Tag: University of Calgary
I’d like to tell you about my visit to the intensive care units at the Rockyview and Foothills hospitals in Calgary.
But the story really begins last fall, in a cozy café in Kent. I met a friend of mine there who spends part of her year in India. With rain streaming against the windows and steam rising from our teacups, I asked what drew her to India.
In India, she said, you see death.
Oh, I said. And then I thought (and I accidentally said this out loud), That’s a strange reason to like a country.
She smiled and said, I just mean that in India, death is more natural. It’s out in the open. You can talk about it.
And then we sipped our tea, ate a sandwich, and talked about death.
But this, of course, is not normal.
As Atul Gawande says in his wise meditation on aging and death, Being Mortal, “In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality and created a new difficulty for mankind: how to die.”
Gawande offers a nuanced discussion on our culture’s inability to face death head-on, and our tendency to prioritize complex medical treatments over quality of life as we near the end. As one ICU team member remarked to me during my visit (we chatted in a quiet spot, removed by several feet from people attached to ventilation machines, heart monitors, IVs and more): You’ll notice that physicians do not choose to die like this.
But Gawande’s text also embodies a growing interest in putting humanity back into medicine. An interest that plays out in the intensive care units I observed.
Let’s begin the story of the ICU by looking backward.
Intensive care medicine has not been around long as a specialty – it’s a junior sibling in the medical family, having grown up in the latter half of the 20th century. Its purposes are wide-ranging: According to Care in Canadian ICUs, published by the Canadian Institute for Health Information, “ICUs serve a broad range of patients, from those with pre-existing conditions to those with unexpected injuries or illness, as well as those who need support before and after undergoing complex procedures.”
So what is intensive care, exactly?
In “A History of Intensive Care Medicine,” Jukka Takala defines intensive care as the prevention, reduction and removal of the temporary risk of death. Takala says that in intensive care medicine, “concentrated investment of human, material, and technological resources for monitoring and treatment are employed to defeat death and morbidity.”
This sounds promising. Removing the temporary risk of death.
How comforting to know that the risk of death can be removed. Picture poor Orpheus, comforted by the thought that he can cheat Hades. Thinking he can pull the beloved Eurydice from the underworld. Just don’t look back, Orpheus.
Picture the glint of a metal blade, slicing open the throat of Hades. If you’re careful, you can do it. Just be very very careful. Don’t look back.
It’s hard not to see, between the lines of Takala’s definition, the inherent human aspiration to immortality. The bald hubris of living one’s life aware of mortality, but believing that one can defeat death. That the messy business of exhaling that long, lonely, terminal breath is something I and only I can skip by. Escaping the gaping maw of mortality, but for the grace of god. The removal of risk. And life is always a risk; every time you walk out the door you take your chances, roll the dice, gamble and hope.
Death, it would seem, can be defeated through the employment of human, material and technological resources.
Of course Takala doesn’t mean that death is something weak and flimsy, the dodge ball captain who chooses players poorly. Takala is talking about defeat as temporary. The fleeting defeat of death. A hopeful holding back of the tide.
Intensive care medicine is about life; the sustaining of. It’s also about decisions. Teamwork. Compassion. It’s about the human body and its opaque complications. And sometimes the ICU is about death.
Which our culture sees as a failure. But as Atul Gawande reminds us, death is not a failure. It’s normal.
Let’s procrastinate a bit longer on discussing death.
Where does the concept of the intensive care unit originate? Takala notes that Florence Nightingale is often credited with establishing the first ICU during the Crimean war in the 1850s.
Nightingale gathered together the most severely injured soldiers in one area, so nurses and doctors could monitor them and intervene efficiently.
According to Takala, some believe the ICU originated from an early postoperative ward in Newcastle, England, in the early 19th century, which housed the sickest patients and those recovering from surgery. As one of the Calgary ICU residents told me, anesthesiology has played an integral role in the history of the ICU. These practitioners would often stay with post-operative patients if they needed extra care. Later, in 1952, a polio outbreak in Denmark also provided some of the inspiration for intensive care medicine, with nurses and medical students manually ventilating patients for days on end.
Beyond its origins, the ICU has come to rely on the innovations of a few maverick physicians.
Consider the case of Werner Forssmann (1904-1979), who, as a young surgeon-in-training in Germany, threw personal safety out the window in the effort to invent a method of catheterizing the hearts of patients at risk for cardiac arrest (again – eliminating the risk of death!). He lubricated a 65-cm-long uretreric catheter and inserted it through his own left brachial vein, checking with a chest X-ray that the tip of the tube had snaked its way into his right atrium.
Forssmann was later fired, after attempting this procedure on a patient. Only to be vindicated later, eventually sharing the 1956 Nobel Prize in Physiology or Medicine.
Forssmann’s willingness to sacrifice his own noble veins in the name of medicine is no doubt unusual. But the same spirit of dedication to medical care lives and breathes in the intensive care units of Calgary.
