Book Review

The Year of Magical Thinking

N Engl J Med 2005; 353:2727December 22, 2005

Article

The Year of Magical Thinking
By Joan Didion. 227 pp. New York, Alfred A. Knopf, 2005. $23.95. ISBN: 1-4000-4314-X

In this devastating anatomy lesson on loss, which received a 2005 National Book Award, respected essayist Joan Didion skillfully dissects her struggle with the denial, pain, and rage that followed the sudden death of her husband of nearly 40 years, writer John Gregory Dunne, and the protracted illness of their daughter, Quintana Roo. The events are cruel. Five days after Quintana was admitted on Christmas night to an intensive care unit (ICU) in a New York City hospital because of pneumonia that rapidly progressed to sepsis, Didion sat down to dinner with Dunne and saw him suffer a massive myocardial infarction from which he never recovered. Several months later, Quintana, finally on the mend, collapsed with a subdural hematoma requiring emergency neurosurgery and extensive rehabilitation.

Didion is adept at describing these complex and unexpected medical scenarios; indeed, she has told interviewers that the book grew out of the medical notes she kept. Moreover, Didion, much as physicians do, felt impelled to “read, learn, work it up, go to the literature,” and she quickly acquired enough knowledge to offer clinical opinions to the physicians caring for Quintana. This investment in the medical decision making arises from the understandable desire to master a terrible situation, but it also represents an effort to mask the sense of vulnerability and alienation Didion experienced.

“At some point I noticed that I was trying like a sheepdog to herd the doctors, pointing out edema to one intern, reminding another to obtain a urine culture to check out the blood in the Foley catheter line,” Didion writes, noting, “These efforts did not endear me to the young men and women who made up the house staff . . . but they made me feel less helpless.” She reflects further on this blurring of caregiver roles after she buys hospital scrubs: “So profound was the isolation in which I was then operating that it did not immediately occur to me that for the mother of a patient to show up at the hospital wearing blue cotton scrubs could only be viewed as a suspicious violation of boundaries.”

Didion's close observations also document some of the careless comments made by members of the hospital staff and will remind physicians that what is said to families during times of stress is not only heard but also remembered. When taken to see her husband's body, she hears the social worker tell the physician in charge, “It's okay. . . . She's a pretty cool customer.” Later, she writes, “I wondered what an uncool customer would be allowed to do. Break down? Require sedation? Scream?” In the neurosurgical ICU where Quintana is slowly recovering, Didion is told, “She's already off the EEG, maybe you didn't notice that.” Didion's response: “Maybe I didn't notice that? My only child? My unconscious child? Maybe I didn't notice when I walked into the ICU that morning that her brain waves were gone?”

The net effect of these moments is not vilification of the medical profession. Rather, these accounts acknowledge the range of feeling that exists in these complicated circumstances — Didion can deeply appreciate the family doctor's efforts on Quintana's behalf, while being angry with another physician who insisted on a tracheostomy. By juxtaposing important clinical developments with their emotional effect, Didion deftly has created the narrative that a medical chart cannot provide — what the events mean for a wife and mother who never imagined that she would be watching paramedics shock her husband in a vain attempt to resuscitate him, or keeping a vigil for her child in an ICU.

In this way, in contrast to the primers on grief and mourning Didion read that proscribe, idealize, or abstract the process of bereavement, her raw prose conveys “the unending absence that follows, the void, the very opposite of meaning, the relentless succession of moments during which we will confront the experience of meaninglessness itself.” She writes: “I didn't get `the news,' I didn't `view the body.' I was there.” This book is a masterly attempt to bear witness to the experience (sadly, Quintana died several months before it was published) and reminds us, as physicians, that what we do can make it easier or harder for those who lose loved ones.

Katerina A. Christopoulos, M.D., M.P.H.
Massachusetts General Hospital, Boston, MA 02114
kchristopoulos@partners.org