78 The Permanente Journal/ Summer 2004/ Volume 8 No. 3

book reviews

The CitadelBy AJ Cronin

Book review by Seth Kivnick, MD

Boston: Back Bay Books;1983. ISBN: 0316161837

Paperback: 368 pages.$19.99

am not sure why, but there just aren’t many greatnovels about what it means to be a doctor. One

such gem is The Citadel, by AJ Cronin. This book waspublished almost 70 years ago at a time when medicalpractice involved hardly any laboratory tests, x-ray films,or specialists. The vivid characters, dramatic plot, andmoral lessons presented in Cronin’s novel make it astimely and readable today as it must have been in the1930s. The Citadel is particularly pertinent to us in Kai-ser Permanente because Cronin’s protagonist beginshis career in a health care system similar to our ownbut which existed in Wales at the beginning of the20th century. The challenges Dr Andrew Manson facesand the ethical issues Cronin presents are essentiallythe same ones each of us in medicine faces today.

As this semiautobiographical novel begins, a youngphysician arrives in a small, Welsh mining town to takehis first job. Fresh out of medical school and up to hisneck in debt, Manson is hired by a coal company to beone of the four doctors employed by aprepaid plan that provides care for min-ers and their families. As the only recentlytrained practitioner in town, Manson meetsstiff resistance from patients as well as fromother doctors who are used to their oldways of doing things. Despite his youthand inexperience, Manson questions medi-cal dogma. He tries to apply current sci-entific knowledge to the problems hispatients bring to the clinic. His diligence,intelligence, and decency soon pay off.Patients begin to respect him and choosehim over his outmoded colleagues.

Young Manson has many admirable qualities. Hejudges people (patients as well as medical colleagues)by their actions—not by their wealth or power. Heconstantly strives to improve his clinical skills, and hebristles at the incompetence and unethical behaviorof colleagues. However, he is not a saint. He isn’talways tactful, and he has trouble choosing whichbattles are worth fighting. Luckily for Manson, a young,female schoolteacher in town finds his brashness en-dearing. When Manson abruptly quits his job overwhat he feels is his unfair compensation agreement,

Christine accepts his precipitous proposal of marriageand accompanies him on his next professional chal-lenge in a larger mining town.

In their new situation, Manson and his wife estab-lish a trusting relationship, which provides a strongfoundation for the doctor’s increasingly demandingpractice. Cronin describes many great clinical casesin which Manson’s curiosity and hard work lead togood patient outcomes. One of the most exciting vi-gnettes is an emergency amputation Manson performsby candlelight, lying on his stomach in a narrow, dankmineshaft to save the life of a miner trapped by apartial roof collapse.

Manson observes a connection between coal dustexposure and lung disease in certain of his patients.He embarks on a research project to prove that suchoccupational exposure can cause disease—a fact thatwas unrecognized at the time. Christine assists Mansonin his research and helps him study for a postdoctoral

examination. Her unstinting support en-ables Manson to travel to London, suc-cessfully defend his research paper, andqualify for the advanced degree—anamazing set of accomplishments for agraduate of an undistinguished medicalschool, practicing in a small town.

In The Citadel, Cronin preaches manylessons: hard work, conscientious patientcare, and intellectual curiosity are thekeys to success in medicine; knowledgeand integrity count for much more in lifethan money; doctors need continuingeducation to remain current and to serve

their patients well. In each of Manson’s professionalendeavors, he befriends a colorful colleague whoselack of material success belies a keen intellect and greatpersonal integrity. These “diamonds in the rough” re-emerge later in Manson’s life to help him through pro-fessional and personal difficulties.

Again in his second position, Manson clashes withthe powers that be. He resigns his provincial post andtakes Christine off to London, where he hopes to be-come a specialist in lung disease and become an at-tending physician at a respected London hospital. He

I

Seth Kivnick, MD, is asurgeon at the SCPMG

West Los AngelesMedical Center. E-mail:

seth.kivnick@kp.org.

The challengesManson faces

and the ethicalissues Croninpresents are

essentially thesame ones each

of us inmedicine faces

today.

79The Permanente Journal/ Summer 2004/ Volume 8 No. 3

book reviews

first takes a position with the occupational health min-istry but quickly becomes disillusioned by the bureau-cracy. He leaves to establish a small private practice.Although Christine and Manson struggle financially,they support each other, build a successful practice,and learn to enjoy the cultural offerings of the bigcity. Manson’s patients are working-class people, hisincome is modest, and his success is based on integ-rity and clinical acumen. Later, however, he meetsaffluent doctors with offices in prime locations forcatering to the carriage trade. When Manson is of-fered, through their schemes, a chance to make “real”money, he greedily accepts. Christine watches withdismay as Manson compromises his erstwhile principles,engages in shady medical practices, and panders torich patients with maladies that are more imagined thanreal. Manson’s materialism and ethical lapses lead to agrowing estrangement from Christine and culminate inthe novel’s dramatic conclusion.

Throughout The Citadel, Cronin explores issues thatare still unresolved in today’s health care environ-

ment. He shows the ways in which reimbursementpatterns can affect physician behavior. He demon-strates the insidious effect drug and equipment com-panies can have on a physician’s judgment. He ar-gues for establishment of integrated, multispecialtygroup practices and suggests the power of clinicalresearch to improve public health. He vividly por-trays the difficulty sometimes experienced by busyphysicians in balancing professional responsibili-ties with their personal lives. None of these is anew problem.

All these themes make The Citadel as relevant todayas it was in the 1930s, and The Citadel is still a “greatread.” Much has changed in the practice of medicinesince this wonderful novel was originally published;however, what will never change are Cronin’s mostbasic points: that medicine is not merely a businesswhose goal is to enrich its practitioners materially; andthat the essence of being a doctor is the use of one’ssenses, knowledge, and experience to reduce suffer-ing and improve people’s lives. ❖

ConnectedYou think your pains and heartbreaks are unprecedented in

the history of the world, but then you read. It was booksthat taught me that the things that tormented me were the

very things that connected me with all the people whowere alive or who have ever been alive.

— James Baldwin, 1924-1987, African-American writer