Tag: Cumming School of Medicine

Treating empathy: an ancient Greek recipe

 

Source: Pexels

Dear gentle readers:

I recently developed a pen-pal sort of relationship with someone – he’s been mentoring me as I perform my writer-in-residence role at the University of Calgary medical school.

Now, this mentor is somewhat unusual.

Is that the right adjective for a pen pal who has been deceased for the past … oh … twenty-four centuries?

Nevertheless, my correspondent is alive and well in the letters below.

I recently presented these epistles to the Family Medicine grand rounds group and the Health Humanities journal club, as part of a presentation on empathy, writing and medicine.  Thanks so much to everyone who provided feedback and suggestions. And thanks to the HH group for such an insightful discussion.

As most of you will know, I am not a physician. I have attended exactly four medical classes and the resulting knowledge is neatly summarized on exactly ten pages of a Staples scribbler.

However, I have done some reading on narrative medicine, and am intrigued by the writerly elements that bind storytelling to medicine.

If you are a physician, please consider the correspondence below as food for thought. Gruel for the clinical soul. I would love to hear your feedback or chat with you over coffee. We could meet at the statue of the stony Greek man in the Health Humanities Center.

Without further ado, then, here are the empathy letters.

All the best,

Jane

 

Dear Hippocrates:

 

I hate to disturb you, but I was walking past you the other day in the Health Sciences building and as it happened I was thinking about empathy and medicine and writing. And I was overcome with the feeling that you might understand this three-pronged interest. Maybe because I had recently perused some of the Hippocratic writings.

Now, I know that these texts – even, possibly the Oath itself – are likely written not just by you but by several of your like-minded peers, but still, it would seem you had an interest in writing. Didn’t Plato find fault with you for writing things down? So that instead of memorizing a fact, we just set it down on paper, or should I say, chisel it into a stone, relieving us from the responsibility of actually knowing … anything? Although I would argue that the act of writing, for a physician, can open a few doors, but that’s a topic for another letter.

 

On the theater of surgery

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The Agnew Clinic by Thomas Eakins, 1889. Wiki Art.

 

I’m dressed in scrubs, wearing an upside-down surgical mask, peering between a medical student and a surgeon, straining for a glimpse of an anal fistula. The patient, whose maleness is undeniable given the angle of my view, lies flat on his back, legs bent at the knee and encased in devices that look like a cross between gynecological stirrups and medieval knee braces.

You shouldn’t be looking at this, I tell myself, and move back to my perch – a padded stool, near the wall of the surgical theater. But the longer I look at those stirrups, the more I think of my own stirrup experiences, and the hours spent flat on my back at the Rockyview hospital maternity ward, with at least one, and sometimes several, men looking on, chatting about weekend plans, then prodding, tugging, reaching, pulling.

Damn it, I’m looking.

I rise from my stool and walk across the OR to the foot of the gurney till I can see between the surgeon, the medical student and the assisting physician.

“Press here,” says the surgeon, and the medical student reaches down, applies pressure to an area I can’t see, somewhere on the flesh between the patient’s legs. Again, I’m struck by the overwhelmingly female ethos of the tableau, the patient’s body prone, legs splayed, held at right angles by stirrups, as if levered into a yoga pose.

Here is the body at its most vulnerable, and again I tell myself I shouldn’t be standing here, looking. But how many times are women in this position, nakedly exposed, for a smear, an exam, a birth? How many men have stood between stirrups?

I stand on tiptoe and get a glimpse of the incision site, a smear of crimson, a glint of steel, a sleeping curl of genitalia.

I ignore the voice in my head that asks, How did you get here?

It’s a voice I will ignore several times on this particular day.

Let me take you back, gentle reader, to the beginning of the day in question. For I have begun, in the irresistible tradition of Homer, in medias res – in the middle of things.

My day began at 6:00 AM, which, as it turns out, is the perfect time to drive down Deerfoot Trail. For those of you who are not from Calgary, imagine the worst of all possible highways in the worst of all possible worlds, and multiply it by Montreal. This is the one place, on Ewan McGregor’s epic “Long Way Around” motorcycle tour, where he was knocked from his bike, where he nearly spotted the end of his own train.

I was heading to the South Health Campus (a phrase I can never say out loud – try it! Who designed this name, which sticks like peanut butter to the roof of your mouth?) to shadow a surgeon – part of my writer-in-residency experience at the University of Calgary medical school.

As the anesthesiologist later asked me, have I ever observed a surgery before?

No.

I also have not slept, instead opting to alternate between lying in bed counting backward from 100, and sitting in front of the television, watching my favorite episode of Brooklyn 99, the one where Jake and Captain Holt are quarantined for the mumps. Even in my sleep-deprived state I could see that this was only loosely connected to medical school research.

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I scoot down Deerfoot Trail, arrive at the South Health Campus well before 7:00 AM, and proceed to the surgical desk, where I ask for the surgeon. He is not there yet, so I am told to wait in a chair in the corner of an open space adjacent to the surgical desk. Men and women in scrubs drift in, chatting, grabbing scrub jackets from a long metal rack like the ones you find at The Bay.

I check my phone. It’s 7:15 and I’m wondering how the day will pan out. I thought the surgeries were supposed to begin at 7:30, and I was hoping to chat with the surgeon beforehand, to find out what I’d be observing. To reduce the chances of passing out or vomiting during the surgery, I’ve been building up a resistance to digital blood by watching surgeries on YouTube. I know enough now to know that my ability to keep my bagel down will depend, at least in part, on what sort of surgery I will observe.

If you’ll forgive a digressive but relevant side bar, I confided in my medical school contact that I was concerned about fainting during the surgery observation. My esteemed colleague emailed me back noting that it would indeed provide hours of amusement for the surgical team if I did indeed lose consciousness or vomit during the procedure. Lol.

So there I sit near the surgery desk. A patient is rolled into the open area, a few feet from my chair, dressed in a royal blue hospital gown, laid out on a gurney. Lying there silently, looking up at the ceiling. I take in the face, the eyes, the hair. I don’t know the patient but I know the feeling of waiting. I remember having my gallbladder out a few years ago, waiting on a gurney in a hallway outside the operating room. Cold, shaky, trying not to think.

A person who might be a surgeon walks in, dressed in scrubs, and has a brief chat with the patient, then comes over and I introduce myself.

The surgeon asks if I’d like to observe in the operating room, and I respond in the affirmative, ignoring my stomach, which is suggesting it might be more prudent to stay here, next to the peaceful rack of surgical jackets.

The surgeon seems to be considering the logistics of the situation. He looks at my clothes and says something about scrubbing in. I look at him, unsure what to say, and at length I come up with:  “Um.” I assume I need to change clothes, but I wonder if I am now causing everything and everyone to be behind schedule – the OR, the nurses, the physicians, the patient.

“Follow me,” says the surgeon, and I jog along after him. He tells me to stay close today; I don’t have a key card and may end up stuck in a stairwell. I stay close. We jog up a set of stairs and he points me toward the women’s locker room. I will find scrubs in there, and a head covering. The surgeon waits for me in the hall.