I expected that the first thing I would notice when I entered the Rockyview ICU would be a smell – I don’t know why. Did I think that here, where patients were the most critically ill, the odors of the healing environment would gather themselves up and swirl together, tornado-like, into a funnel of concentrated pungence?
At the Rockyview I remember the smell of spaghetti, heating in the microwave. At the Foothills, the smell of vanilla in one patient’s room … the vestige of a topical cream.
No funnel of foreign odors.
But there was no shortage of newness. The foreignness of an environment, signalled by the newness of words. Vocabulary that has shaped itself into a dialect over time, as a team of people work together in a specific environment. As they confer, intubate, teach and tend, they pour their words into the vessel of the ICU. And the words retain the shape of that vessel, like metal in a mold. Here is how they sound to tender ears:
Rounding (it is a verb)
Attending (it is a noun)
Fentanyl (it is a medication)
Sleep (it is a dream)
Pain (it is a measurement)
Bowel (it is a sound)
Grimace (it is a measurement)
Quiet (it is a jinx – don’t say “it’s quiet today!”)
Failure (it is a beginning)
Silence (it is a teaching moment)
Resistance (it is relative)
Tachy (it is pronounced tacky, but means swift)
Crackle (it is a prophesy)
Sundown (it is a verb: erratic nighttime behavior)
Physio (it’s your new best friend)
A good death (it is peaceful)
The opportunity to die (it is a gift)
Striving in adversity (it is the norm)
Excellence (it is the minimum)
Competence (it is your identity)
Just a quick note as we dive into the ICU: I refer to team members below, but I’ve mixed together team members from both the Rockyview and the Foothills. The comments are tied together by context, not geography.
My day at Rockyview begins with rounding (verb; to conduct a teaching conference or a meeting in which the clinical problems encountered in the practice of medicine are discussed).
The team moves from patient to patient, from room to room, spelling out the details that define that person while they inhabit the ICU. I am surprised by the size of the team – four residents, an attending physician, a pharmacist, a dietician, a respiratory therapist (RT), the nurse assigned to that patient, and a nurse clinician. And today, the writer in residence.
The ward at Rockyview is a double-lined hallway of individual patient rooms – each has a number above the door, so the inhabitants become, at times, Bed 1 or Bed 8. At first this seems impersonal; a human being who was riding the CTrain or taking a grandchild to swimming lessons the day before, becomes a piece of furniture upon which they will lie, falling in and out of consciousness, until they are well enough to leave the unit. Or not.
But as the day wears on I learn to appreciate the nomenclature. I understand the need for clarity. The sheer volume of details surrounding each patient is overwhelming. If I were in Bed 1, I would not want to be confused with bed 8. In any event, the “bed” terminology is used only occasionally. When discussing the patients, the physicians and nurses tend to use their actual names. Names, the human code; in intensive care, codes merge with names, technology is deeply personal, tubes flood the body and replenish the lungs, monitors turn the human inside out.
As I will discover, the inhabitants of the ICU are treated as people with rich, sometimes thorny stories – people who just happen to be stuck in a chapter where their bodies have stumbled, and are struggling to rise. The trouble is, you don’t always have time to dig deeply into the personal stories when patients arrive in distress.
One team member told me about a former patient who did not seem responsive when they spoke to them; in the initial wave of caring for a new patient, they assumed this person might have a brain disorder of some sort. Only to find out from the spouse that the patient had neglected to bring their hearing aids to the hospital.
Inhabitants of the ICU are often living out chapters that are circular, a groundhog-day loop where one problem becomes another becomes another. Repeat. And some of the inhabitants have been wedged into this particular chapter for a very long time. The chapter can be a highly complex read.
A common conversation with patients’ families involves reminding them that the original health issue for which the patient was admitted has not yet been resolved. It has simply dissolved like ink in water, reaching through veins and arteries, confounding the original diagnosis.
Back to rounding. We cluster around the doorway of the first patient’s room. He is enclosed by glass walls and an open doorway. His room is full of so much equipment that it blurs together and I have trouble distinguishing one apparatus from another. There are monitors, tubes – the sort you might find on a vacuum, and the sort that transport drugs, blood, bodily fluids. The nurses sit outside the room, giving the impression of a night watch. The diligence of the observation process here is mind-boggling. This is why they call it “intensive care.”
As the residents and nurses begin the litany of medical statistics describing the patient, the doors to the unit whoosh open and a bed is rolled in; the hallways are relatively narrow, so everyone squishes together, melting backward and filling the small spaces behind the ward desk or against the walls.
The bed passes and we flow back into our semi-circle, listening as the nurse, the resident, the pharmacist, the RT and dietician as they provide updates on the patient’s status. The updates sound like lists, and I grasp the syllables that sound familiar: septic, grimace, “ow,” fentanyl, bowel, hemoglobin, platelets.
