by Xi Chen

In the opening pages of Anna DeForest’s sophomore novel Our Long Marvelous Dying, the nameless narrator, a first-year palliative care fellow at a hospital in Manhattan, speaks to a patient who claims to have psychic visions. The patient, bedbound and dying of pancreatic cancer, sees “disaster” and “catastrophe” in the world, but when asked about his future, he is afraid to look: “I want only one thing, he tells me, but I already know what it is. He wants to live forever.” But the narrator, with the aid of medical science, can envision the future too: “He will suffer a lot, and then he will die.”

This isn’t the first time DeForest has set fiction in the medical world. Their first novel, A History of Present Illness (Little, Brown, 2022), is a tale about the trials of medical school and residency told by a narrator “raised with a reverence for catastrophe.” That narrator makes a telling comment: “This fascination with disaster, both fear and fetish, I never quite outgrew. The truth is, you start to sort of wish for it.” Similarly, the narrator of Our Long Marvelous Dying trains “to be an expert in pain unto death,” surrounded at every moment by patients at the end even as the television reports pandemic deaths continuing to snowball and a cyclone hitting New York, drowning tenants in basement apartments. 

But why do some people pursue a medical subspecialty always surrounded by death? This question is often levied at people going into palliative care, which prioritizes minimizing suffering over curing disease—often but not always in patients with terminal illnesses. For many, the field of palliative care means escaping, at least to some degree, the plagues of academic medicine: elitist medical students, bigoted doctors, and detachment from the lived experiences of patients. Others may have a spiritual calling, or like DeForest’s narrator, they may be seeking spiritual enlightenment themselves. As a chaplain “from a line of monks who follow in the steps of the great Buddhist saints and meditate in the charnel grounds in India” says in the novel’s last chapter, “If you get through the morning forgetting that you will die . . . the morning has been wasted.”

While DeForest’s narrator may be looking for a deeper understanding of death, however, what they find instead is PR. During orientation, the fellows are given a lecture about “talking points, branding, an early introduction to the field’s bad rap.” The problem, the lecturer claims, “is all this talk about dying. The public does not want to hear about death. Lead with life, she says, lead with what you have to offer.” The fellows are instructed to avoid words like “Hospice,” “End-of-Life,” and “Terminal Illness,” which are “too aversively death-oriented and therefore unattractive” to patients and their families.

Medical bureaucracy’s penchant for sanitizing language and “burying the lede, elevating the plus side so patients will be willing to talk to us” is the villain of DeForest’s fiction, and it rears its ugly head throughout the book. Providers shield themselves with clinical lingo; for instance, the palliative nephrologist who observes the narrator question a patient about his metaphysical visions asks, “What was the therapeutic intent?” Many characters use gallows humor; after declaring a patient dead, a nurse practitioner laughs. “I used to have nightmares that my patients would die, she says. But now I have nightmares that they will not!”

Author Danielle Spencer, a scholar of narrative medicine, has written that the medical training tale is typically a quest narrative in which new trainees lose their idealism during the demanding rite of passage to becoming a doctor, until a “humbling and epiphanic experience about the essential humanity of doctors and patients” changes them and allows them to “practice medicine with greater empathy and caring.” DeForest’s novels are unique in the world of medical fiction in that they leave out this final redemptive step. Many patient encounters are described in Our Long Marvelous Dying, but not once does the narrator perform an action that substantially helps patients in any way. If they grow, it is not in clinical acumen but rather in helplessness and vulnerability, since patient encounters are frequently used as springboards for unearthing fragments of the narrator’s past traumas. 

Perhaps that is the point: the all-knowing physician only exists in the imagination. DeForest has no interest in showing their narrator being a healthcare hero, a figure whose illusory omnipotence comes from the assumption that clinical work is unambiguously empirical rather than interpretative. The narrator muses that if a doctor’s role is to save lives, then every life-saving act by a doctor is necessarily a failure because we all die. Medical crises frustrate patients and their families because seeing doctors appear powerless to help them can indeed feel like being abandoned by an uncaring god. 

Existential despair about this absence of authority under the weight of the medical sublime suffuses DeForest’s work. In A History of Present Illness, the narrator contemplates theodicies in the hospital and has long conversations about early Christianity with a seminarian. In Our Long Marvelous Dying, the narrator continuously ruminates on the missing male figures in their personal life: the sudden death of their bigoted father, the disappearance of their brother into drug rehab, and their increasing distance from their possibly cheating husband Eli, who is also a pastor. Where DeForest’s debut explored academic medicine’s obsession with absolution as an analog to Christianity, however, Our Long Marvelous Dying finds a religious parallel to palliative care in Buddhism and its interest in the worldly attachments responsible for human suffering.

After witnessing a series of deaths near the start of their fellowship, the narrator escapes upstate for several weekend trips to a monastery—one where nuns and monks have names like Sister Empathy and Brother Emptiness and speak only in Vietnamese. It immediately feels like home, the narrator says. Among strangers all traumatized by recent losses, the narrator can shake the role of doctor and become an anonymous listener in communion with others. One visitor has lost his son to suicide; another reveals that she’s been diagnosed with cancer and is awaiting surgery. When it’s the narrator’s turn to unload, they simply state, “I am taking a break from work.”

In an essay titled “Narrative Medicine and Negative Capability,” physician-writer Terence Holt argues that the dominant mode of public medical writing has been confessional: Atul Gawande admitting he botched a procedure in The New Yorker in 2011, for example, or Jerome Groopman atoning for missing a fatal diagnosis in her 2007 book How Doctors Think. Here, DeForest’s narrator refuses to confess. One could read this as evidence that the narrator has been rendered apathetic by their work, or worse, that they’re a parasite, only interested in collecting other people’s stories. Even when seeing a therapist, the narrator admits that they “avoided any self-disclosures; I turned all of our talks onto him . . . his time in finance, brief work as a Baptist pastor.”  But the reader has a different relationship with the narrator, who is constantly revealing aspects of their personal lives to us, including the “same tearing pain in the chest” that comes with every patient’s death. So, why doesn’t the doctor weep?

On their first day working in a clinic outside the hospital, the narrator meets a patient known as a “splitter,” a person whose judgments fall into stark binaries of good and evil. “I tend to fall on splitters’ good sides,” the narrator notes, “a tendency that points to something I know is wrong with my character: I allow too much.” The splitter has been treating her lung cancer with essential oils, and at a later visit reveals that she’s an anti-vaxxer, an anti-masker, a chem-trail believer, and a 9/11 truther. The narrator begins to “listen with two ears, two minds, one for what is real and one for what is true.” They become afraid of the splitter, to the point of canceling upcoming appointments. “She has shown me something strange inside of me,” the narrator explains, “a wound shaped like distrust and disgust and familiarity.”

Later, when the narrator hears that the splitter has died, they hardly seem fazed at all. This negative capability, or the ability to tolerate an ego divided by uncertainty, is the true endgame for both medical training and writing: It’s a way of being that allows humans to endure the daily assault of death, be it in our families, in the news, or in the dying person who needs care if you’re a medical professional—all while thinking about one’s own life and past traumas without breaking down. DeForest aims to cultivate this negative capability in the reader through their driven, elliptical prose, which even within one paragraph can shift from the practical details of organ donation to the emotional resonance of childhood trauma and calls to family members informing them of their loved one’s death. Among the most risk-taking American physician-writers working today, DeForest nimbly toes the line between fact and fiction until we find some footing in our mortality.