I break whatever speed records have been established for changing one’s clothes, and then realize I should have brought a lock. I have brought my briefcase, complete with phone and wallet, and have nowhere to put it. I stand still for a good 30 seconds, pondering. Do I ask the surgeon to stow my briefcase somewhere? Do I stuff it into a locker and hope? If there is a security camera and anyone is watching, they will think the camera has stopped working. I stand still, thinking. Aware that the OR is now, possibly, another 30 seconds behind schedule.

Finally I grab the briefcase and head into the hall. The surgeon does not appear alarmed at my idiocy; he takes it in stride. Does he feel it’s normal for an English major to crack under the pressure of a briefcase-related crisis? He simply takes the briefcase, says, “Wait here,” and jogs to the men’s locker room, where he locks it in his own locker. I no longer know what time it is, but I suspect it is after 7:30.

We jog down another hallway to the operating room.

Just outside the OR, he points at small boxes of gloves and masks, and I begin trying to tie two sets of strings behind my head. I pull on the thin gloves and follow him into the room. The first surgery is to be an appendectomy.

The patient is lying flat on the gurney, unconscious – it’s the same patient I sat next to upstairs when I first arrived. It was just moments ago that the patient lay there, alert, chatting with the surgeon while their brain likely darted between panic and pleasantries. Now they are inert, limp.

In a matter of moments this patient slips from conscious to unconscious (I recall being asked to count backward from 100 before my gallbladder operation, but have no memory of the numbers themselves – did the numbers actually tumble from my lips or did they get lost en route from my sleepy brain?). Not for this patient the luxurious meanderings between consciousness and unconsciousness: no sleepy stretches, no yawning through a few pages of a novel, no stubborn refusal of the mind to switch off the events of the day. For surely, today, these are events not easily switched off – the removal of one’s clothing and the donning of a blue gown; the laying out of one’s body onto the gurney; the ceiling tiles rolling by as the gurney passes through beige hallways, silent but for the squeak of the orderly’s soles.

And yet these unfamiliar events are switched off in seconds as the anesthetic creeps into the patient’s veins. The patient is limp, blank, asleep, and someone has already stretched a broad belt across their thighs and gently shifted the arms so they reach out sideways, palms up, as if offering themselves to the possibility of a nail or two.

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St. Matthew’s Church, Morley, UK

 

This positioning makes me wonder what is being sacrificed here. One’s conscious state, perhaps, or one’s agency – all for one’s ultimate health? It’s as if the patient flings out their arms, leaving the belly unsheltered, unprotected, relaxed, unhindered by the tension of muscles. Take me, the patient says. Do what you said you would do. I’ve agreed, I’ve committed myself to your care. I trust you.

The medical student who has yet to enter the OR will tell me later that there are two different “patients” – the one you talk to before the surgery, with whom you establish a relationship and empathize with, and the one you operate on. This unconscious person is draped in cloth, and the spot on her belly, on which you will operate, is a site of skill development. This unconscious patient is a sort of space where you want to do your very best work so that the waking patient who smiles, chats and frowns, can be as healthy as possible.

Having had minor surgery a few years ago, it’s odd to think of my own body as a site for skill development, or an arena for the exercising of skills. But as I watch the surgical team make their incisions in the square of exposed flesh, I understand this shift from the personal to the professional. Surely it would be unproductive to imagine the patient’s musical laugh as you place your scalpel on her flesh. And surely it would be best to train all your mental faculties on the logistics of the surgical task, rather than the hopeful expression on the patient’s face as he says, I can hardly wait to get back to lacrosse!

Not that you would want to lose touch with the humanity of the patient.

The surgeon I’m shadowing will tell me later that it’s important to get to know your patients. Patients often need to work with the surgeon on resolving issues, and you will build a relationship with them. It helps the patient to know you’re interested. Building relationships, the surgeon said, is one of the things that make the job enjoyable. Meaningful.

The medical student also told me later that the shift between the waking patient and the unconscious patient can be unsettling. One of the first surgeries the student observed was in an obstetrics/ gynecology rotation. The student remembers talking with the patient right before the operation, and within moments the patient was lying on the operating table with an open belly and out came her bowels.

It was overwhelming, the student said – it was necessary to sit down afterward and let the experience sink in.

Which brings us back to the element of trust. The patient lying outstretched, entrusted to another. Which is such an uncharacteristic mental pose in this day and age: how often do we open ourselves so completely to the will of another? There is something beautiful about the moment, even as it emphasizes vulnerability. It harbors the potential for danger – what if the surgeon is unethical? Unwell? – but the patient has placed their trust in our health care system, which trains a physician over the course of years, putting them under the tutelage of wiser, more experienced practitioners. The patient has met the surgeon, has looked them up and down, held their gaze, posed a few probing questions, read a few posts on RateMDs.com, and decided this surgeon can be trusted.

This element of trust has not always informed the patient–surgeon relationship. Let’s look back – way back – to the Code of Hammurabi, the first recorded code related to medicine, written around 1790 BC.

The Code outlines the ramifications for causing harm.

“If a physician shall make a severe wound with the bronze operating-knife and kill him, or shall open a growth with a bronze operating-knife and destroy his eye, his hands shall be cut off.”

These malpractice penalties, notes medical historian Robert Greenspan, M.D., “were quite harsh.”

I’m going to give Greenspan the benefit of the doubt and assume he is being ironic here. The Code, which was written by lawyers, takes its approach from lex talionis, or the law of retaliation – think “an eye for an eye; a tooth for a tooth.” Thus leaving surgeons fairly exposed as they draw back the flesh of a patient.

In fact the public’s conception of surgeons has varied widely across the centuries. The view of a surgeon as godlike can be traced back to Imhoptep, who was a great astronomer and architect of the first pyramid, the step pyramid of Saqqara.

Imhoptep was worshipped throughout Egypt, and became the model for the Greek god of medicine, Aesculapius.

But in early medieval times, the task of repairing the human body slipped a few rungs on the social ladder. Deep inside the monasteries of medieval Europe, the role of the surgeon was conflated with the role of the barber. In these dim, dusky cells, the trimmers of beards became the setters of bones.

Gentle reader, this conflation may be hard to imagine. In our world we do not walk into a barber shop and ask for a bladder-stone removal. But there is a method to this evolution.

Remember that in medieval times, animism shaped European world views. People commonly thought that evil spirits caused disease. The boils on one’s chin could be traced to one’s reluctance to attend Mass every Sunday. So medical care often took place in a religious setting and monks offered various forms of therapy. But they delegated surgical procedures to the barbers who visited monasteries to trim beards.

Barbers were handy with razors, so why not let them cut into the human body?

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The Extraction of the Stone of Madness by Jan Sanders van Hemessen, 1550-1555 (Museo del Prado)

So began a tradition of seeing the surgeon as a crude hacker of flesh. Soon barbers were performing dental extractions, lancing boils, repairing fractures and, sometimes, removing bladder stones. But they were looked down on by university-trained physicians who prescribed medications and performed more sophisticated surgeries, like amputations. No, barber-surgeons were not part of the medical community; they knew no Latin and couldn’t read. Greenspan notes that in London, England, surgery was an unfit profession for a gentleman; it was simply a trade.

One surgeon who railed against this medical binary was Ambroise Paré, now considered the first great modern surgeon. Perhaps his medical prowess proves itself through longevity; Paré lived to the age of 80, which, during the 16th century was no small feat – he was outliving his male friends by 50 years.

