A Synthesizer of Complexities Within the American Medical-Industrial Complex: on The Paregoric Realism of Anna DeForest

In a piece on the craft of writing published by LitHub, novelist, palliative-care physician, and neurologist Anna DeForest proffers their literary position. “The writing I admire and aim to produce works in a language that is entirely without artifice. This means, to be direct, short blunt words without flourish, minimal description, limited internality, and a lot of direct observation of the external world. I prefer to write in the first person, for the same reason, an atheist stance—there is no one outside of the story, there is no place outside from which to tell it.” Now maybe I’m just an opponent of the intentional fallacy or maybe I’m one of those ‘even documentaries aren’t capital-R “Real”’ guys reminding you that it’s all in the framing, that ‘realism’ is both the greatest and the most basic writing trick there is, that of course anything/everything within the pages of a book is invented, fabricated, subjectivized, and debatable, that even nonfiction is fiction, yet still I marvel at the miniaturist word sculptures in DeForest’s first two novels, each pocketsized hardcovers of around 200 pages —A History of Present Illness (2022) and Our Long Marvelous Dying (2024).

These minimalist works are blurbed by bastions of the epigrammatic literary landscape like Jenny Offill, Garielle Lutz, Sarah Manguso, and Amy Hempel. Contemporaries Lydia Davis, Claire-Louise Bennett, Juliann Garey, Kathryn Scanlan, Yiyun Li, and Christine Schutt (like a number of these writers, DeForest has received tutelage from editorial legend Gordon Lish) also bear mention. A review of their debut by Ellen Barry in the New York Times claims that DeForest “offers us the perspective of a doctor who feels everything. [DeForest’s] writing is dreamlike and fragmentary, a sequence of evocative scenes that the reader must piece together, like a puzzle.” This seems at odds with DeForest’s stance that they’re a straightshooter disinterested in language games and non-naturalist structures.

What makes DeForest inimitable is their conflation (and perhaps confabulation; I wouldn’t label their works ‘autofiction,’ but just how much of these novels is remembered or semi-remembered from their own medical training and practice is worth considering) of the imaginative and the documentary, their ability to synthesize. Ellen’s piece also asserts that DeForest writes in the genre of the “prosecutorial, documenting life inside a system that is closed to most of us. To anyone caring for someone near the end of life, ‘A History of Present Illness’ provides a powerful argument to push back against the juggernaut of the hospital, to wrest control of the process.” A badly broken system it is, downright unseemly and criminal at times, but this is a sentimentalization. Novels aren’t guidebooks about how or why someone should speak up at a family meeting to espouse a more pain-free life for an aged, enfeebled, or critically-injured relative, nor are they manuals for peering over the ICU nurse’s or attending’s shoulder, asking for a play-by-play of diagnoses, treatments, or insurance claims.

The most ensorcelling characteristic of the prose is what I’ll call its unhideboundness, the myriad approaches via which DeForest “draws from her profession to write on sickness, healing, and loss,” to quote an NPR interview from 2022. The transmogrification into art is what matters. “DeForest nimbly toes the line between fact and fiction until we find some footing in our mortality,” is how Xi Chen appraises their work in Rain Taxi, and here I concur. It’s the sentence-level successes, the reflexive and clinical-but-not-wholly nature of DeForest’s prose that makes the ascendent academic term ‘medical humanities’ something more interrogative and illuminating than mere subcategory or directory heading.

As an undergrad, DeForest studied literature at Eugene Lang College of Liberal Arts at The New School in Greenwich Village and graduated during the economic turmoil of 2008. They advanced toward an MFA from Brooklyn College mostly to defer student loans. After adjuncting on a miniscule salary (sometimes < $20K/year) and living liminally in Brooklyn in their early twenties, they opted for medical school. Child of a nurse, DeForest had a disorder where they thought about death incessantly, so it became their goal to go “from sad loner weirdo to sad loner weirdo doctor writer,” as they told Garielle Lutz on the Beyond the Zero podcast in 2024. They took two more years of undergrad classes before moving on to an MD from Colombia that encompassed four years of med school, a one-year internship, a one-year fellowship, and three years of residency. They presently live in Manhattan and work as a supportive-care physician (an expert in pain and symptom management for cancer, specializing in hospice care) at Memorial Sloan Kettering Cancer Center. Their writing has appeared in prestigious literary magazines like The Yale Review, Alaska Quarterly Review, and The Paris Review (blog) and respected medical sources such as Journal of the American Medical Association (JAMA) and The New England Journal of Medicine.

