissonance." Two of the women cry for their family. For Ofri, it is not only the inevitable death of this young woman, but also the impotence of medicine-her skills-to save her patient.

The limits of perception and the perils of hubris are apparent in the award-winning chapter "Merced;' the last of the stories in this collection. Again, it is about a young, vibrant woman, with mysterious but not too alarming symptoms. Ofri is pleased with herself to have been the only resident to consider Lyme disease; indeed, the patient's blood test returns positive for the disease. Never mind that Lyme is very rare in the inner city. The woman goes home with medication. Within two days she returns to Bellevue, seriously ill. She dies. Her blood test was a false positive. Time had been wasted pursuing the wrong diagnosis. Ofri is devastated, less for the lost luster of her diagnostic brilliance, more for the "death of my belief that intellect conquers all,... I might as well have applied amulets and recited incantations." Her open expression of grief at the death of a recently vital young adult was "perhaps my most authentic experience as a doctor. Something was sad. And I cried." Her response is that of the person within the professional, a human being touched by the fate of another.

Bellevue, the oldest public hospital in the country, is iconic for its former psychiatric hospital, once a true urban bedlam, now owned by NYU Medical Center. There is nothing here specific to medically indigent patients, other than the fact, as Ofri notes, that they assume that anyone in a white coat is a doctor. Ofri could have experienced "singular intimacies" in just about any urban, acute care hospital in the country. Now an attending physician at Bellevue, with an academic appointment at NYU, Ofri co-founded the Bellevue Literary Review, a national literary journal focused on the human condition.

Singular Intimacies is not a polemical book, a bashing of modern medicine or other doctors. There are critiques of medical education and clinical medicine, but nothing really new: Doctors don't know when to back off when a patient is terminally ill; doctors are so concerned with the privileges attached to rank that they can be a barrier to life-saving patient decisions. Readers contemplating a career in medicine will learn about the soul of a healer. But I suspect that this book is intended as a literary undertaking, not an insider's guide to medical training.

The author's growth is chronicled in the lives of those she tries to heal. Every patient deserves a doctor of Ofri's sensibility, one who recognizes the profound vulnerability of relying on strangers.

Sharon Lieberman