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Ambroise Paré, who introduced the ligature of arteries. By Josep Planella Coromina (Art.com)

True to the barber-surgeon strategy, Paré worked with his hands, and his approach worked well: he was surgeon to four kings. According to Greenspan, Paré once rebelled against his professors, saying, “How dare you teach me surgery, you who have done nothing all your life but look at books! Surgery is learnt with the hand and the eye.”

Paré’s emphasis on practical training resonates in the pedagogical reforms of William Osler, who designed the medical residency program commonly used in North America. A graduate of McGill, Osler insisted on getting medical students onto hospital wards early in their training – he wanted them taking patient histories, performing physicals, and doing lab tests, not just sitting in lecture halls. Osler was quoted as saying, “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.”

Perhaps we have Paré to thank, at least in part, for the hands-on approach taken by schools like the University of Calgary, where medical students begin their practical clinical (or patient) exposure in their first year. They learn to communicate with patients through staged encounters with “standardized patients” (actors playing the role of a particular patient) and they are assigned to rotations like Pediatrics, Emergency and Surgery, where they work with residents and attending physicians to get hands-on training – like the medical student I met in the South Health Campus operating room.

So the next time you’re in a hospital and you describe your symptoms to what seems like ten different people, take courage. Your body is a textbook. You’re giving medical students a chance to learn à la Paré. A chance to go to sea and truly sail. And if you have a medical student assisting during your surgery, you’re helping them to learn with their hands and eyes.

But Paré was unable to completely shift the European perspective on the surgeon. Witness the fictional surgeon in Henry Fielding’s novel, Tom Jones: A Foundling. (Fun English major fact – this text is considered by most scholars to be the first novel in the English language).

Writing in 1749, Fielding displays a lack of respect toward the surgeon that likely prevailed in his native country – but let’s not forget that Fielding displayed a hilarious lack of respect for almost everything about his native country. So here’s a look at Fielding’s fictional surgeon.

Our heroine, Sophia, is recovering from a fall from a horse (don’t worry, gentle reader, she was caught by the hero, Tom Jones). Sophia is feeling faint, in the way of all eighteenth-century heroines. She tells her father, Squire Weston, that she feels fine, but he decides blood-letting is in order to maintain her spirits. The narrator tells us that “Sophia soon yielded to the commands of her father, though entirely contrary to her own inclinations, for she suspected, I believe, less danger from the fright, than either the squire or the surgeon.”

Indeed, Sophia is magnanimous in her treatment of the haphazard surgeon. “If you open an artery,” she says, “I promise you I’ll forgive you.”

The surgeon assures Sophia there is no cause for worry; he is not one of those monstrous pretenders who are ignorant of surgery but collect gobs of money from innocent patients.

The surgeon proceeds to bleed her “with as much dexterity as he had promised; and with as much quickness: for he took but little blood from her, saying, it was much safer to bleed again and again, than to take away too much at once.” So much for the integrity of the eighteenth-century surgeon.

Speed continued to be one of the key attributes of an effective surgeon, particularly in the days before anesthetic. It’s easy enough to imagine why speed is essential to the unfrozen version of surgery – especially when a limb is being amputated. One of the marvels of speed-surgery was Dr. Robert Liston, a 19th-century surgeon who could perform an amputation in only a few minutes. But, in the manner of Icarus, Liston pushed himself to dangerous heights, flying too close to the sun.

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The Fall of Icarus (detail) by Merry-Joseph Blondel, 1819. Wikimedia Commons.

While trying to break his speed record he accidentally amputated both of his patient’s testicles, and on another occasion cut off his assistant’s fingers.

But history has left the Listons and the blood-letters and the barbers in the distant past. As Jacalyn Duffin notes, “no medical heroes have enjoyed greater prestige than the surgeons of the late nineteenth and early twentieth centuries.” But that optimism, says Duffin, has now faded. Today’s complex surgical procedures are enormously expensive and health-care costs are rising against a landscape of economic ups and downs (mostly downs).

To all this chatter of history and technique, the outstretched patient at the South Health campus is oblivious. This patient is oblivious to the cool, damp sensation as the nurse spreads a reddish substance over the belly. The patient is oblivious to my presence in the room.

The surgical team, on the other hand, is alerted to my presence by the surgeon, who introduces me as the medical school’s writer in residence. My entrance is followed by that of a medical student, and then there are jokes about the number of peripheral people in the room – We’ll need grandstand seating in a minute! Chuckles emanate from papery masks.

Then, silence falls as the team prepares the patient, laying blue drapery across thighs and chest. The silence is broken by the anesthesiologist, who says:

Jane – have you ever observed a surgery before?

I swivel on my padded stool. Several eyes glance at me over masks.

No, I haven’t.

So Jane, says the anesthesiologist. Have you ever passed out before?

No, I haven’t. (I decide that blacking out while rolling down Whitemud Hill at the age of eight doesn’t count).

Ah. The anesthesiologist nods. Let me walk you through the process… First you’ll feel very warm, and your face will feel flushed. This is exacerbated by the mask you’re wearing. You’ll feel warmer and warmer.

Here my mind veers in two directions. On the one hand, the anesthesiologist may be messing with me. On the other hand, I become acutely aware of the heat of my own breath, and I imagine the accumulation of carbon dioxide within the papery folds of my mask.

Just tell us if you feel faint, the anesthesiologist is saying. And be sure you’re sitting down.

Okay, I say, looking around at the pairs of eyes. I tell myself not to miss anything before I pass out; writers are observant. I will need concrete detail for the blog.

There is much to observe here. Here is the surgical nurse, and another nurse who has not scrubbed in – she sits near me at a desk, typing occasionally on a keyboard. There is an assisting physician, and I later find out that this is often a physician from another country. There is the surgeon, who is being helped into a gown, and the medical student.

And there is the beep of the heart monitor, which drags my own pulse into its footsteps as I tell myself that a little imaginary carbon dioxide never hurt anyone. I will not pass out. Not today.

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The Effect of Melodrama by Louis Leopold Boilly, 1830 How Stuff Works

 

The nurse sitting behind me, as if reading my mind, leans over and says, Pinch your nose.

I pinch my nose.

No, the mask, she says.

Oh.

I pinch the mask over my nose.

Huh. She gets up and takes a look. Ah, she says. You put it on upside down.

I look at her mask and see that there is a stiff strip of something on the top part of her mask, which she has pinched in order to … I assume to create a bit of a tent around her nostrils? I google this later and discover that the main intent is to create a tight seal around the nose, but also to facilitate breathing. For now, I will have to live through the appendectomy pinchless.

The nurse also explains that because I have not fully scrubbed in, I cannot approach the patient. I have not disinfected my hands or donned the full surgical gear, so I will have to imagine a field of sterility around the patient and not enter this field.

But feel free to get up and walk around so you can see better, she says.

Her tone is warm and friendly – helpful, as if I were someone who actually belonged there. She asks me about my writer-in-residence role and I tell her about it. She seems genuinely interested, and I feel less jittery. The air beneath my mask is less hot.

As the surgeon, the medical student and the assisting physician take their places around the patient, I make some mental notes. I’ve left my notebook in my briefcase, and consider asking the nurse for a pen and paper, but decide it’s going too far. Later the surgeon will kindly retrieve my briefcase, and I will have the luxury of written notes.

