A family physician works in an inner-city government-subsidized clinic treating patients with tuberculosis, substance abuse problems, syphilis, injuries from domestic violence, unwanted pregnancies, the acquired immunodeficiency syndrome, and failure to thrive. The physician, too, fails to thrive. His anger toward his not-altogether-blameless patients, his undue pessimism alternating with delusions of grandeur, and his corrupting cynicism prove to be too much. After 2 years, he leaves the clinic, his guilt compounded when he learns that the entire clinic will be closed once he is gone.

Rather than a series of clinical tales or a bildungsroman about the development of an idealistic young physician, this book is a pathography, that is, an autobiography of an illness. Not referenced, Law IV of Samuel Shem's The House of God is quoted. "Don't forget, the patient is the one with the illness," the protagonist is told by a resident. The book is not about the patients' illnesses but about the grave illness of the physician-protagonist of these stories.

The author of the book, according to the acknowledgments and introduction, is married and has two children. He has many colleagues and friends and teachers who read his manuscripts and give him encouragement, criticism, and advice. The speaker of the book, on the other hand, is altogether isolated. Two-dimensional, this physician has no trusted colleagues, no one to come home to, no nourishment to offset the undeniable sacrifices that his practice demands of him. He spends a lot of time looking out of windows—onto projects, vacant lots, trees planted in the sidewalk, drug deals, rain filling ruts and cracks of the sidewalk. He broods about his detachment from his patients, about his need to protect himself from emotion, about his helplessness and his rage. "I wish there were someone to turn to for advice ... Now I am the attending physician." What an unfortunate state of affairs for a brand-new physician. Sadly, the speaker seems not to know that these are universal themes in the making of the physician. Sadly, there seems to be no one who will listen to this suffering man.

Near the end of this beautifully written but one-sided narrative, the speaker describes a few patients who seemed to have done well. They stuck it out in drug treatment, they used their birth control, they finished high school—impressive accomplishments for a marginalized and powerless group of urban residents. The reader has no cause for optimism about the physician-protagonist, however. (The title of the book is, on reflection, rather ominous.) The physician moves on from this clinic because of frustration and an inability to tolerate the ambiguity and sadness of sick persons' lives. Taking an epigraph from "The Rime of the Ancient Mariner" reflects some realization that the telling is the thing; perhaps the experience of having written On the Ledge will have led to some illumination, humility, and a sense of joy in medicine.