And suddenly the discussion is over. I have the sensation of having walked through a brief but powerful wind storm.
Ten thousand words have been blown past me and I have understood the meaning of approximately seven.
I am shoulder-to-shoulder with the team, mere inches from a fifth-year resident and a pharmacist, we hear the same words and see the same people lying in beds. But I feel like a green-skinned creature masquerading as human among this group of humans. Their world is so finely tuned to this moment, to this particular hallway in this particular hospital, that their language requires translation. Between patients the attending physician steps toward me and explains in plain language what the patient is suffering from, or the medical challenges facing the team.
As the patient reports swirl around me, I notice that we stand ten feet from patients but refer to them in the third person. I notice that the language used is often highly technical, long strands of jargon and acronyms. But by the end of the day I am swept up in the wind storm of the team. I see only the overt signs of the gale as it blows by, but I sense the magnitude of the unseen air mass – the intellectual challenge of the diagnosis, the strength of the team, the desire to help. I have the sensation of switching sides, seeing the patient from the medical point of view. I see the appeal.
Yet you can’t help but wonder how much of the technical jargon is a protective mechanism for these humans who care so intensively for the most critically ill. One team member mentioned that ICU staff don’t always talk openly enough about the over-arching trajectory of the patient’s story. This person is chronically ill. They may not leave the hospital. We don’t always have as much control as we seem to, the team member told me.
Is this sense of control an illusion? Medicine was not always seen as a potential savior for the suffering. Let’s consider the succinct and practical advice of Greek physicians like Hippocrates, who wrote in the 4th to 5th centuries BCE:
“Now to restore every patient to health is impossible. To do so indeed would have been better even than forecasting the future.”
As Atul Gawande points out, prior to the middle of the 20th century, hospital staff performed more of a custodial role. Gawande quotes physician-writer Lewis Thomas: “Whether you survived or not depended on the natural history of the disease itself. Medicine made little or no difference.” No one pretended to understand the crystal ball.
But of course medicine has changed drastically since then. Witness penicillin, blood pressure meds, heart surgery, artificial respirators and organ transplants. Says Gawande, “doctors became heroes, and the hospital transformed from a symbol of sickness and despondency to a place of hope and cure.”
A vehicle for defeating mortality; a place of hope and cure. Which begs the question, what is hope?
The Oxford English Dictionary offers this definition:
- Expectation of something desired; desire combined with expectation.
It would seem that humans have a long history of hoping; the word “hope” dates back to ancient Old English, having belonged originally to Saxon and Low German.
To demonstrate the word’s meaning, the Oxford English Dictionary reminds us that “hope” is often personified, along with its Christian sisters, Love and Faith. The OED offers a quote from a Hannah More’s Sacred Dramas:
“Fair hope, with smiling face but ling’ring foot / Has long deceiv’d me.”
Hope, then, with the façade of optimism, but the limping truth of hesitation, slowness. Lingering.
More’s poem reminds me of a piece I read in the latest issue of The Longview, a creative writing journal published by medical students at the University of Calgary. The piece, titled “Dum Spiro Spero” (Latin: While I breathe, I hope), tells the story of the writer’s aunt, who has multiple myeloma, and who says, “The greatest curse my doctor gave me was hope.” The aunt regrets not being able to prepare for her death, and achieve the closure she needs at the end of her life. The narrator asks, “when did hope become tragic? When did it become dishonest and irresponsible for a physician to dispense hope?” The piece ends by acknowledging that hope is a Hobson’s choice, but erring on the side of optimism for physicians: “we, ourselves, must hope that hope can save patients, even when it can’t save their lives.”
But we were speaking of hope and cure, the evolution of the heroic physician from Hippocrates and his skeptical take on cure. The lack of control felt by ICU clinicians when the technical side of medicine falls short of the cure. The alternative, as one clinician noted, is to be part of the patient’s journey, as it bends and forks – even if it meanders in a downward spiral. Indeed, the team often open discussions around supporting the dying process. They sometimes have to tell people that if they go home at a certain stage of the treatment process, they will simply end up returning to the ICU.
They often try to give patients peace as they discuss options with spouses and children. And if the journey appears to be nearing its end, they support a peaceful death.
Some ICU inhabitants have thought about options. Some just want to go home and have a glass of wine; most don’t want to be lying here attached to machines.
But this is not always the case. The ICU chooses its inhabitants; it selects for those who want to fight, rather than go home and have a glass of wine.
For other patients, the ICU is a sort of non-place – a place they are unaware of, in the long run. One practitioner noted that most patients do not remember their time in ICU. They often don’t realize how sick they were. Is ICU, for these patients, a sort of dream world?
Their time in intensive care passes through their unconscious in shadowy sensations, nocturnal, curled up under a comforter, alongside the creaking of floorboards, the clunk of a furnace and the dark shapes in a closet. Part of the deepest interior monologue of the person’s life narrative. The murmured subtext of a life. That liminal space between conscious and unconscious.