The room itself seems ordinary – what had I expected? Something atmospheric, otherworldly, something worthy of the serious nature of the work undertaken here? But the room is just a room; one that happens to have a surgery happening in it. Having said that, the accoutrements here are extraordinary. A technological device hangs from the ceiling with plug-ins, cables, presumably to power the tools used during the operation. There is the anesthesiology module with what look like gas tanks on it, a ventilation unit that sighs up and down, different colored cables, outlets, a fan-like metal object labeled “anesthesia.” On a different module there are plastic jugs with red lids, standing empty, as if at the ready. On my right is the computer workstation where a nurse stands. On my left, a trolley, a sort of cabinet on wheels with cardboard boxes of suture materials.

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Source: Geekymedics

 

The boxes are labeled with names like:

Chromic gut

Perma-hand silk

Monocryl

For some reason I hear the names of the sutures being read over a PA in a grandstand, a brassy voice echoing over the pounding of horses’ hooves in soil: On the inside – Chromic Gut, followed by Monocryl and Perma-Hand Silk! This, I think, is how far removed I feel from the world I am observing today. Borrowing from my extensive experience in horse-racing to interpret the lexicon of sutures.

During the appendectomy (affectionately known as an “appie”), I remain seated on my stool, peeking half-heartedly between the backs of the medical student and the assisting physician. I will be here for four surgeries, why push my luck? I will acclimatize now, adjust to elevated CO2 levels. I will take a closer look later. For now I content myself with glimpses of scalpels, and the laparoscopic tools that look like a cross between a gaming joystick and the grabbers that elderly people use for hard-to-reach objects.

I watch the proceedings on the monitors, where I can see the appendix being clipped away from its fleshy housing. Somehow, inexplicably, the surgeon uses the laparoscopic tools to insert a tiny plastic bag into the abdominal cavity, open the bag, and slip the appendix inside. When the organ is removed, it’s placed in a plastic jar and handed to a nurse. She holds it up so I can see.

It is pink, sleepy, innocent. How could it have caused so much pain? I realize the nurse is waiting to hear the insights of the medical school’s writer in residence, but all I can think to say is:  It’s so small.

After the operation, the patient is brought back. I miss the process of awakening; perhaps the surgeon was speaking with me, or perhaps I was imagining the equine strides of suture silks. But when I see the waking patient, they are shaking. It’s a full-body tremble, one that lifts the torso, the body curling up and I’m not sure if they are in shock or simply cold. It is not easy to watch. A nurse moves to the patient quickly and covers them with extra blankets. I wonder if the patient will remember the blanket.

It’s a gesture that makes me think of a time, years ago, when I lay in Emerg at the Rockyview, the remains of a pre-child shape slipping away from my body. I lay on a gurney, shaking, as cold as I’ve ever been. Surrounded by people who were sick, sicker than I was – I wasn’t really sick, was I? So I just lay there waiting. Waiting and shaking.

I don’t remember much about that day, but I do remember a nurse coming up to me and standing silently at my side, then disappearing, and returning with a blanket. Not just any blanket. A heated blanket. A blanket like an August afternoon. A blanket that made me remember lying on the dock at Shuswap, the lazy slosh of water beneath the planks and the soft nub of towel beneath my skin.

It was a simple gesture, but to me it was meaningful. In the chaos of the emergency room, one woman took the time to look, sense and help. Under the heat of the blanket I felt it wasn’t so bad; I would get through this.

And there, the person who has just had three small holes stitched up on their belly is still now, perhaps comforted by the weight of a blanket. By the sense that someone is watching, sensing, helping. Or perhaps they’re just more awake now.

After the surgery, I am whisked away to a lounge, where the surgeon, the medical student and I perch on couches. It’s a debrief, and a teaching moment. The surgeon turns to the student and asks what causes appendicitis. Why does the appendix burst? Why do we even have an appendix? The last question gives the student pause, and the physician says, not unkindly, Look it up and tell me next time. They discuss different presentations of appendicitis, and the surgeon presents a few hypotheticals: what would you do if …

At one point the surgeon asks what else a mass on the appendix might be. The student is stumped, so the physician offers clues. What is the patient’s darkest fear? He asks.

Cancer, I think. … Cancer, I think more loudly.

Cancer is the answer I’m looking for here, says the surgeon, not unkindly.

The student struggles with some of the surgeon’s questions but comes across as engaged and motivated to learn. I can scarcely imagine trying to learn what med students learn in their first couple of years.

I feel bad for adding to the stress of the quizzing – no one likes to struggle in front of an audience. The surgeon acknowledges the potential for stress as he teaches; when the topic of blood pressure is broached he makes a little joke – it rises, he says. Kind of like when you’re being grilled. They each manage a smile.

The surgeon will tell me later that there’s a balancing act here. You want to build confidence in students, he says. If the pedagogical situations get too overwhelming they get anxious, understandably.

The student will tell the surgeon later, as we wait in the hall between surgeries, that it’s nice to have this much one-on-one time with a mentor. Apparently this doesn’t always happen. The surgeon suggests going to the less accessible physicians and saying, Hey, can I get fifteen minutes with you today to ask you about X?

Good idea, the student says, seeming pleased not only to have gotten some solid training from the surgeon, but to have received solid advice on how to learn as much as you can during the clerkship years.

The discussion makes me realize how diverse the clerking experience must be, depending on the personality, inclinations and strengths of the physician placed in a teaching role.

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Archival photo:  Grand Rounds session at the Jacobs School of Medicine. Source: University Archives, Jacobs School of Medicine

This particular surgeon enjoys the role of instructor – he’s been doing many of these surgeries for decades, and he says the teaching makes his work interesting now. Most of the students are very bright, he says, but he seems equally interested in their work ethic. They should come to the hospital wanting to get to work, he says, like the student today. Pitching in, unasked, helping out the nurses and the assisting physician with whatever needs doing. This student is a keeper.

The hands-on learning approach in medicine is completely different from classroom learning – which med students do mainly in their first and second year. Once they start clerking, it’s a whole other world where they are thrown into working with patients. It must be terrifying at times, but highly rewarding at others. There is always a support system of residents and attending physicians to guide the students, but they are given quite a lot of responsibility as soon as they hit the wards. On this day, the student has assisted with opening and closing. On other rotations this student has opened, closed and removed a breast cancer lump.

Put in the context of the series of four surgeries that will take place today, the med student’s tasks seem relatively minor. But really, this person, who has but a few years of medical experience under the belt, (and of those years part of it is classroom based) is performing a role that most of us would find weighty, stressful, perhaps unimaginable. Who can picture taking up a slender knife and slicing away at the layers of flesh on a fellow human’s abdomen? Who does not tremble with anxiety at the thought of cutting away an internal organ and pulling it from a fellow human’s body? Atul Gawande sums up this solemn relationship with one’s fellow beings in Better: A Surgeons’ Notes on Performance. He writes that living the life of a doctor is “to live a life of responsibility.”

I recently discussed the weightiness of this responsibility with another Calgary surgeon. I confessed that I had trouble imagining the stress of the surgeon’s life. I lose sleep, I told the surgeon, over grading essays inconsistently, losing control of an event I’m organizing, or portraying someone inaccurately in an article. I have felt sick to my stomach over these worries. I have lain awake all night. How can anyone learn to live with the worries of making mistakes that affect people’s bodies, their health, their lives?