Both DeForest novels are narrated by insiders, queer female (or femme/AFAB) protagonists who reflect on varied stages of their journeys through, and discomfited inhabitance of, the corporate labyrinths that constitute the modern medical-industrial complex. They’re also individuals tackling the age-old job of self-preservation in the metropolis that is New York City. DeForest’s readers get glimpses into how doctors are trained, coached, and encouraged to ‘stay on script.’ These books can be pored over slowly or devoured in a single day. Their unnamed first-person narrators are not related or contiguous, and the second book is not a sequel to the first. Each spelunks into the professional self and the at-home self. Take as exemplar, from Our Long Marvelous Dying: “Today’s first patient, I have been warned, is a splitter. A splitter is a patient who likes some people, but she doesn’t like you. She, but they are always women. In the hospital, only some kinds of cognitive dissonance are pathologized. The inference is that she has a disorder of personality, that she oscillates meaninglessly between extreme assessments of the value of others. Fine. I tend to fall on splitters’ good sides, a tendency that points to something I know is wrong with my character: I allow too much.” Later in the chapter, the narrator will recall how she met her husband (love at first sight, “acute and viral”) and note that doctors assign the wrong cause of death one time out of three (!!!), before asserting that she herself is an anti-Heisenbergian absolute relativist, one who sees the world’s unknowability as a fact, and admits that “I once saw a therapist for just a few sessions who believed you could use hypnosis to cure brain tumors.” The chapter ends with the narrator being followed home by a man who saw her looking at his tattoos on the subway, perhaps admiringly. He attempts to chat her up in romantic ingress but is rebuffed. No reason or excuse is given. There’s no further conflict. He doesn’t call her a misogynist name or become a recurring threat. He simply walks away, an incident rendered.

The following chapter, “Visiting Hours,” delves into a dream about the surreality of watching horror movies while living inside one as a doctor in the earliest stages of the Covid pandemic before the narrator contemplates her niece Sarah, whom she’s raising, and how the kindergartener “knows I am a doctor and holds some interest in this fact. She is afraid of her pediatrician, an austere stranger who sometimes causes pain. She seems to know about death but does not ask about it directly. For instance, in a children’s song including the line Perhaps she’ll die, Sarah adds after that the word forever in a blaring trombonish tone.” Readers are implicitly offered the opportunity to analyze the author-character relationship because DeForest themself lives with their niece, who is approximately the age of the Sarah character in the novel.

Anna Reesman, director of the Program for Humanities and Medicine at the Yale School of Medicine, avers that DeForest’s writing “blazes with intelligence and wit. In ever-present curiosity and questioning, she calls out the hypocrisies of medicine and explores them in a really kind of unique and wonderful and interesting way and really makes us think about what we take for granted in the bizarre field that we are in.” I agree re: the predations and outlandishness of medical practice. Reading a medical novel, I’m almost always reminded of the existentialism of Camus’s The Plague and the misanthropy of Ricardo Piglia’s The Absent City, which contains the line “Doctors are always failures, it is only a matter of giving them enough time.” DeForest’s protagonists captivate me with recollections of colleagues from grad school, their early years as student doctors, with whom they essentially went through boot camp.

The narrator of A History of Present Illness, financially the poorest of her cohort, the most first-generation collegian of the lot, contrasting sharply her primarily Ivy League compadres, refers to them through shorthand such as “the seminarian” or “the Texan.” She and the seminarian do mushrooms, look at a junk shop painting until they hallucinate that it’s moving, “and after that we did all the things two people who don’t have sex can do.” She and the Texan are friends “inasmuch as he gave me little doses of the drugs he ordered from local teenagers by text messages and sometimes, without context, late at night, would send me links to gay pornography.” The Texan is pansexual and the narrator exhibits components of both bisexuality and asexuality. She has a celibate union with a theology student while the Texan has a crush on the seminarian. Also in their group, there’s “a woman on a military scholarship,” an evangelical whom the narrator will offend.

