'The Liver Doctor': Moving stories of hope, loss, and healing inside the sanctuary of modern clinical medicine

It is impossible to introduce The Liver Doctor: Stories of Love, Loss and Regeneration without introducing its author. Cyriac Abby Phillips is a hepatologist of some repute, better known to the public by his X handle @theliverdoc. Some may have read his posts, heard him on podcasts, or seen him on social media or television. He is an empathetic and caring physician, an avid researcher, and very articulate—the trifecta of a modern doctor.

His passion for getting to the root of the matter, investigating further than most others would, aided by his trusty pathologist, led him to identify many traditional and herbal remedies as the cause of severe, life-threatening liver disease in his patients. Much of this research has been conducted at his own expense and has led to publications in medical literature that have educated others about these drug-induced liver diseases. Unfortunately, Dr Phillips’s publications, particularly his tweets, attract backlash from practitioners of alternative medicine. Although his research and its conclusions cannot be faulted, his forthrightness, abrasive statements and rebuttals have brought him a certain notoriety and some perhaps not entirely unwanted publicity. He has bravely stood up to his detractors and has the dubious distinction of being the doctor with the most FIRs filed against him, as reported by NDTV recently.

I was interested to learn from the prologue that Dr Phillips always wanted to be a writer rather than a doctor, and he writes very well indeed. His patients’ stories are conveyed beautifully. The step-by-step process of making a diagnosis in the real world is fascinating. I particularly enjoyed the historical vignettes, such as the discovery of mechanisms of liver regeneration, and the determination that hepatic encephalopathy (or cognitive decline due to liver disease) is a consequence of hyperammonemia to name just a few. They help explain the role of various diagnostic and therapeutic tools used to treat patients with liver disease, although they are sometimes presented in too much detail for readers who are not medical professionals. I certainly learned a great deal about supposedly innocuous herbal remedies, such as various arishtams and asavams, that resulted in catastrophic liver injury.

Hepatologists see drug-induced liver injury often in their practice and, like Dr Phillips, treat it syndromically. Dr Phillips is unique in that he goes above and beyond the average hepatologist in identifying the culprit. His emphasis on clinical medicine first and appropriate investigation thereafter is, unfortunately, a dying art, and, as he states, a hill he is willing to die on. Many of us older physicians identify with this sentiment.

Along with a detailed history and clinical examination, one of the pillars of clinical medicine is the continued personal interaction between the physician and the patient as well as the physician and the primary caregiver. These interactions, in all their complexity, are brought out in the book. The difficulty of providing hope whilst being truthful, of providing optimal care to patients struggling for subsistence, and of acknowledging the futility of care in young patients are candidly presented and discussed. While each patient’s story is unique and compelling, towards the end of the book, the stories become rather random and somewhat repetitive. Some of these could have been omitted.

Dr Phillips quotes Canadian physician and co-founder of Johns Hopkins University, William Osler, who said, “Medicine is a science of uncertainty and an art of probability”, and goes on to write, “Embracing uncertainty in clinical medicine makes a doctor more humane. Doubting one’s decision opens vulnerabilities that require a physician to think outside the box and learn new ways to tackle that knowledge gap. A self-questioning physician is far better than one who hides behind a made-up wall of confidence.” The book is peppered with little pieces of wisdom of this nature.

The author also captures the emotional toll that caring for critically ill patients takes on physicians. The anxiety and pressure can lead to compassion fatigue or burnout. He describes both the excitement of reaching a difficult diagnosis that offers hope and the despair of losing a patient despite every effort. I could readily identify with his description of the conflicting feelings physicians experience upon the death of a patient after a tough battle.

“You experience love and hate for being a doctor. Hate because a victory remained unsatisfied, and love thinking of the glorious fight and near triumph that brought together strangers in the sanctuary of clinical medicine,” he writes.

Even under intense pressure, Dr Phillips remains empathetic and compassionate. He credits his wife, children, dogs and the occasional banana fritter with helping him recover during difficult times. At times, however, his flair for drama feels excessive. He quotes patients saying, “Only you can save her” and “You are exhausted, but you keep going”; while these remarks may be genuine, they are somewhat jarring.

Dr Phillips has a very personal relationship with death. Given that the spectre of death is ever-present in patients with severe liver disease, I understand Dr Phillips’s use of this imagery. It adds a certain drama to his writing, though it slides into overuse and awkwardness after a point. The illustrations are beautifully done, but Dr Phillips’s portrait in each of them unnecessarily draws the focus to the author rather than the patient—just as “The Liver Doctor” in the title needlessly shifts attention away from the patient.

Overall, this is a book that educates the reader on a wide range of topics, including how clinical medicine works, the burden of disease on patients, relatives and doctors, and the history of medicine. It highlights that clinical research and enquiry have clearly demonstrated that apparently benign remedies can produce life-threatening illnesses—now if only we would all care to listen.

Sanjay Govil is hepatobiliary and liver transplant surgeon at Apollo Hospitals, Bengaluru.