Oh, I freak out about all sorts of things, the surgeon told me. Not just the surgery stuff.

Which was not the response I was expecting. I was expecting a speech about a magical blend of yoga, controlled empathy and mindfulness to cope with the stress of surgery. Not the admission that surgeons worry about everything other people worry about – plus their own professional woes. Worrying about jeopardizing a patient’s health doesn’t preclude worrying about being late picking up your kids from school.

Meanwhile, back in the operating room, the next surgery is a hernia operation. By this point I am easing into the idea of being in an OR. My face is less hot; I feel comfortable looking at metal blades as they pass through flesh. I am still aware that there are two more surgeries to go after this one. And I feel instantly guilty. All I have to do in this OR is sit. Observe. Think interesting thoughts.

It’s the surgeon, of course, who is putting in the real time. He will tell me later about the hours he put in as a resident. Eighty to one hundred hours a week, in order to build up the kind of experience necessary to become an expert in the field, as per Malcolm Gladwell’s 10,000-hour rule. The brutal regime of residency is surely enough to make the faint of heart turn away from specializations like surgery. Of course, says the surgeon, it makes a difference when you like your job.

Given that my eyes are untrained in the art of surgery, and unskilled at identifying tools, organs and procedures, I can offer only the most pedestrian of observations on the hernia operation, listed as bullet points. Here goes.

  • It’s an exercise in care. The surgery begins with a “Time Out,” where a team member reads the name of the patient, the details of the operation. It’s as if they’re saying: If anyone knows of a just cause why this patient should not be lawfully operated on, speak now or forever hold your peace.
  • It’s a gathering of minds and hands. As the surgeon speaks, the assisting physician and medical student lean in, drawn to a magnetic center.
  • It’s mostly silent. Punctuated by the surgeon’s polite requests for tools.
  • It’s hidden from the patient. A blue vertical drape stands between the patient’s closed eyes and the surgical team. Should the patient’s dreaming eyes wish to see the deft movements of the team, they will be disappointed.
  • It’s magical – metaphorically. To the surgical neophyte, there is magic around the act of parting two soft stretches of flesh and reaching inside to heal. It’s surreal to see the tips of fingers disappearing into a person’s belly. These parts of us are meant to be closed, sealed, a continuous expanse of skin, the outer surface that provides the illusion of the unbroken, that hides the lumpy, ripe interior of the human body where one false move will have your head. Where the truth of mortality rests.
    • Bullet point side bar: Maybe it’s because I’m watching season two of Westworld, but I think of the shock of seeing an android’s “flesh” pulled back, exposing the inner workings of its body as a series of cogs, wires, circuit boards and ball bearings.
    • Related image

