Book Review

Surviving the Fall: The personal journey of an AIDS doctor

N Engl J Med 1998; 338:846-847March 19, 1998

Article

Surviving the Fall: The personal journey of an AIDS doctor
By Peter A. Selwyn. 176 pp. New Haven, Conn., Yale University Press, 1998. $20. ISBN: 0-300-07126-4

Physicians have made substantial contributions to the autobiographical literature, but not many have passed the test of soul-baring, Augustinian self-analysis required by confessional literature. William Carlos Williams is among the few. More recently, Rafael Campo and Jack Coulehan — like Williams, both are physician-poets — have made their marks on the literature of private thoughts. Now Peter Selwyn brings us Surviving the Fall, a wrenching account of his search for self-discovery. Selwyn's story of how he confronted his past is much more than autobiography. It is an examination of a personal crisis brought on by the stress of working with patients afflicted by both drug addiction and AIDS.

I was drawn to Selwyn's book because it contains a strand of remarkable parallels in our lives. He was born the year I graduated from medical school, we were both medical house officers at Montefiore Hospital in New York, and we both went on to Yale, where I continued my medical training and he accepted a faculty position after spending eight years as director of Montefiore's drug-abuse–treatment program. As children, both of us had lost a parent. There was also the jarring fact that in 1985 Montefiore Hospital was sponsoring a methadone-maintenance program for 950 patients in the Bronx. When I was there in the 1950s, we knew little of drug addiction. Montefiore was a place where elderly patients, mainly of eastern European origin, went for treatment of heart failure, diabetes, or cancer. It housed a living neurologic museum where almost every known eponymic hereditary neurologic disease could be found among the patients who had lived there for years, and it was one of the few research hospitals in New York with the capability for very long term metabolic studies.

In the 1950s and when Selwyn began his internship in 1981, Katz's delicatessen on nearby Jerome Avenue was redolent of hot pastrami and the counterman's arm bore a tattoo of blue numbers — a souvenir of Auschwitz. But during Selwyn's time in the Bronx, Katz's disappeared, tattoos grew more decorative, and AIDS began to bark at the gates of Montefiore. The days of stately rounds in starched whites were over. Selwyn found himself at the epicenter of the onslaught because of his position in the drug-abuse–treatment program. “Epicenter” and “onslaught” are not exaggerations, for Selwyn was stuck by a needle from a patient infected with the human immunodeficiency virus (HIV) at a time when it took weeks to get the result of an HIV test. He escaped infection, fortunately, but until the result of the test was known, he suffered mightily from grief, guilt, and worry about his young family. Selwyn was living, as he says, by Nietzche's dictum, “Whatever doesn't kill me makes me stronger.”

By 1986, Selwyn was an authority on AIDS in users of illicit intravenous drugs, but with little to offer his patients except moral support and relief from suffering. Ironically, at the same hospital 30 years earlier, I had only the same to offer my patients with heart failure or cancer — where I saw cardiac cachexia, he now saw wasting from AIDS. Selwyn points to the difficulties of treating AIDS in drug-addicted patients. For them even the promising new multidrug anti-HIV therapy has limited value, because addiction and borderline resources are formidable obstacles to compliance with such complex and costly treatment. Selwyn's thoughts on drug addiction are important. He makes no judgments but tries to understand the addict's agony and the physician's frustration: “This phenomenon is beyond blame and mortality. . . . Neither can we save them nor do we have the right to condemn them.”

At about its midpoint, Surviving the Fall becomes a confessional, and we learn the meaning of the book's title. After six demanding years in the AIDS maelstrom, Selwyn has reached a crucial point in his life. Exhausted by daily tragedies and too many funerals, he at last succumbs to the blow of his father's death 30 years earlier. For three decades his well-meaning mother and aunts hid the story of Aaron Selwyn's fall (or leap) from a skyscraper window. They even suppressed memories of the dead father, leaving only some faded photographs and a few personal possessions (a wedding ring, an old razor) for Selwyn to discover later. No wonder Selwyn conflates suicide and AIDS as variations on the theme of secret stigmas.

Helped by workshops conducted by the Elizabeth Kübler-Ross Center, Selwyn slowly discovers ways to mourn and to begin to resolve the discord of his childhood. Forty years after his father's death, Selwyn at last obtains from his mother the information he needs to find the window on the 23rd floor of 30 Broad Street in the financial district of Manhattan, the window from which Aaron Selwyn, at the age of 35, fell or jumped in 1955. The scar heals only when Selwyn visits the crematorium holding his father's ashes and orders them moved from a neglected corner to the Hall of Tranquility. With this gesture, Selwyn finally lets go.

Physicians engaged in high-stress medicine often pay a hidden price for continuing their professional work. Trauma surgeons, oncologists, and AIDS specialists, among others, call it burnout, an exhaustion of the personal resources required for technically demanding procedures and humane medical care. Surviving the Fall is not really about burnout, but the turmoil engendered by the AIDS epidemic in a literate and sensitive physician who was already psychologically wounded. Under pressure, Selwyn's suppressed childhood hurts burst forth and merge with the trauma of watching young patients die of an infectious disease. Surviving the Fall tells an ennobling story of how one physician sorted out his professional obligations and his life.

Robert S. Schwartz, M.D.