“So much of medicine is just learning the words for things,” this narrator opines. “In psychiatry, for example, hallucination is perception without an object, while illusion is true perception interpreted incorrectly, like seeing tree branches as reaching arms or hearing murmured voices in the susurrus of running water. A delusion is a deeply held belief that is either false or at least—said the doctor leading the class—unshared by your community.” She then pugnaciously asks their putative professor if religion is the exception. “Is the delusion of chosen ones, of resurrection, or the reign of an all-knowing sky man somehow less insane if enough of us agree to share it?” The narrator is not cowed when the Texan says she shouldn’t say things like that; she’s seen the military woman’s pictures, the armed-forces evangelical “beaming in fatigues, posing with guns of all shapes and sizes, even the large lead-pipe ones that shoot rockets or grenades.” This unsparing irony (a woman who poses with instruments of mass murder aspires to be a lifesaver and is thin-skinned re: others’ failure to genuflect before her ‘faith’) runs deep in DeForest’s works, such as when they complicate the abortion binary with unflinching descriptions of the autopsy of a fetus, its “skull split like an old tomato, and the little limbs lay limp, almost translucent, the perfect hands and fingers of someone who would never use them,” putting seeming givens under the precision of their linguistic microscope, noting that dejected first-year student-doctors sometimes head to an inpatient unit midweek to recuperate from the horrors they witness. Some ghost the program. Others commit suicide. “There were deaths, of course, and vanishings. In a city of tall buildings, it was the young resident doctors who tended to jump off. When a resident died, announcements were made, referring the other students to the proper places to go for emotional support, and the terraces were closed for the installation of protective fencing.”

Bleakness salts these literary streets. Our Long Marvelous Dying’s aforementioned splitter, “when she enters the room, it fills at once with a strange and wonderful smell—frankincense, I soon find out, and balsam fir from the tropical oils she is using to treat her cancer. A tumor the size of a dove nests in her left lung.” This is the cornucopic lyricism that leads me to question the author’s abjuring of words without flourish. I for one see flair in dove tumors and style in the downright farcical exposing of a buffoonish section chief: “In his luxury condo building he steals from an alcove in a common hallway a small bronze statue of Christopher Columbus and destroys it in misplaced solidarity with an uprising caused by the brutal public murder of a Black man by the police.” Later, she’s told by a doctor-in-training that “if you grow up smart in Nigeria, you have to become a doctor; right at the end of childhood they send you off to become a doctor without even asking if you want to spend your working life tending to the ill and injured.” We then spin into an aside about how “another Nigerian doctor I met was an unyielding gender essentialist. He would bend himself into strange shapes to open doors for me wherever we went. It is not right, he said once when I bought him a coffee.” This mixture of the banal, the comic, and the life-and-death serious makes reading a DeForest text feel novel, original, a rare sensation in a literary landscape of effaced edges and smoothed-safe prose.

“Gallows humor is the foundation of medicine,” DeForest states on the Beyond the Zero podcast. “At least far as I’ve known it. The reason for that is we have no other modalities to process our despair.” This remedy can be overdone and overindulged, but it harkens back through existentialism all the way to the foundational aspects of literature itself—the tragedy/comedy binary revealed as yet another false one. And DeForest’s aesthetic, their professional book jacket author photos and the like, very much plays in the conflationary sandbox of the androgynous.

Patients appear in the books as well, of course, including a woman described as “a minor celebrity” and a man with priceless paintings in his home that drop the jaw of DeForest’s avatar, but only the really impactful ones get names, like Ada in the first novel, though even there DeForest dissembles and layers: “Now I am calling her Ada,” the nameless narrator admits, “and the false name is starting to fill up with her and hurt in another way. I miss her.” Ada is her “last patient, the last for now, a younger woman with a slow encephalitis, a spreading inflammation in the tissues of her brain. In an early draft I had been calling her the woman with encephalitis, because giving her a name that can’t be her own felt false.” There’s a delectable behind-the-scenes quality to DeForest’s deadpan compositions. It’s like watching a favorite film with the commentary track on, one intoned by the whipsmart snark who opens an Electric Literature listicle by recommending “7 books that vividly capture hospitalization” with the line, “I used to think I was afraid of death because it is the only problem in life you can’t fix with a good retelling.”