      Scene from Westworld Space.ca

    • Such is the shock of witnessing a surgery – the dermal layers pulled back to reveal the human body as a series of systems, rotating, contracting, rushing, pulsing. Here is the inconvenient reminder that our bodies are fallible. No one wants to see these inner workings. Sew us up, quick! We want the pink flush of flesh, the perfect promise of tomorrow, a guarantee against the elements, against the tick of the clock. Protection from the onslaught of wrinkles, punctures, fissures, divots, breaks, strokes, scrapes and aches. It is this safeguard of flesh that the surgeon dares to pierce. Here, he says to the patient. Close your eyes for a moment while I reach into your belly, into the inconvenient systems of truth, and perform an act of healing.
  • It’s magical – literally. During the hernia operation the surgeon pulls a long piece of gauze from the opening in the patient’s belly. He pulls and he pulls; the gauze stretches long and longer. It’s a magician’s act, the old pull the scarf from my mouth trick. The gauze, once extracted, is pink and damp, as if torn from the skirt of a tired ballerina.
  • It’s a ballet of gestures. The white gloved hands of the surgeon perform a nimble, white pas de bourée as they suture. They twist, pull, pirouette, guiding a fine thread through flesh.
  • It’s about muscular patience. The assisting physician, who stands hovering over the patient, torso at a slight angle, for the bulk of the operation, occasionally shifts, looks up at the ceiling and stretches his neck. I can feel this phantom ache in my neck, the stiffness in my shoulders.
  • It’s about surfaces. The delicately spotted surface of the belly, crimson on white, that jiggles and bounces like a cake that’s not quite ready to come out.

~~~

When I find out that the third surgery will be a gallbladder removal, I feel an echo of familiarity. I have seen this operation from the gurney. I want to see it from the other side, but I don’t. I’d almost forgotten about it, really. I’m not sure that I want to relive this particular experience. Not that it was especially traumatic. But I remember lying on the gurney in a hallway. That feeling of Oh. It’s like going through childbirth: you get to a point where you’re not terribly interested in moving forward, but there’s no way back.

Again, the patient is swabbed with an antiseptic solution and draped in blue sheeting, leaving a tidy square of flesh, like a target. It’s easier to watch this way, and undoubtedly easier to operate on. The blue field defines a particular area of interest, removing the focus from the clunky bundle of limbs, digits, eyes, lips, shoulders and hips.

Meanwhile, the surgeon selects the musical background.  He surfs the options on the computer behind me. It’s all about finding songs that everyone will like, he says.

I smile at him – the pointless smile of a masked observer. The democratic impetus of this musical strategy hardly fits the image of surgeon as Imhotep. In moments the OR swells with the strains of REO Speedwagon:  Just can’t fight this feeling anymore!

I am transported back in time to… university basement parties? Backyard barbecues?

The surgeon has moved on. In moments, the incisions have been made and he is quizzing the medical student about the gallbladder. He is maneuvering two sets of tools that look like grabbers, and he seems to be cutting away the clingy layers of flesh around the tiny gallbladder even as he pursues a line of Socratic questioning.

The computer switches songs.

That’s just the way it is, explains Bruce Hornsby. Some things will never change.

The patient’s belly lifts and rounds. Oh dear, I think, the patient will be unhappy about this step later on.  I remember the most painful part of the recovery process stemming from the gas pumped into my abdominal cavity during the operation. I remember getting into bed the night after my surgery and leaping up to ease the stabbing pain in my abdomen.

The surgery grinds to a halt as an X-Ray machine is brought in. The surgeon has requested additional imaging and we huddle behind a pane of glass which will, I hope, shelter my fragile nerves, blood and bones from the radiation of the machine. Fire when ready, the surgeon calls out once we are safely huddled.

There is Bono, in the background. He still hasn’t found what he’s looking for.

As the surgery wears on, a nurse lowers the lights so we can see the monitors more clearly. There’s something of a video game to this experience; it must be so unlike the days of traditional surgery where it was just you, your hands and the patient’s body. Now your hands control a tool which does the actual work, and you see the effects of your labor on a screen. Not unlike nudging a joystick with the precision of a child who can nail an alien from a hundred and fifty meters. Or so it seems to me.

This is the end, announces Don Henley, of the innocence.

The tool is not a joystick, after all, and this is not a game – Don Henley knows this intrinsically. The surgeon is cutting through a layer of flesh around the gallbladder and the blood begins to flow. He cuts through a new layer; he is unbelievably deft with the laparoscopic tools and the tiny scalpel shapes rather than cuts. The blade shaves away, nudging the flesh, encouraging it, cajoling, as a sculptor eases the weight of clay beneath her fingers, willing a gradual change in shape.

In the background, Freddie Mercury is singing about this thing called love. He must get round to it.

The surgeon irrigates, sending a waterfall over the cleft flesh. On the monitor the scene is of a pool, a fountain: Flesh, quenched in a human landscape, it might be called, were it a baroque painting.

It cries, sings Freddie Mercury, in a cradle all night.

And there is something childlike, so vulnerable, about the scene on the monitor. A landscape of plummy hills and valleys, threaded with delicate veins. The pink horizons swollen with liquid life, bouncing back with sanguine resilience, chortling at the thin blade that pokes at it.

It shakes all over like a jelly fish, says Freddie.

The surgeon has threaded a small plastic bag into the patient’s abdominal cavity and is tucking the gallbladder, now freed from its surroundings, into the bag. Soon he hands the bag to the nurse, who tips the organ into a little plastic jar, where it lands with a resigned thwip. Or maybe I’ve imagined the sound.

The surgeon steps away from the patient and the energy in the room shifts. The student and the assisting physician lean close over the incision sites to close. The room is tidied, prepared for the next surgery. This is the housekeeping part of the day, the bridge between verses.

I duck out for a moment and grab the sandwich I’ve tucked into an office down the hall. A nurse stops me and tells me not to eat in the barn. At my blank look she explains, indicating the “barn” area as the hallway outside the OR. I step inside the office, where another nurse tells me to tuck my hair into my cap.

I tuck my hair into my cap. It falls out. I give some thought to finding another one, but the surgeon has instructed me not to go off on my own. I picture myself locked in a stairwell and give another go at stuffing my hair under my cap.

When I return to the OR, the final patient is in place, his legs raised in stirrups, and I am faced with the dilemma of witnessing the all-too-intimate performance of the final surgery. It’s a procedure you don’t discuss at dinner parties, the surgeon told me when I asked what the final operation would be. People will talk about having their appendix out, or their gallbladder, while the turkey is being carved. But no one mentions the anal fistulotomy.

After the last patient is wheeled from the room, I follow the surgeon to the locker room, congratulating myself on making it through four surgeries. I am exhausted but intact; my mother will be relieved (why are you doing this, she said to me the day before).

The surgeon and I part ways. We will speak later – he is in a hurry to get to his clinic, so he can see the patients waiting for him. I say nothing; my own neck aches and my legs could be pressed into a dessert mould without much resistance. I will go find a cup of tea and slump into a booth in the hospital foyer, while he jogs upstairs to follow up with patients, or prep them for procedures. Of course, I tell myself, he has experienced this day a thousand times. For me, it is a first. I am simply an observer.

As I blow across my cup of peppermint tea, I wonder if there are any threads connecting the function of surgeon to that of a writer. Perhaps Shakespeare would have seen a connection more clearly. In his Sonnet 18, which begins with, Shall I compare thee to a summer’s day? Shakespeare suggests that by capturing his subject in a sonnet, he can offer immortality. Their healthy glow will never fade.

Nor shall Death brag thou wander’st in his shade,
When in eternal lines to time thou grow’st;
So long as men can breathe or eyes can see,
So long lives this, and this gives life to thee.

 

But I am not Shakespeare and I cannot share his confidence.

What does a writer share, then, with a surgeon?

The love of a craft, perhaps. The willingness to work into the smallest of hours, nudging into line the object of your effort. The desire to make sense of a chaotic world where bones break, hearts arrest, appendixes burst, students try their hardest, and humans discover that their impermeable layer of flesh is permeable after all. Here, perhaps, in the dim depths glimpsed only briefly by Orpheus (don’t look back!) is some common ground. What writer does not seek, on some level, to grapple with the ultimate end game?

Writers are a gloomy lot – not without their moments of joy, but often fixating on the existential. As Don DeLillo writes in White Noise, “all plots tend to lead deathwards.”

Why this obsession with death? To answer this question, let us consult a writer whose concerns with death are easily justified. Paul Kalanithi, a neurosurgeon who penned his memoir as he was dying of cancer, delved unflinchingly into the subject of death.

Image result for paul kalanithi

Paul Kalanithi Source: Good Reads

He is also a good writer to consult about connections between writing and medicine. His first love was literature, and he pursued its study in university, seeing it as “an almost supernatural force, existing between people, bringing our brains, shielded in centimeter-thick skulls, in to communion” (When Breath Becomes Air). He was seeking connections between biology, morality, literature and philosophy. But he began to see words as weightless, and craved what he called “direct experience,” turning instead to medicine, where answers were not found in books but in the human body. He determined to “keep following the question of what makes human life meaningful, even in the face of death and decay.”