Which makes me wonder about the difference between the two – perhaps because I spoke with a team member whose interests lie at the intersection of anesthesiology and critical care. We spoke for some time about the difference between consciousness and unconsciousness (do you see now why I get nothing done on my dissertation?). I had never really considered the different layers of consciousness – is it best to see them as a spectrum or as layers? Which is the top layer, though, and which the bottom? Where does one plot “suspended” on the spectrum, and where does “altered” or “disconnected” fit in? Where is the state in which patients exist in the ICU while not exactly conscious?
And where does one plot “delirium?” One of the serious challenges facing ICU patients, which clinicians strive to mitigate. The word “delirium” comes from the Latin word delirare, meaning “deviate from a straight track,” and was documented as far back as 2,500 years ago in the Hippocratic writings. The American Psychiatric Association tells us that delirium involves disturbance in awareness and attention; it can fluctuate and may involve altered perception; it is a direct physiological consequence of another medical condition.
In other words, it’s a confused, disoriented, scrambled state of mind. One of those adumbral layers wedged into the sedimentary depths of the human mind. Part of the interior monologue which may be forgotten, at least in part, when the patient goes home.
But we should return to the Rockyview ICU, where the team is still rounding. They are between patients now, a lull.
I follow the group of residents as they relax for a moment and chat. This is the water cooler moment, I realize, but there is no water cooler. There are no cubicles, no baffles, no white noise, dress codes or corporate value statements.
There is talk of sleep. The need for it, the desire for it. You can see it hanging overhead, thick and sweet, like cotton candy. You can almost reach it.
Some of the team have small children. If they would just sleep through the night! Remember the days when you slept for eight hours? This is the parenting moment, the classic realization that sleep is precious; it once was and now is not. But the discussion on sleep here is deeply layered. Complicated by shifts worked on call, around the clock, nodding off for a few minutes in sleeping rooms.
We move to the next patient. A resident speaks of respiratory failure, intubation, a trach is being considered. Tracheostomy. The physician indicates that the white count is coming down, and asks the residents why this change has occurred. It’s a teaching moment. The residents turn their eyes upward, take a stab at the answer. Their responses begin with phrases like, “As far as I can recall” and “To the best of my knowledge” and “From what I understand…”
It’s a reminder of how complex the medical profession is, and how long the learning process is. These residents finished their undergraduate education in medicine from two to five years ago, and have been working as residents ever since, rotating through specialties like family medicine, cardiology, psychiatry, internal medicine and OB/GYN (obstetrics and gynecology). Most of them will spend about four weeks in the ICU, and that may be their only rotation here; most do not aim to become intensive care physicians. They are expert medical practitioners; they can prescribe and treat and diagnose. But it takes years to become the physician who shepherds residents through the learning process. It takes years to understand the nuances of life in ICU. The looping progressions of acute disease.
The attending is talking about intubation now, the urban myths you see on TV (my ears prick up; I have seen this – a pocket knife is all you need, right? And a tube of some sort?). The myths seem ridiculous but the attending has heard of a doctor saving someone in a Chinese food restaurant using a Bic pen. The residents lift their eyebrows and smile appreciatively.
I wonder if some recoil at the thought of throwing down their chopsticks, pulling out their MEC Swiss Army knife and slicing open the throat of a stranger while fellow diners look on, 911 at the ready, chow mein roiling in their stomachs. Or would some of the residents here relish the opportunity, the burn of adrenaline, the moment where you rise to the challenge of giving breath to the breathless?
Speaking of breath, one of the RTs I spoke with said their job is rewarding, in part, because of the excitement of a code (cardiopulmonary arrest). It sounds a bit demented, they acknowledged, but when a code is announced and they assist with a resuscitation, it’s a pinnacle moment. The RT is at the top of their game, functioning at maximum capacity, a climber on oxygen, stretching to the summit of their knowledge and expertise: This is the moment I’ve been training for.
The Bic pen story slips into dénouement and then the act of rounding continues. More lists are presented and the team discusses possible changes and outcomes. The structure of the team appears to be relatively flat, without a noticeable hierarchy. The team is large but well synchronized. Their collective knowledge fits together like jigsaw pieces, as words flow between team members: warfarin, anticoagulant, delirium, tracheostomy, edema, shortness of breath, respiratory failure.
There is a rhythm to the lists and I begin to feel more relaxed. The patients here seem relatively stable, assisted as they are by the machines that huff, hum and beep alongside the beds. I will make it through the day; at noon I will eat my sandwich, interview some residents and make jokes about sleep deprivation.
A beeper goes off. A new patient, incoming from Emerg. Needing intubation.
The attending physician says, I need to go to Emerg. Would you like to come?
No, I think.
Yes, I say.