Sophomore effort Our Long Marvelous Dying is set later in Covid-19’s midst. Whereas A History of Present Illness presents like a profound series of journal entries with a whiff of creative nonfiction, Our Long Marvelous Dying is more redolent of the novel proper, not quite poetic/lyrical but a mode that cherishes the digressive; it weaves and connects, its flow defined by an intellectualized and Sontagian breadth, an ode-on-urn compaction. This is a dense-terse work that emanates recollection but gives off anything but pseudo-memoir vibes. This nameless narrator is more encompassing, moving seamlessly from workplace stories about life and death (mostly death) in a palliative-care unit and its attendant angry, wracked, and wrecked family members to hyperrational colleagues (“An activist against homeopathy” tells the narrator, who’s questioning the efficacy of rationalism: “It is always dangerous to teach patients that magic is real.”) to the surrogate-parenting theme where she and her husband Eli are raising Sarah because the narrator’s brother is an addict. This narrator has suffered trauma from past relationships, and in an earlier phase of her marriage, when drunk, sometimes became an abuser herself, of her husband. There’s also a dog and an acupuncturist, and the narrator confronts her father’s recent death by working through their barely-there relationship, an aloof-at-best parent whose worldview, values, and day-to-day moods were outdated by decades, crossing fully into misogyny, selfishness, and recklessness. This novel also features a spirited suite of sections about spirituality, as the narrator escapes to a monastery led by cultish figures with names like Sister Empathy and Brother Emptiness, but in this unlikely venue she seeks, and even finds, therapeutic and meditative relief.  Silent retreats and other woo-woo/new-agey rural spaces appear in a sort of Fleabag-ian motif throughout DeForest’s work (see: “A Mild Irreversible Form of Enlightenment” from The Yale Review), and the viscerality of Denis Johnson’s Jesus’ Son and Todd Haynes’s Safe and also scan as lodestars.

This is not to completely countervail DeForest’s initial claim, because at times their sentences do read like they’ve come straight from the Hemingway app: “I have a lot of things I have lost. It barely bothers me now. I can pull my heart out over work and then go home to nothing. I sleep like the dead.” This is DeForest the squirrel, hoarding commas for winter, in a chapter from A History of Present Illness called “Reaction Formation.” The withholding nature of the medicalized chapter titles reads as very child-of-the-‘90s. There’s a desaturated void-state element to “Anatomy,” “Family of Origin,” “Modified Trauma,” “Show of Force,” “Complicated Grief,” “Distress Tolerance,” “Alignment,” “Samsara,” “Mortality Class,” and “Full Code.” An undeniably post–William Carlos Williams (the apex of the doctor-writer in American literature) “no ideas but in things” thesis percolates herein, alongside a pain-embracing defenestration of whimsy. These appellations also sound like grunge, industrial, or metal songs, reminiscent of Nirvana, Pearl Jam, Nine Inch Nails, and Tool. Dourness is eschewed but there’s some earned sulk here (to allude to Radiohead as well) in a pair of narrators who’ve seen and endured a lot at a relatively young age and marinate in their own PTSD. Both reflect piquantly on violent, abusive, or neglectful childhoods where their mothers and fathers mostly fail to meet the threshold of foundational pediatrician/psychiatrist (and another canonical doctor-writer) Donald Winnicott’s formulation of the “good enough” parent.

Honesty reigns in DeForest’s work, which calls to mind Raymond Carver’s (“That’s all we have, finally, the words, and they had better be the right ones”) exhortations toward “honest fiction” and the K-Mart realism he instantiated. Take a meta-reflection like this one from the protagonist of A History of Present Illness re: her days in writing workshops. After reciting a series of abusive stepfathers that include one who told her brothers stories about serial killers like John Wayne Gacy murdering small boys and piling the bodies in the basement, and then locked said brothers in their own basement to ‘make men of them,’ and at other times beat them with an extension cord, the narrator states, “When I first started writing, this was what I wrote. Grotesque, my classmates called it, prohibitively dark. It doesn’t matter just because it happened, someone told me more than once. But that’s not true; I know that now. It matters most because it happened, if you learn to tell it right. You learn to leave things out until truth is what it sounds like.”