And perhaps this juxtaposition of life and death is an ideal frame for a study of human existence. As a palliative care specialist recently told me, her work is rewarding because it takes place in the most “real” moments of people’s lives. There, hanging in the balance between this world and the next, moments take on a brilliance, a piercing singularity where the meaningless falls away and reveals the starkness of the truly real.

Yet, when faced with his own diagnosis of terminal cancer, Kalanithi turned back to literature to make sense of his mortality. “To understand my own direct experiences,” he says, “I would have to translate them back into language.”

Here is one of the purposes of narrative medicine, the study of medicine through the lens of literature and creative writing: providing physicians with a method for retreating from the world of direct clinical experience long enough to reflect deeply on what it means, how it should be performed, how patients should be best understood – ethically, morally, empathetically.

And here, somewhere in this crossroads where life, death, meaning, medicine and language intersect, is the place where writer and physician find common ground.

 

 

 

 

 

Of birdwatchers and brutes

Image result for aeneas treated by physician first century fresco casa di sirico pompeii

Aeneas treated by a physician. First-century fresco from Casa di Sirico, Pompeii. As seen in Medicine: Perspectives in History and Art, by Robert Greenspan, M.D.

 

Three weeks into my residency at the U of C medical school, I feel overwhelmed. Overwhelmed by the generous welcome extended to me by faculty, administrators and students. Overwhelmed by the shockingly concrete but cerebral nature of the medical world. Overwhelmed at my inability to navigate the medical school administration structure (my kingdom for an org chart!). Overwhelmed by the volume of information that can be passed on to students in one short hour.

And I feel vicariously overwhelmed, listening to students as they unwind, commiserate. Someone will express their shock at the sheer volume of notes they’ve produced for one class, or their shock at the sheer longevity of their fatigue since beginning medical school. Or their struggle to stay abreast with the curriculum: Surely they can’t fail us all! Or a more pleasant shock, realizing they are capable of witnessing a surgical procedure without sinking to their knees, without losing the integrity of their peripheral vision to the thick, dark curtain of consciousness (which makes me wonder … what would I do if I witnessed the true slice of a knife – correction, what will I do, since I have asked to view a surgical procedure during my tenure as writer in residence at the medical school?).

 

As part of my effort to immerse myself in the medical school culture, I recently attended a lecture on heart failure pathophysiology. Sitting in the vast, tiered space of the Libin Theater, I was not surprised to find  much of the terminology foreign to me. Yet I managed to follow the gist of the lecture – thanks in part to the instructor’s use of analogies.

Side bar:  There is a down-side to a lecture that pierces the non-scientific brain while illuminating the imaginative potential of said brain … I exited the lecture theater convinced that I had congestive heart failure. But please don’t worry yourself, gentle reader; I have since convinced myself that I have a lingering cold.

But we were speaking of analogies. I had never considered the similarities between a toilet and a heart before, but how useful is this unexpected comparison! Equally useful, the evocation of a garden hose to discuss pressure and flow – stepping on a hose stops the water from proceeding but does not decrease the flow or the pressure.

The PowerPoint slides in this lecture will, if all goes well, directly inform students’ experiences in examination rooms, Emergency rooms or operating theaters as they move through their clerkships and residencies, placing stethoscopes on the shivering skin of a patient (a feng shui consultant? A spelling bee prodigy? A failed astrologer?).

The practical applications of the PowerPoint slides separate the medical world from the English studies class, the value of which often befuddles even those of us who truly believe in the value of literature. As an English instructor and TA, I’ve created hundreds (thousands? Oh dear; why is this so alarming?) of PowerPoint slides, some of which draw elegant, meta-level dotted lines between learning outcomes and real-world skills: A close reading of The Tempest will bolster critical thinking, and enable you to employ language in all its layers of nuance and subtext.

In teaching English 201, a literature/composition class for non-majors, I continually pointed out the skill set we were building:  societal critique, collaboration, understanding the power of language and rhetoric, and, of course, writing clearly and persuasively.

As someone who has worked in communications and marketing, I know that these skills are useful in the workplace (at least, the workplaces I’ve known). Ask any professional writer what it’s like to have their work reviewed by a director unaccustomed to tracking the twists and turns of verbs, nouns and adjectives.

The writer will simply grunt, being too polite to comment further.

But I also know that millennials often struggle to imagine how skills like close reading and the interpretation of literature can benefit them once they step outside the English classroom.

So I was pleasantly surprised by my visit to an Ethics class during the first week of my residency. The instructor had told me I absolutely needed to attend her Ethics class – and she was absolutely right. I hustled from a meeting about my potential role in physician learning programs, but arrived late to the class, interrupting a group of second-year students who were presenting book reports.

Now, you may be thinking: Is this really what medical students do? Book reports? When you saw the phrase, “book report” you may have closed your eyes and relived a nostalgic grade-three montage:

You select a dog-eared paperback from your book case. You dig a Sprite-stained scribbler from your backpack, sharpen your pencil and scrawl a few quick lines: “… and that’s when his brother sprouted fur on his elbows!” You read your manuscript in a wavering voice to your classmates while curling your toes inside your sneakers.

 

But the Ethics class was no sophomoric exercise in plot summary.

These students conducted a rigorous investigation into the role of ethics in medical practice, using literary representations of physicians as a departure point for discussion.

When I barged into the class (the students kindly making space for me), two participants were discussing a collection of short texts by Richard Selzer titled, Letters to a Young Doctor. The presenters explained that the texts were meant to teach junior doctors the art of humility – a trait held in high esteem by the ethics class. But the book’s purported purpose and its actual message had little in common, according to the presenters.

The writer in me was fascinated by this exploration of the old creative writing maxim:  Show, don’t tell. Selzer tells his readers that his essays and letters promote humility, but the words on the page show a completely different ideal: the doctor as a version of Alexander the Great.

Rather than a book that shows how physicians can treat patients with respect, the collection, according to the presenters, acts as a cautionary tale to those wanting to pursue the life of a physician (note the apt use of literary terminology to characterize the unintended and ironic effect of the stories).

As the class described one particular piece titled “Brute,” in which a physician sutures a flailing patient to the table in order to treat a laceration, one student confessed:

I hated this book.

After all, here was a portrait of a doctor as a God-like man, written by an old-school surgeon who could never live up to the standards of the 21st century. A surgeon who knows he behaves inappropriately but doesn’t know how to change.

A few days later, I decide the much-maligned Richard Selzer merits a closer look. Perhaps a non-medical reader would be more sympathetic to this patriarchal dinosaur. As it turns out, the U of C library has not made space for this particular tome on its shelves, so I download it on Kindle.

I come across an introductory section titled, “Textbook,” in which the narrator offers advice to a fictional addressee, presumably an intern. In discussing the physical examination process, the narrator says, “If your examination is performed with honesty and humility,” messages will be sent between patient and physician that “will cause the divining powers of the Augurs to be passed on to you – their last heir.”

Augurs.

 

I imagine Richard Selzer draped in his trabea, brandishing his lituus, interpreting the gestures of gods.

What a revealing reference.

I think Selzer is trying to emphasize that a physician’s power comes from an honest and humble connection to the patient, but I can’t get past this reference to the augur, to which he alludes again at the end of the chapter. Is it simply arrogance couched in humility?

Bear with me while we travel back in time.

The role of the augur shifted over the years, but originally these religious officials of ancient Rome were men of great merit and high birth. The role had great political importance – augurs advised governors on divine omens integral to decision-making processes. And their divinations focused on the observation of … birds.

To properly interpret the will of the gods, the augur would select an elevated spot affording a panoramic view of the Roman landscape and sky.

 

Between midnight and dawn he staked out his position, ready to read the creatures who fluttered past. The east on his left, the west on his right.  Signs occurring on the left-hand side of the augur indicated prosperity; those on the right were unlucky.

Here it should be noted that in Greece, augurs found the opposite to be true.

How did the augur interpret his fowlish friends? Certain birds, such as vultures and eagles, offered information through their manner of flying. Others, such as owls and crows, exposed divine secrets through their distinctive cries. Having interpreted these bird signs, the augur would render his report. If positive, he would intone:

“The birds allow it.”