We make our way to Emerg, only to return; the patient will be brought to ICU. Intubation is one of the specialties of the ICU; this is one reason why a rotation through the ICU is appealing to residents wanting to specialize in internal medicine. They become proficient at skills like intubating and inserting arterial lines.
As the nurses get the new patient settled in, the attending physician asks which residents need experience with intubation. I can’t tell if the residents want to be selected or not. I think they do. The attending selects one. The team gathers outside the patient’s room, and the core team drifts in as the nurses work briskly to change the hospital gown and get the patient in position. The physicians stand in a circle around the bed and I hang back in the hallway.
I sense that in the ICU, chapters vary in length. Some are languorous, they take their time, stretching over days, weeks, months. Others clip by. Arrivals. Curtains. Intubations.
The rhythm is hard to predict.
The attending physician will tell me later that this is one of the most challenging aspects of medicine. It is unpredictable.
How does working in the intensive care environment affect health care practitioners? For an outsider, their work appears to be stressful, full of emotional moments, difficult decisions and weighty responsibilities.
Team members gave a variety of responses when I asked how the ICU world affects them. Some said they found the big emotional swings challenging. One said they didn’t cry at work but waited till they got home, where they could cry with their partner. One said they always felt guilty – guilty about being at home, away from work, and then guilty about being at work, away from home. Others found it humbling – it puts your own problems in perspective. Some said it required them to take better care of themselves physically and mentally. This environment is intense, and the intensity can be challenging, particularly when it extends across five, eight, twelve days in a row.
That intensity is mitigated by the team environment. There are nurses, RTs, physicians, residents, pharmacists, psychiatrists and more to help you with difficult situations. If you’re intubating someone for the first time, there’s someone standing beside you who has done it a thousand times.
When I asked the ICU team about the most challenging aspects of their job, a common theme was the possibility of not doing one’s best and letting down the patient, the family, the team. Here are some of the questions that keep them awake at night:
Could I have done more?
Why didn’t I see that coming?
Did I do the right thing?
What did I miss?
Several told me they had strong relationships with team members, in part because it’s difficult to share your experiences with someone who doesn’t understand the ICU world. Some said they used to take their work home with them, but decided that wasn’t feasible. You can’t think about it too much when you’re not there. One physician said they were able to empathize with patients without getting personally involved in their emotions – recognizing the importance of the patients’ and families’ emotions without losing themselves in those emotions.
Which makes sense to this potential patient – I would want my situation to be taken seriously, for it to be seen as meaningful, but I wouldn’t want my story to drain the physician to the point where they are unable to perform from their work.
The upside to working in ICU?
The sense of meaning and purpose that comes from believing you’re helping those who really need it. Both patients and families. And the extraordinary feeling when a critically ill patient pulls through. It could be a young mother recovering from influenza, for example. To be part of the team that helps her heal is an incredibly meaningful experience. And as the RT noted earlier, there is something to be said for the intense moments that arise in places like the ICU. They ask you to live up to your full professional potential, to think on your feet, to be deeply curious about each and every patient.
The day I observed the Rockyview team was a quiet one, something of an anomaly. This was my first clinical experience and I was somewhat relieved to arrive that Monday morning and see a half-empty ward. Later, a nurse explained why the atmosphere was so peaceful: some of the patients had not made it through the weekend. When the nurse told me this, I felt that quick flash of cold in my stomach, a subtle stab, somewhere on the spectrum between guilt and fear. I, after all, was not raised in India where death is familiar; I keep a comfortable Canadian distance from mortality. But some of the ICU had already rubbed off on me. I tucked away the feeling of guilt and fear, and took out my pen and paper. I would no doubt feel it later, once I was at home – perhaps while writing, or while drinking a quiet glass of wine.
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?
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.
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.
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?
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.
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.
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.
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.
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.
The boxes are labeled with names like:
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.
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.
- 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.
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.
Dear gentle readers:
I’ve recently developed a sort of pen-pal relationship with someone who’s been mentoring me as I perform the role of writer-in-residence at the University of Calgary medical school.
He is an unusual mentor.
Is that the right adjective for an adviser who has been dead for twenty-four centuries?
Nevertheless, the man is alive and well in the letters below.
I recently shared these epistles as part of a presentation on empathy, medicine and writing, given to the Family Medicine grand rounds group, and the Health Humanities journal club at the U of C medical school. Thanks so much to everyone who offered feedback, suggestions and thoughtful discussion.
Before I get to the letters … a brief disclaimer. Most of you will know that I am not a physician: I have attended exactly four medical classes and the resulting knowledge is summarized in exactly twelve pages of notes in a Staples scribbler.
So if you are a health care practitioner, please consider the letters below as food for thought. Gruel for the soul. My correspondent and I toss out our ideas on empathy, hoping they will spark discussion, or spark ideas on incorporating narrative into the practice of medicine.
