As Audrey Young describes her process of becoming a compassionate internist in a besieged public hospital, she simultaneously argues for turning the hospital's patient care and financial practices into a model for improving health care in America.  Young, a compelling storyteller, first entered Seattle's Harborview Medical Center in 1996 as a third-year medical student on trauma surgery service.  She completed a residency there in general internal medicine and stayed on as an attending for six more years.  She stayed, she tells us, because she met physicians "committed to a vision of equality" who were "the sort of people I hoped to become" (xiii).   She also "fell in love" with "the story of a unique place" (xiii).  Young's stories of that often chaotic place, where ambulances regularly transport homeless, indigent, addicted, and mentally ill refugees from neighboring private hospitals, emphasizes the ways the Harborview staff manages to treat patients with dignity and to choose an ethic of hope in the face of dire circumstances.           

We quickly learn that at Harborview compassion is expressed concretely as actions toward patients.  Michael Copass, known as "the mostly benign dictator of emergency operations," pronounced the core of these actions in what came to be known as his commandments:  "1. Work hard.  2. Be polite.  3. Treat the patient graciously, even if he is not the president of the United States" (9).  Politeness always meant asking "'How may I help you, sir?'" regardless of the patient's social status or addiction history.  Politeness sometimes meant finding a way to reach the patient who regularly threatened the staff.  Young finds ways and creates a therapeutic bond.  But working hard and treating patients considerately also took measurable forms, such as not allowing emergency patients to wait.  Facing a flurry of admissions, the Emergency Department (ED) staff interpreted a young Ethiopian's complaints about pain as a drug addict's ploy.  Because Young glanced at the admissions board and noticed that he remained unattended for three hours--far longer than Copass could tolerate--she jumped into action.  He suffered, she discovered, from a collapsed lung. 

However, Young moves her narrative beyond individual doctor and patient encounters and into the larger, interrelated social and financial structures in which medicine is practiced.  For instance, she links meager funding for drug and alcohol rehabilitation programs with expensive ED admissions and rising healthcare costs.  In the chapter "Bunks for Drunks," Young visits an experimental residence that houses homeless addicts in furnished studios with private baths and cooking appliances.  Although residents can keep alcohol in their rooms and elect not to participate in the home's social services, including counseling, alcohol consumption and ED admissions decrease.  While the chapter points out the cost savings of such arrangements, Young further urges readers to value the dignity residents experience there.

In "Black Friday," Young details the hospital's tense, but ingenious responses to a Mass Casualty Incident, the result of carbon monoxide poisoning, which almost depleted the resources of all of Seattle's medical centers.  The final chapter, "A Vision," outlines how Harborview has tried to succeed as both a charitable institution and a business, as a provider of both indigent and luxury care, with the hope that others will follow the medical center's example.  However, in presenting her recommendations for "health justice," Audrey Young also makes the case that "seemingly ordinary citizens" are implicated in healthcare reform (231).  To enable their informed participation in making changes, Young includes an appendix with further readings and another that lists strategies for effecting reform.  


Anyone interested in the workings of an urban Emergency Department, in narratives by physicians (especially young ones), in becoming a doctor or teaching residents, in the economics of healthcare, or in creating just medical practices and systems can appreciate Audrey Young's memoir.  While Young is unambiguous about the need for reform, she invites readers into her arguments, story by story, rather than imposing her views.  While she remains optimistic about the possibility of reform, she doesn't spare us her disappointments or misjudgments as she treats individual patients nor ignore the complications that accompany her recommendations.      

In the growing collection of narratives by novice physicians, Young's book resides between two notable collections of narrative essays: Danielle Ofri's Singular Intimacies: On Becoming a Doctor at Bellevue and Atul Gawande's Complications: A Surgeon's Notes on an Imperfect Science, (see annotations).  Young serves a patient population that resembles Ofri's.  However, Young's writing focuses less on reflections of her inner life as she works with patients and more on the larger structures that bring Young and her patients together and on the ways she resists those structures to compassionately serve her patients.  Like Gawande, Young interrogates moments in the clinic to understand how to provide the best possible care.  But Young emphasizes circumstances beyond the clinic--the lack of health insurance for all, the social disregard for the poor--in her recommendations for effective and ethical care.  More than most physician-writers, Audrey Young is concerned not only with how to make a diagnosis or respond to patients, but also with what happens to her patients after they're discharged from the hospital.


I wish to thank my Haverford College students in the seminar "Becoming: Life Writing about Science and Medicine" for their discussions and writing about Young's book that enriched my reading of it.



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