So what does Selzer’s association of the physician with the augur signify? Does he see the medical doctor as having a special relationship with divine powers, able to interpret data and guide the population toward insightful decisions and, ultimately, healthy lives? Or is Selzer simply spelling out an equation:

Humble physician + patient = useful insight

The reference to augurs foreshadows a discussion that took place later in the Ethics class as students reflected on the power invested in physicians – a power they will, one day, wield. Students acknowledged that humility seems well within their grasps now, but they wondered how easy it would be to remain humble in a world where physicians – and particularly surgeons – are hoisted onto pedestals, raised to dizzying heights.

You, the patient, might abhor an arrogant surgeon while your body is strong and well, but the moment your flesh fails you, will you seek out a surgeon who slices into your flesh with the confidence of the nearly divine birdwatcher? Will you be part of the pedestal problem?       

Setting aside the hypocrisy of the patient, I next make my way to a piece by Selzer titled “Brute.” It’s written in the second person (“you”), a point of view that can be either accusatory or inclusive. The story begins with the narrator, once again the experienced mentor, speaking to an intern. The intern has treated a patient badly, in part because the intern was tired. “You must never again set your anger upon a patient,” warns the narrator.

The narrator then asks the intern to step into the shoes of an imaginary patient. “You are worried that there is something the matter with your heart,” the narrator tells his addressee. “Chest pain is your Chief Complaint. It happens that your doctor has been awake all night with a patient who has been bleeding from a peptic ulcer of his stomach. That is your doctor’s Chief Complaint. I have chest pain, you tell him. I am tired, he says.”

As a student of empathy, I’m fascinated by this narrator, a construct of Selzer’s brain. How interesting that this augurly narrator would ask a medical neophyte to put themselves in the shoes of an anxious patient. And how interesting that the narrator minimizes the physician’s fatigue. Selzer tries to show, with a minimum of sentimentality, that a patient’s need for treatment should always trump a physician’s physical requirements.

But is this a case of the surgeon recognizing himself as a subject whose physical state has less value than the patient’s? Or does this passage imply that surgeons should always have the emotional and physical wherewithal to raise themselves up (as high as a pedestal?) out of the mire of the mere mortal, to a higher plane (a hill near Rome perhaps), where the air is somewhat rarified?

Let’s look at what happens next to answer that question.

Next in “Brute” we have a story within a story. The initial incident, in which the mute intern is called onto the carpet by the narrator, is simply a frame to the real narrative. The real protagonist here is not the intern but the wise and generous narrator, who proceeds to recounts the incident which, as I mentioned earlier, caused one of the Ethics class students to profess their hatred for this book.

I click to the next page of “Brute,” telling myself to remain open, objective. Sure, Richard Selzer has compared himself to a Roman sitting atop the highest peak, divining the meaning of the noble eagle. But surely this piece will reveal more about Selzer’s vision of the physician than an ego on a hill.

And indeed it does. But it’s not a revelation that endears Selzer to this particular reader.

Four sentences in to the story-within-a-story, the physician narrator hears a commotion and a “huge black man” is escorted into Emerge in handcuffs. Already, I am on my guard. Why the reference to the color of the man’s skin?

Two sentences later, “the man rears.” Then, the “mythic beast” resists, “rearing and roaring” to shake off the police officers.

I suddenly need to know when the book was written and I find the date – 1982. Not surprising that Selzer was not writing in the 21st century – this sort of animalistic portrayal would never have been condoned by a modern editor. But I continue on.

The narrator continues to identify the patient as a black man, noting a deep laceration on his forehead, and adds, “Had he horns he would gore [the police officers].”  He “roars something, not quite language.”

Now my hackles are fully raised.

I’m also flashing back to Shakespeare … The Tempest. I hear the European Miranda upbraiding the lowly islander, Caliban, saying that he would “gabble like a thing most brutish.”

 

When I see “brutish” and equate Caliban’s gabbling with the black patient’s “not quite language,” I wonder if Selzer is a student of The Bard, and is pulling from The Tempest for inspiration. Is he fascinated with Prospero, the authoritarian Magus who colonized the barely human Caliban?

 

Prospero, too, is an augur of sorts, a wielder of knowledge and power, an alchemist and scientist, a man who can perceive the mind of God.

Then again, maybe Selzer is Shakespeare himself in this scenario. Some scholars argue that Shakespeare tried, with his seventeenth-century quill, to bestow some dignity onto the colonized Caliban. Caliban, to the careful reader, only babbled because Prospero did not speak the language of the islander.

And surely there is more to the black patient’s “roaring” than meets the eye. Surely readers in 2018 cannot help, as they read this narrative, hearing the names that have been shouted and keened across the United States and around the world:  Michael Brown, Philando Castile, Alton Sterling, Walter Scott and more.

 

The racist language continues throughout “Brute.” I will spare you the details.

By the time the narrator finally makes a feeble attempt to empathize with the patient (“What is he thinking? I wonder.”) the situation has escalated beyond hope. The patient is strapped down on a stretcher and the narrator tells him to hold still so he can stitch the laceration. But the man rolls his head, spitting and cursing, and tells the doctor, “You fuckin’ hold still.”

Our intrepid narrator, exhausted by a long shift and sucked into the panther-like brutality of the patient, threads a needle and … stitches his patient’s ears to the stretcher.

To his credit, the narrator looks back on his actions with a certain level of self-awareness. When he grins at the prisoner, it is the cruelest grin of his life, he tells us. The grin of a torturer.

For a brief moment the narrator speculates on the patient’s motivations: he is so wild that ripping off his earlobes would not faze him. But he must harbor a “beastly wisdom” which tells him he has lost. Perhaps he has a woman waiting for him, or a child, who will elicit paternal shame by asking about his father’s scars.

Here is the narrator’s attempt at empathy. Speculation, fueled by his vision of the patient as less than human, about the man’s barbaric intuition, his family situation, his paternal pride.

A huge gap exists here.

What is the patient’s back-story? Shouldn’t the police officers have pulled the physician aside and told him why the patient is in such a state of rage?

Let me digress for a moment, to tell you that I recently spoke with a physician who runs a palliative care program called CAMPP for homeless people, out of the Foothills Hospital. He laments the current lack of understanding around homeless people and their back-stories, and works hard to advocate for his patients as they move through Calgary’s health care system.  He and his team understand the need to know a patient, to establish a trust-based relationship with them, and to know enough about them to properly empathize.

Surely this is the sort of compassionate medical practice that Selzer’s narrator should have striven for.

Now, I’m not assuming that our narrator’s patient is homeless; it just seems that knowing something about his history would be more helpful than speculating about a patient’s beastly wisdom.

But let’s return to the Ethics class. The race-based analysis of Selzer’s narrative demonstrates how a book report can spark discussion on the issues physicians will likely face in the curtained spaces of Emergency rooms. The class didn’t get to a discussion of race, but they explored the issue of humility, as raised by Selzer’s collection. Prompted by their instructor, students reflected on the importance of preserving their humility, and the vulnerability required to assume the perspective of a patient.

Toward the end of the discussion, the Ethics class students returned to the idea of Selzer’s text as a cautionary tale. The presenters were not sold on the narrator’s eventual desire for atonement (“How sorry I will always be. Not being able to make it up to him for that grin.”) Where is the sincerity? Where is the narrator’s recognition of his paternalistic language?

The narrator’s lack of authentic empathy, combined with the racist attitude in “Brute” makes it difficult to sympathize with the narrator. But the text does make you question whether the narrator is simply a monster, or if there is something about working shift after shift in Emerge that erodes your capacity for compassion. Something that makes you think you’re in a battlefield.

I can’t help but wonder if the Ethics students were considering how they themselves will respond when faced with a challenging patient. Will there be an urge to strike out, to shout, to exercise the power of a physician, as granted by our culture? And if so, how will they control this urge?

Will any of the students recall, in a moment of frustration and anger, their feeling of repugnance as they read Selzer’s narrative? If so, the memory of this Ethics class – one planted firmly in the limbo between humanities and medicine – would underscore the value of using art and literature to foster reflection on medical issues.

The discussion in this class ranged from meta-level explorations of the role of a physician to case study-like investigations of specific ethical issues. A text such as Selzer’s enacts, in intimate detail, situations in which physicians must make choices with ethical implications.

Indeed, all the books discussed in the class provided students with complex, provocative jumping-off points for reflecting on the ethical dilemmas ahead of them. The students seemed passionately engaged in discussion, and genuinely concerned about the challenges ahead of them. They approached the topics with sensitivity, eloquence and insight, unafraid to tackle issues such as euthanasia, exploitation of minority groups, compassion for the vulnerable Other, and the stereotype of the egomaniacal surgeon.

All this, from a simple exercise on book reports.

 

 

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