Which is a subject I’ve been exploring. To any physicians reading this – I would be delighted to speak with you about incorporating narrative into your practice or pedagogical strategies. Let me know if you’d like to chat.
We could, perhaps, meet for coffee near the stony Greek man in the Health Science Center atrium.
If you’d like to follow up on some of the ideas I discuss, take a look at the reading list at the end of the post.
But let’s get to the letters. Be forewarned: they are lengthy. Feel free to peruse or skim.
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.
I picture you in your cloudy firmament, drinking wine, eating a balanced diet of citrus and lean meat, reading the marks I’ve made on this newfangled material called paper.
I realize this is a long shot, Hippocrates, but I did want to ask you about the idea of empathy. Pardon my dabbling with your language, but the word comes from the Greek “en” meaning “in” and “pathos” meaning suffering or feeling.
The word is quite new, but I suspect you felt it, those three syllables of in and pathos. You felt them wordlessly, didn’t you? Even as you held your hand against the damp skin of a feverish child. Didn’t you once write: “Where there is love for the man, there is also love for the art?”
I believe empathy existed back in your century, on your home island of Cos, even without the solidity of a word to define it, just a jiggling mass, a yolk and a white of meaning, yet to be enclosed by the pearly crust of syllables. I’d like to think you’ve reflected about connections between in-pathos, medicine and writing.
If you could just tell me you’ll help, Hippocrates. Or just send me a sign. I could use a sign just now – do you ever get that … dreary feeling? But I should dash – there’s the dog; he’s creaking to his feet and shuffling to the door.
All the best,
Dear Miss Chamberlin,
How lovely to hear from you. I so seldom receive correspondence from the earthy set. How quaint that you picture me perched on a cloud. How quaint that you think I recorded my cases by hacking them into a stone, when papyrus and skins were at hand. Here is my own historical context, blown to the four winds … Can you imagine how this makes me feel? I will give you a hint. Overlooked. Forgotten. Blurred.
Do you also believe the legends about me? That I once burned down the Temple of Kos? That I convinced King Perdiccas to fall out of love with his mother? That I refused to help the poor Persians combat the plague?
Well now, that one might be true… But the point is, I am skeptical. Do you really understand empathy? Have you poked it, prodded it, felt its brow? You offer its etymology, but can you even define it?
Until then, I must, as you say, “dash.”
By all the gods and more,
PS … if you feel “dreary,” as you put it, I suggest softening the body with warm compresses.
PPS … you mention dog, but do take care with this treatment – boiling rather than roasting will produce a meat that is light and will cleanse the body in a downward fashion.
I’m honored that you would respond to my letter… I must confess I had tossed it into the postal box as one tosses a bottle into the ocean.
I should also apologize for my clichéd vision of your environment… I do see how that would make you feel misunderstood, or, as you put it, blurred.
Blurred … what a wonderful metaphor! The outline of your body rubbed at, smudged, when someone makes assumptions about you.
But to the matter at hand. Empathy.
It’s a slippery term. I feel sorry for it, actually – it has so much responsibility. Empathy has its evolutionary roots in parenting. The drive to keep a child alive and happy at all costs.
Scholars say empathy is crucial to developing social relationships, being part of a group. It’s key to moral development and possibly altruistic behavior. Philosopher Martha Nussbaum says it’s the foundation of moral citizenship.
Imagine bearing those burdens, shouldering the weight of the world. Never mind the fact that empathy is so often exploited.
Barack Obama once cited empathy as a requirement for supreme court justice nominees.
Corporations ask managers to rate employees’ empathy skills. Researchers are hot on the trail of an inverse correlation between wealth and empathy. Empathy is the answer to everything from economic inequality to bullying to global conflict to product design.
A few years ago Ford had its engineers wear an “Empathy Belly” … Please consider the ergonomics of the driver’s seat from the What to Expect When You’re Expecting point of view.
Here’s conservative commentator Glenn Beck … accusing liberals of empathetic fascism, then, later, calling for empathy for the Black Lives Matter movement – drawing fire from the alt right.
Empathy is smacked about, back and forth, drifting in the wind, its definition a work of creative writing.
But I should apologize, Hippocrates. I have drifted from my purpose – defining empathy. A Herculean task, if you will. There are dozens of definitions out there, but here’s one to get us started.
From neuroscientist Jean Decety: Empathy is the natural capacity to share, understand, and respond with care to the affective states of others.
Not everyone agrees that empathy means sharing an emotion. The Society for General Internal Medicine defines empathy as: “The act of correctly acknowledging the emotional state of another without experiencing that state oneself” (Markakis et al. 1999).
And not everyone would agree that empathy includes responding to others. Some see empathy as passive, a self-satisfied sentiment that leads nowhere.
Affect scholars like Lauren Berlant and Megan Boler suggest that empathy can obscure power imbalances, and is dangerous because it gives you the illusion of knowing just how someone else feels … when you are often so different that relating with any precision is impossible.
