Book Review

On the Ledge: A doctor's stories from the inner city

N Engl J Med 1996; 335:1077-1078October 3, 1996

Article

On the Ledge: A doctor's stories from the inner city
By Neil S. Skolnik. 157 pp. Winchester, Mass., Faber & Faber, 1996. $19.95. ISBN: 0-571-19883-X

This book chronicles the experiences of a young family doctor practicing in an inner-city clinic in Philadelphia, where, apparently, he is surprised to find complex and seemingly intractable social problems among a patient population mired in severe urban poverty. The chapters are, in essence, experiential essays describing the realities of providing health care in such a setting.

For physicians who have trained or practiced in economically depressed communities, this book offers little in the way of new insight into the lives of poor, generally disenfranchised people grappling with every manner of adversity. On the other hand, the reader learns a great deal about Dr. Skolnik, who tends to react to the realities of his practice with his own somewhat awkwardly expressed feelings of helplessness, frustration, and anger.

By page 3, the author describes himself as “powerless” and muses that, at the end of his two-year odyssey, he has “given fewer immunizations than I should have.” (The reader wonders why this was so; the book offers little explanation.) Although he does refer a patient to a domestic-violence program and another to drug rehab, most of the stories end without much satisfaction or resolution. Only passing reference is made to the many other experiences that, one assumes, were more rewarding for patient or physician.

This was not an easy read, perhaps because too many of Dr. Skolnik's own misgivings and frustrations were shared in a string of rather clichéd and self-absorbed musings. Although this is a short book, I counted no less than 21 references to his “looking” or “staring” out the window while pondering his own fate, the condition of the surrounding neighborhood, or the hopeless lives of his patients.

In one telling — and particularly distressing — chapter, Dr. Skolnik describes how he listened passively during a staff meeting as the announcement was made that his clinic would be closed. The reader waits for the reaction of protest, the doctor leaping up to defend his work, articulating the desperate need of medical services in that neighborhood, at least expressing a desire to help seek community support and funding to keep the program going. Nothing happens. Skolnik listens in silence, looking out the window.

The fact is that now, more than ever, physicians need to be activists, to engage the world around them on behalf of their profession and their patients. Government cutbacks, a diminishing commitment to maintaining a basic social safety net, rapidly expanding market forces in health care, and a greater need to solve local problems locally should represent a call to action for doctors.

In reality, there is much that could be done. Working with colleagues in local and national organizations and developing liaisons with community groups and social-service agencies are legitimate avenues for physicians who want to make a difference with respect to access and the quality of care for underserved populations.

Not only can an expanded vision of the scope of practice in depressed communities help the residents of those areas, but it can also ameliorate the feelings of isolation and helplessness that doomed Skolnik's attempt to make a go of inner-city practice. Even getting a partner or working more with a local residency-training program could have been reasonable antidotes to the author's unbounded frustrations.

Young physicians who want to work with the underserved should not be deterred by this gloomy book. On the contrary, doctors whose careers encompass medical care and social activism often find great personal rewards and an extraordinary sense of fulfillment. This is not to say that taking on the challenges of health care on the frontlines is easy. It isn't. But neither is trauma care or ophthalmology. The point is that working to provide excellent medical care to folks for whom access to decent, compassionate services has been a chronically difficult ordeal is exactly what many of us had in mind when we chose medical school in the first place.

Irwin Redlener, M.D.
Montefiore Medical Center–Albert Einstein College of Medicine, Bronx, NY 10467