NEJM review of “Incidental Findings”

by Robert Schwartz
New England Journal of Medicine

In her first book, Singular Intimacies: Becoming a Doctor at Bellevue (Boston: Beacon Press, 2003), Danielle Ofri describes how it was to be a medical student at Bellevue Hospital in New York. Now, in Incidental Findings, Ofri tells how it is to be an attending physician on one of the general medical services of Bellevue, a large (1200-bed) city hospital with more than 25,000 admissions and 400,000 clinic visits each year.

After finishing her residency at Bellevue, Ofri takes time off to travel and supports herself as a locum tenens whenever she needs money. In a clinic on the Gulf Coast of Florida, she is not permitted to treat hypertension in a Honduran fruit picker because he doesn’t have medical insurance. She is told by the medical director of a facility in an unnamed New England town, “We are a Catholic medical center. . . . Do you have any issues with that?” Ofri, puzzled, wonders whether he asked her this because she looked Jewish. In a village in New Mexico, she wants to treat disfiguring acne with isotretinoin in a Navajo woman who has had a tubal ligation, but the medication is not available. (“Where did I get the absurd notion that I might be a healer?”)

Back in Manhattan after her Wanderjahr, Ofri picks up the thread of her career as an attending physician in internal medicine. She has “the odd sensation of making medical decisions without the requirement, or even the convention, of discussing them with someone else.” In the outpatient clinic, her first assignment, a new patient arrives every 20 minutes: a Brazilian woman with crippling rheumatoid arthritis, a Dominican woman with a sore throat, a Bangladeshi man with diabetes, a Mauritanian woman with endless complaints, an Egyptian woman with diabetes, a Puerto Rican man with hypertension, an Ecuadorian woman with aches and pains everywhere, a Chinese man who turns out to have a metastatic brain tumor, a Puerto Rican man with emphysema, a man with schizophrenia, a man with arthritis, a woman with heartburn, a woman with hypertension — all this, plus the pettifoggery of a clerk who exploits a technicality to refuse to deliver a laboratory requisition. Welcome to New York City, Dr. Ofri.

There are memorable characters. Mr. McCreary, sent from the prison on Riker’s Island with heart failure and severe diabetic neuropathy, is now well enough to return there. Huddled under the sheets with his neuropathic pain, he says, “You can’t send me out feeling like this.” An intern comments later to Ofri, “Those hyper-pain guys drive you crazy; nothing ever makes them feel better.” There is also Mr. Karlin — articulate, urbane, 75 years old, and outraged by every indignity a big city hospital can offer. He is admitted after a fainting spell, but his main problem is severe leg pain. None of the resident physicians believe his story that an international expert on nerves has been treating him with monthly protein injections until the neurology consultant diagnoses an autoimmune neuropathy and points out that the “protein” is intravenous gamma globulin. Vindicated, Karlin tells Ofri that the neurologist was “the first guy around here that I’ve seen wearing a tie — a bow tie, no less,” and “I used to give lectures on professionalism, and I think your motley crew could use a lesson or two.” Then there is 29-year-old Cheryl Holloway, in the cardiac care unit with chest pain, a drug seeker who complains about a nurse whose name might well be Ratched — “That bitch won’t give me my medicine” — and causes Ofri to fantasize escape into the music of a remembered concert at Carnegie Hall.

The 14 stories in Incidental Findings make clear Ofri’s commitment — her moral duty — to her patients. The strands woven into them are humility, compassion, and respect for patients. Ofri reminds us that medicine is really about the bond between a patient and a physician. She writes in the final pages of her powerful book,

Many industries have been automated, and medicine is no exception. I can’t deny the increased efficiency provided by computerized lab results, telemetry monitoring, and wireless e-mail. But no matter how much our field is pushed to streamline and to maximize efficiency, there is an asymptotic limit. In the end, medicine will always be about one patient and one physician together in one room, connecting through the most basic of communication systems: touch. In an age of breathless innovation, this is almost antediluvian. But medicine simply cannot be automated beyond this point.

Incidental Findings is a beautiful book. Ofri has enough faith in her patients, her profession, and herself to tell it all.