Most scholars do agree that empathy is a two-sided coin, both emotional and cognitive.
On the cognitive side, we figure out the intentions, motivations and desires of the other person. You might know this side as theory of mind, or perspective taking.
On the emotional side, feeling with the other person. Like when we cringe, seeing someone in pain. Neuroscientists have done functional MRi studies that show that the same neural circuits get involved in the actual experience of physical pain, as the experience of seeing someone else in pain.
This makes it sound like emotional contagion.
Imagine if you will, Hippocrates, walking down the main street of Athens, and seeing one of your students threatened at knife point.
The student’s face contorts, the eyebrows lift, the eyes widen, the lips part and go rigid. You see his face contorted in fear and you, too, feel fear. You will tell your fellow physicians later that a hot jolt of terror thundered through your chest, and you felt exactly what the student felt as the flesh of the blade pressed against his neck.
But Hippocrates, this would not be exactly true. Psychologist Abigail Marsh says that only a portion of the neural structures involved in the student’s reaction will actually be activated by your vicarious experience of the student’s fear. So you don’t really catch fear like you catch a cold. The student’s feelings resonate in you, but you don’t fully feel their pain.
So what is this thing called empathy, then? We feel someone’s pain, but we don’t quite feel it? Is that not then misleading? Is it dangerous to assume we can hop into another person’s shoes? What good is empathy anyway, if it doesn’t fully enable us to share someone’s pain?
I must call it a night now, Hippocrates, for my head begins to ache. It’s as if a band of metal is being wrapped around my temples.
Now my dog is pushing his kibble around his bowl; I remember when he used to swallow it down whole with the power of a Hoover. Perhaps I’ll try scrambling him some eggs. But first I will go for a walk and try to enjoy the evening air. I hope to hear from you soon.
All the best,
PS … A quick clarification about pets. Please note that dogs nowadays are more likely to end up sleeping on your bed than sitting in a cast iron pot.
PPS … Please call me Jane
Dear Miss Chamberlin:
How strange that I experience a shimmer in my temples, not unlike pain, when you describe the ache in your head. And how quaint that you seek the evening air in order to heal this pain. Taking exercise may help, but I suggest washing your head with copious hot water, followed by a vigorous course of sneezing, to carry off the phlegm. Then a strict regimen of gruel and drinking water, but do not take any wine, not even white… although my neighbor would disagree. She once told me this treatment is like “stumbling about in the dark with a musket.” She is a difficult woman; I fail to understand why she was placed in such proximity to me. She understands medicine but she is obsessed with bandages and soap and compassion.
But we were speaking of empathy. Allow me to explicate a particular medical case. A female patient from Athens. Let us call her Olive, since she reminded me of an olive tree, silvery and fruitful. She had five sturdy children, although only one of them was a son. I had been treating her quite successfully for a wound in her thigh.
One day I came to her home and was ushered by her slave to the back of the house, all the way to the women’s quarters, and there she was, reclining on her bed. I approached, taking care to walk humbly, with moderate speed, in the manner of a dignified physician. I greeted her in quite an animated manner, though – each patient is different, and this one preferred animated conversation.
“You are looking better each day,” I told her. “One would think you had swallowed an entire cauldron of gruel!”
But she scarcely looked up. I quickly noted that she had all the signs of acute disease: sharp nose, hollow eyes, cold ears, their lobes turned outwards. Vomit the color of leeks, and a fever. Plus, the odor of the humors. I of course recommended gruel from the finest barley, thrice a day, the purest of drinking water, and poultices. I examined her wound, surprised to see that it had surpassed its former state of redness and inflammation.
“Have your daughters not been administering the poultices?” I asked.
“My daughters are here every day without fail,” she said, her voice as frail as a faded reed.
“I do not understand,” I told her. “The poultices should be much more effective.”
At that moment one of the daughters entered the room, and Olive attempted to embrace the girl, saying: “Your husband has released you for a moment, has he?”
The girl turned to me and said, “Is she well? I have meals to cook and children to feed.”
Olive’s inflammation worsened over the next few days, and I sent one of my students around each day, tending Olive with poultices, warm baths and gruel, to ensure it was all done properly, and she did eventually heal. But the process was slow and painful, as if she resented the pink flesh that knit itself to her leg.
I was unable to determine the cause of this delay until I discussed it with my neighbor, here. When I finished the story, my neighbor said, with that impatient jut of her chin, “It’s obvious. Olive wanted the company of her daughters more than she wanted the comfort of good health. Consider how she must have felt. As long as her wound was on fire, her daughters would come to her.” And then, in the manner of a woman who cannot leave well enough alone, she said, “You, Hippo, suffer from an incurable lack of curiosity.” And I said, “What has curiosity to do with Olive?”
Later, having administered a poultice to my dignity, I attempted this exercise of curiosity.
