Surviving the Fall: The Personal Journey of an AIDS Doctor

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9780300071269: Surviving the Fall: The Personal Journey of an AIDS Doctor

This is a memoir of the first decade of the AIDS epidemic in the Bronx, a physician's firsthand account of the emergence of an epidemic and the lives that it touched. It is also an exploration of how the physician was himself transformed by his experience with these patients. Dr. Peter Selwyn, now a well-known researcher and clinician in the area of HIV and drug abuse, came to Montefiore Medical Centre in the Bronx as a medical intern in June 1981. He remained there for ten years, caring for patients with AIDS. During that same span he married and became a father. Absorbed in the pain and losses of his patients and their families, Dr. Selwyn finally acknowledged the grief he had carried for decades following the sudden death (and apparent suicide) of his father when the author was an infant. He realized that, like AIDS, suicide stigmatizes both those who die and those who survive. Surrounded by young patients who were dying, he understood what it meant to have a father and to be one. For him, it was a process of healing in the midst of the epidemic. His story can help us see AIDS (and any life-threatening illness) as an opportunity to go through our own fear, pain and darkness and to come out on the other side. Recognizing the darkness and passing through it, observes Dr. Selwyn, is a prerequisite for anyone seeking to be an effective caregiver, whether professional or personal. It is a process that can teach us how to accompany patients or loved ones through illness and to witness and relive their suffering as they approach death. This is a story of loss, discovery and coming to terms with the past, a story with a message for anyone dealing with the challenges of living, dying, and being human.

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About the Author:

Peter A. Selwyn, M.D., is professor and chairman of the Department of Family Medicine at Montefiore Medical Center and Albert Einstein College of Medicine in the Bronx, New York. He has been a caregiver for patients with AIDS and their families for more than fifteen years.

From The New England Journal of Medicine:

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 Kubler-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.

Reviewed by Robert S. Schwartz, M.D.
Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

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