Surgery...after all, is an affair of the spirit; it is a fierce test of a man's technical skill, sometimes, but, in a grim or long fight, it is above all
    a trial of the spirit; and there are few things that can not be conquered if a man's heart is set on victory.
        -Sir Berkeley Moynihan

Imagine my surprise, having just written about the unusual pleasures of Atul Gawande's much-heralded Complications, to have another excellent set of essays by a surgeon come over the transom.   We don't after all think of hospitals generally, let alone surgical theaters, as literary hotbeds.  But Across the Red Line, by Dr. Richard C. Karl, is every bit as lyrical and well written as Complications and in some ways, both because he is more experienced as a doctor and because of his unusual experiences as a patient, is more compelling.

The similarities and differences between the two books are both instructive.  Mr. Gawande is just finishing his surgery residency in Boston, but is already regularly published in Slate and The New Yorker.  Richard Karl is the Chairman of the Department of Surgery at the University of South Florida College of Medicine and has a couple of decades as a surgeon under his belt.  His writing career (non-technical writing that is) began almost accidentally, when Eugene C. Patterson, editor emeritus of the St. Petersburg Times, prevailed upon him to write down some of the stories he enjoyed telling about what went on "across the red line", the line that separates patient and surgical team from the rest of the hospital and family and friends.  At least one of the essays here has previously appeared in that paper  and hopefully this book will earn him the wider audience he richly deserves.

As in Mr. Gawande's book, one of the best pieces in this collection concerns the ritual of the Morbidity and Mortality Conference, where a doctor presents the details of a problematic case and his colleagues proceed to grill him on what he might have done differently, kind of a medical version of Prime Minister's Question Time.  Both men are justifiably proud of this tradition, with its emphasis on physicians holding each other accountable and correcting deficiencies in timely fashion.

Because Dr. Karl is a teacher, he presents the process of training new surgeons from the opposite perspective that Mr. Gawande gave us.  Here we see the mentor trying to encourage his charges while at the same time keeping them focussed and humble.  In one essay he deals with the high drama of Match Day, when students across the country find out what training program they have matched with and where they are headed for their residency.   It's interesting to see how this emotionally draining event  impacts someone whose been through it himself and now has a roting interest where his own students and the incoming residents are concerned.

The most revealing pieces in the book though come when Dr. Karl describes his own encounters with the medical system from the patient's side of the table.  In his first year as an assistant professor at the University of Chicago, the doctor received a needle prick and developed hepatitis.  This gave him an appreciation for the fear that a patient feels (particularly when a somewhat brusque older doctor casually told him, "The last surgeon I treated for hepatitis, died.") and for how precious his own life is and how important it is to keep such things in perspective.  Years later, after wrestling an unruly patient to the floor, he developed a pain between his shoulders, which eventually turned out to be a broken neck.  But in the meantime he endured misdiagnosis, inappropriate humor, the terrifying trauma of an MRI, the strange sensation of having his name in the patient's spot instead of the doctor's on his hospital wristband, what seems to have been a fairly sketchy surgery, and some very unsatisfactory results.  Most of all, there was one moment where a lack of eye contact, the inability to consult with one of his original doctors, came to symbolize for him the reason why patients sue.

Dr. Karl is extraordinarily open and honest with the reader throughout these essays, from a moving tribute to his father that captures the strange ambivalence of many sons toward their dads, to a story about guiding a family away from prolonging a patient's life where he wonders if he may have overstepped ethical boundaries.  On this last, I personally think the answer may be, yes he did, but it also seems, from the seriousness with which he approached the situation and the straightforwardness with which he relates the details, that he deserves the benefit of the doubt.   Let's put it this way, after reading this fine book, even if I'd disagree with Dr. Karl on a few specific issues, I'd be honored and pleased to be under his care and I look forward to reading more of his essays in the future.

(Reviewed:05-May-02)

Grade: (A-) Orrin C. Judd

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