Tag: medical ethics
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.”
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.