Not “truth is what it is,” but “truth is what it sounds like,” which returns me to the recipe, the inventioneering DeForest denies. They’re actually closer to a page-bound version of Errol Morris, the great American documentarian who’s shunned declamations of objectivity, who vacillates between ‘quirky’ and ‘dead serious’ in films like Gates of Heaven; Vernon, Florida; The Thin Blue Line; Fast, Cheap & Out of Control; and The Fog of War, making sporadic interludes into the political/legal (The Thin Blue Line overturned a conviction and saved the life of Randall Dale Adams, sentenced to death for a murder he didn’t commit). Morris has documented pet cemeteries, Floridian weirdness, a frame job in the shooting death of a Dallas police detective, and justifications for the Vietnam War offered by former US Secretary of Defense Robert McNamara. What DeForest documents in their fictions both short (“Family Meeting” from Socrates on the Beach is an unqualified gem) and long is sometimes directly political—chronicling the medical establishment’s systemic discriminations against women, minorities, the poor, the neurodivergent, and those with mental illnesses—but more often their characters are just trying to navigate the contemporary American ‘now,’ to mitigate the stressors of the overwhelming mental, emotional, spiritual, and fiscal demands faced by everyday citizens in the country’s biggest city. Their narrators are smart, damaged women committed to the cause of assuaging the pain of death in their work lives and assuaging the pain of life in their everyday interactions. Therefore, I disagree with the writing-workshop classmates—the darkness conjured isn’t prohibitive, it’s welcoming and worthwhile.

DeForest has crafted slim volumes that can be sluiced in a single sitting, but also books that make you want to return to investigate how they pulled off the prestidigitatious trick of form + function, a writer’s writer who’s also an audience pleaser, one aware of the aurality of language, not despite the grim subject matter but via lifting the harshness of the topic of mortality into something elegant, beautiful, and uncluttered. DeForest’s palpable lack of fear, their willingness to dirty themself inside the tunnels of corporate dehumanization that exist right down to the level of jargon, euphemism, circumlocution, and bias, the defanged and obfuscatory nature of a concept/word like ‘healthcare,’ this is their great strength—the will to intermingle their characters with the nitty gritty, with ordeal itself and how far the human body and mind can be strained and still survive.

The world in which DeForest immerses their readers is stark, and their characters are wearied and worn, but to go on living is an inherently triumphal gesture, and language can literally keep us alive, fomenting an oppositional attitude toward our undeniable transience. This author’s discants on medicine are simultaneously skeptical and gallant. Their most recent book unspools it: “See it all, and call it something else. There are days where the dawn breaks so bright it seems there is no more sorrow. Then there are days it weighs in the air: the looming accident, the unknown illness, waiting, just waiting. Oh, it is only a bruise. It is only a headache.” We are creatures forced into existence without our consent. Ailments, diseases, disabilities, severe mental conditions; any of them could appear suddenly and without discernible cause, a blight to our lives or our loved ones. The best literature provides a level of palliation that the most well-intentioned of our genius-level doctors and the most sophisticated of our all-but-science-fictional medical technologies cannot. So swallow some of DeForest’s tablets. It’s harsh medicine, but it soothes. In 2000, literary critic James Wood famously coined the term ‘hysterical realism’ to classify what he saw as an emerging genre of postmodern literature (initiated by Thomas Pynchon and Don DeLillo and moving toward David Foster Wallace and Zadie Smith); perhaps a quarter-century later, the categorization for DeForest’s nascent genre would be paregoric realism.

Sean Hooks is originally from New Jersey. He now lives in Dallas and teaches at the University of Texas at Arlington. He has previously resided in Las Vegas, Berlin, and Los Angeles. He holds a BA-Liberal Arts from Drew University, an MFA-Fiction from the University of Nevada, Las Vegas, and an MA-English from Loyola Marymount University.

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