Pediatrician Ronald Spiegel was at a crossroads when he picked up a copy of 'The Citadel.'
I have enjoyed reading the Physicians Practice Writer Search essays for some time now. When I read this month's topic - "What book has influenced your work as a physician?" - a bell went off in my head immediately. "The Citadel" by A.J. Cronin, first published in 1937, sprang from my lips. Just remembering the book made me smile.
I first read it when I was in high school, circa 1985. I have since read it two or three more times. My first reading was special however. I was at a crossroads: I was beginning to seriously consider what I wanted to do with my life. The idea of being a doctor was always one that intrigued me. If I was fortunate to get through the rigors of the study and training that would be necessary, I liked the idea of caring for people and getting to know them. But, being a teenager at the time, I was not certain that should be my path.
I stumbled upon the book as I browsed through a book store in my neighborhood at the time, back when this was something people actually did routinely. I liked the idea of the premise of the book after reading the summary and thumbing through it, so I decided to purchase it. I must have read it in just two or three days. Simply put, I loved it. It was well-written and captivating from the first pages. A real world depiction of flawed characters and less then perfect institutions surrounding a newbie doctor as he settles into and then weaves his way through the everyday realities of doctoring.
I distinctly recall reading the last pages and then quietly smoothing out the last page before closing it gently on my lap. I sat silently for a while staring at the book's cover. I recall a feeling deep in my chest, that though fleeting, was profound. I had an epiphany - the kind of which James Joyce himself would be proud. Something physiologically happened to me, but I could not, I still cannot properly describe it. It was significant enough to alter the course of my life. I knew I had to become a doctor.
I, of course, pondered the idea over many days to come and over the years that followed. Yet, I unashamedly admit that this book truly affected my career choice. There are just not very many books out there that capture the meaning of what being a doctor really entails; the true essence of the thing. I came from a working class family. I eventually went on to become the first person in my family to graduate from college. I did not have the support of family members in the medical field. This book was my resource.
A.J. Cronin's book tells the story of a freshly graduated general practitioner named Dr. Andrew Manson who arrives in a small Welsh mining town with his diploma still warm in his hands from the presses. He is hired by the local mining company to care for its workers and their families. He literally has to pick an office and open up a new practice and get to work in short order. As he enters the venture he is challenged by "the old way of doing things" as he brings his new ideas to bear. Despite his own uncertainty he uses knowledge and diligence to care for his patients the best way he can. His sincerity and decency help him persevere. There are a number of wonderful vignettes with various cases he must handle. With each patient interaction his patients and even his colleagues are forced to respect him. Along the way he scoffs at unscrupulous practices and challenges outmoded ideas armed with his desire to learn and improve himself each day. This is powerfully portrayed as he begins to surmise and later prove that the coalminers are suffering from the coal dust inhaled on the job.
Later in the book, as his ability to practice is hampered by his employer, the mining company who is not happy about his findings, he is forced to confront the realities of trying to do the right thing and make a living. Eventually Manson chooses to move his practice with his new wife to a busy, more urban practice. He later makes another move to a more influential and prestigious practice and is forced to come to grips with the desire to make money and stay true to his ideals of practice. This challenge leads to a crisis of conscience involving the very fabric of his married life. He must decide whether to stay and sell out his ideals or to be true to himself, and his wife, and place his patient's care first.
Throughout the book the author, a physician himself, explores the challenges and general themes that are found in everyday medicine. These same themes ring true today. He deals head-on with the subtleties of bedside manner, challenging the popular beliefs about how to practice medicine and questioning the ideas that there are just "certain way things are done" by other physicians. He delves into how reimbursement issues affect a doctor's choices. He quite handily demonstrates the insidious way that drug companies and equipment companies creep into physician's lives. Even more impressive was the way the author touched all of these issues while walking the reader through the nuances of married life. The protagonist's wife plays a tremendous role in his life and in his choices.
The idea of "the citadel" standing out there on the hill just over the tree line is a wonderful image. It represents all that is good and noble in our profession. It fosters that ideal that if we just work hard enough and do the right thing as we care for our patients we can reach that pinnacle of our profession.
All of it seems quite relevant today. Cronin wrote about it so eloquently many decades ago. His story captured the true essence of this profession of ours. I can think of no other work that influenced me more. Though there have been a few mentors and patients that have shaped me and my practice, there has only been one book that has been equally profound. This one was an easy choice for me. I hope others will read this book and enjoy it as I did. I think I might just dust it off and give another read myself.
Ronald Spiegel, MD, is board certified in pediatrics and practices medicine in Snoqualmie, Washington.