Opioid addiction, medical ethics: two of the questions Toronto doctor Vincent Lam explores in his new book “On the Ravine”

Before Chen hops on his bike to go help addicts in the streets of Toronto, he wakes up in his downtown condo and, like so many of us when we can’t sleep at night, immediately grabs his phone and starts scrolling. A quotidian gesture, to be sure. But instead of heading to Twitter for distraction, he scrolls through a photo gallery: of those who were lost.

“Junior’s baby-face scowl for the camera, teardrop tattoo beneath the left eye … Siobhan, whose mascara was smudged in her photo, as it often was in the mornings after work … Ahmed, hard-faced. No one would guess he knew how to knit …”

They, and others, are the faces of the “what-ifs,” the patients who didn’t make it.

“One of the difficult things that I think all doctors experience … is that there are patients who we recall, and whose stories intersected with ours, whom we know have passed away,” says Vincent Lam as we talk on the phone about his latest book “On the Ravine.”

“And so we think of them with a whole range of feelings: there’s a sense of loss, there’s a sense of sadness. There is also sometimes the great sense of questioning and the questioning is often around … could something have been different.”

They are also questions, he points out, that aren’t unique to the medical profession; they’re questions we all have, wondering if, had we done something differently, their lives would have turned out differently.

You might remember Chen from Lam’s short-story collection “Bloodletting & Miraculous Cures,” which won the 2006 Scotiabank Giller Prize. Also joining him from that first novel is Fitzgerald, with whom Chen went through medical school. Since that book, the two went on to devote themselves to the treatment of opioid addictions. And that’s where the story starts.

Lam himself, of course, is a medical doctor as well as being a writer. He spent the first part of his career in emergency medicine, which thrust him into “all sorts of situations very suddenly.” But it didn’t really give him the chance “to follow people’s stories in a longitudinal way.” He found himself drawn to addiction medicine, which is what he’s been practising for a little over a decade now.

What he realized very quickly, he said, was that the experiences of his patients, their stories, were familiar and universal.

“The fundamental desires that we all have for a sense of belonging, for a sense of safety, for experiences that are enjoyable, to be free of pain, to be free of anxiety.” Those things drive much of what we do and also drive “many things that happen in the lives of my patients.” Themes and experiences, he said, that he felt were important to explore within fiction.

The book centres around Claire, a violinist who teaches music and who plays at a local restaurant. She is initially prescribed opioids after she has an accident and injures her shoulder; she is away in Europe on a music scholarship and the injury is jeopardizing her future.

Meantime, Chen has opened a clinic that treats patients with drug addictions, often heading out to the streets to give out safety packages and, sometimes, to meet his old friend Fitzgerald. The clinic is also working with a drug company on an experimental treatment.

Fitzgerald has a house in Rosedale, right on the ravine, up the hill from some of the encampments where people are living.

Their three lives intersect in a variety of ways and propel the narrative forward.

The experience of being on the outside looking in is one we’re all familiar with: driving down Rosedale Valley Road, for example, looking up to the houses, wondering what’s going on inside; or to the encampments and wondering who the people are, why they’re there and how they live their lives.

“It’s one of the paradoxes of living in cities, that we’re really close to lots of people … who are in different circumstances, just in the course of everyday movement,” said Lam. “And that we really are, in many instances, just interacting within our own circles and in these narrow little corridors.”

This is where he sees the great possibilities of novels and what he appreciates himself as a reader: to read about places he hasn’t had the chance to go or about spaces within his own world where he might not have travelled. It “gives us a chance to humanize stories we might not otherwise be familiar with.”

While the characters Claire and Chen, and others, appear to give a face to the various communities they’re from, Lam said he didn’t set out to impose any values on his characters.

He usually starts, he said, from a “vague sense of who they are.” And, as he gets to know them over the course of writing, “there comes a point when the things they do become obvious to me, because now I understand them.”

It’s a process that typically takes years for him — he began writing “On the Ravine” a few years after starting up his addiction practice — to get to know the characters and then, understand what they’re going to do. He’s not a planner, not a plotter and the whole process, he said, is “tremendously inefficient.” Some of the characters he started out with aren’t in the book, some changed, some were sort of amalgamated.

“If someone knows how to write a novel in a more organized way, I hope that they’ll send me an email and tell me how to do it,” he laughed.

His approach forces him to “create material,” writing a lot more than he’s ever going to use. As with his previous novel, “The Headmaster’s Wager,” he writes “hundreds” of pages that never see a printing press. The process of writing them allows him to explore questions that had to be asked and worked through.

Throughout the book, too, are letters addressed “to a student of medicine.” They give a glimpse into the way a doctor might approach a patient; how they diagnose, factors they might consider and look at. A mentor guiding a younger doctor to use all of the tools available to them and to consider people in a broader context.

“I’m going to have to peel back the curtain and let you into the workshop,” he laughed, when I asked him about those letters.

Initially, he said, there was this “interstitial” text throughout the book, but it took a much different form: a textbook. That is, until his editor, Martha Kanya-Forstner, stepped in and suggested that they weren’t quite working. They were essential to a relationship that develops in the book and so he turned them into letters. “They were a solution to a writing problem.”

But what they do is help us understand the process around making decisions: peeling back the curtain, to borrow his phrase, on the ethics of medicine, the way doctors decide.

Moral ambiguity and questions about the medical system naturally find their way into the narrative. Questions around, for example, prescribing opioids or medical testing.

Lam is careful as he answers. “I think the question of whether a medication has been started for the right or wrong reason would suggest that the medication itself is the main issue. I think very often the issue instead is whether that particular thing is workable for that problem in the long run.”

Put another way, while in our real lives we’re trying to make sense of situations, in fiction, “we have the privilege of being able to play those things out while observing from a third party stance.” We are able to see context and other perspectives.

Again, he hearkened back to what he wants to see as a reader himself. “I know that I have a much more rich experience of reading a novel when I’m asking harder questions and asking questions in a way that is more deeply informed by my sense of human dynamics.”

As he walks the line, through the interview as in his writing, between doctor, medicine and understanding human beings, the human condition, he comes back to the importance of the novel and the role it plays in society.

“Right now, we seem to be living in a society where the popular discourse narrows everything down into simplistic messages. And those simplistic messages often exist in echo chambers, in which the echo chamber amplifies the simplicity and the sense of certainty about that message for the people in the echo chamber.”

Novels are important to expanding questions, rather than contracting them, broadening questions and making them more complicated. That approach makes for a fascinating, entertaining and important read.

“I know that I enjoy and appreciate novels, which leave me with further questions rather than a sense that I’ve been told what I should think,” he said. “That’s what I hope for this novel, (that) it helps people to ask more questions in a different way.”

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