I imagined my former patient, sitting in her quarters at the back of the house, sewing and spinning and whatever it is that women do (I suppose I don’t really know). But I know enough to imagine Olive watching as the last of her girls is married off, and thinking: This is the end of life as I know it. The last one has packed up her chitons and joined her new husband. Who will I talk to? Who will I laugh with? How long the days will seem.
Silence echoing through empty hallways.
I suppose I could have thought more deeply about this woman all those years ago. But she inhabited a world I rarely saw. Should I have attempted to befriend her? Should I have spent more time asking questions?
But I must call it a night, as you say. My neighbor tried to insist that I take dinner with her – Really! I shall remain here, where I can reflect in peace, and ruminate on the value of solitude. The smell of barley stew, coming from my neighbor’s abode, will not distract me from my thoughts.
By all the gods and more,
PS … You mentioned preparing eggs for your animal, so one of the following is true: 1. you are a soft-hearted fool, or 2. Your animal is infirm. In the latter case, I recommend feeding it a gruel of white barley.
PPS … You may call me Hippo, as does my meddlesome neighbor.
I’m so sorry about your headache – perhaps some company would distract you. Would it be so terrible to accept your neighbor’s dinner invitation?
I loved your story of Olive and her daughters – in part because I know what she’s going through, having watched my own two sons walk out the door, and having borne the silent echoes of hallways.
But I suppose I’m projecting myself into her story – her silence would be different from mine, it would have shrouded her entire day, since her life revolved around the home. Her silence would be darker, more claustrophobic.
I was also interested to hear that you imagined the interior monologue of your female patient – her envisioning the end of life as she knew it. The interior monologue is such a writerly gesture. It’s one of the things I love about writing a novel – trying to let go of your own feelings and imagining the interior life of someone living inside a different skin.
In fact, there are studies showing that reading literary novels, which are filled with interior monologues, has been shown to improve cognitive empathy skills. We read the inner lives of characters and we get practice at interpreting the motivations of others – that process known as theory of mind. Reading literary novels, some say, changes the way we employ theory of mind. Through reading, we remember that it’s okay to be unsure about something, to recognize that not every question has a straightforward answer. That one person’s truth is another person’s lie.
But I should leave it there, my friend (I hope I can call you friend). It’s almost evening now, the clouds have rolled in and they unroll like a leaden tarp in the sky.
I should see if my dog will venture outside with me, although I suspect the gesture will be futile. I may try your recipe for barley gruel.
All the best,
PS … Why not pop over and see how your neighbor is getting on?
How quaint that you think it appropriate for me to “pop” over to my neighbor’s abode.
I must confess I do not make friends easily – my neighbor once told me I would find comfort in a wider circle of acquaintances. She once introduced me to a military captain and forced us to debate the virtues of hygiene. Why I tolerate her, I shall never know.
I am intrigued by your ideas on writing and empathy – I was never a writer of poetry or fiction, but I can quote by heart from the illustrious Homer:
“his dear wife, clear and faithful, in his arms,
longed for as the sunwarmed earth is longed for by a swimmer
spent in rough water”
Homer refers to Odysseus and Penelope here, but still, the passage sums up the longing that Olive had for her daughters. I find myself drawn to this particular passage … it’s strange; it swallows me up, drains my limbs until they are limp and unfeeling, the emptiness of open arms, the silence of vacant hallways.
And there, now … how have we returned to Olive? Perhaps because the relationship between patient and physician must be close – almost intimate. Does the patient not put her life into your very hands?
But I was speaking of Homer. This passage is a favorite of mine; it is a passage I wish I had written myself, if I had any such talent. But then, why have I never made the attempt? Is it too late, I wonder, for an old physician? Perhaps I will jot down a note or two on Olive. I will, perhaps, read this to my neighbor … but she would no doubt offer a scathing critique of my ramblings. Perhaps it is best to leave my medical thoughts as thoughts.
By all the gods and more,
PS … What is the age and breed of your domesticated dog?
I must confess, I feel ill equipped to advise you on anything to do with medicine – it’s a bit like telling Shakespeare: Hey, let’s spitball some ideas on sonnets!
So I decided to educate myself a little bit, and I looked at an article on clinical empathy by Jodi Halpern, professor of bioethics and medical humanities.
She echoes your neighbor’s suggestion that curiosity is important in the physician-patient relationship. She suggests thinking of the patient as a story, and being curious about that story, asking questions, reading between the lines, trying to catch all the allusions and suggestions of meaning.
By understanding this story you can better understand the patient’s symptoms, desires and contexts – things that aren’t always said out loud. Like Olive, needing her daughters more than she needed to get well.
So the physician can empathize through deeper listening, building a narrative together with the patient.
Maybe this is what you meant when you said the relationship between patient and physician is intimate … but Halpern doesn’t emphasize intimacy as such. She points out that it’s not easy to feel with patients day in, day out, especially if they’re in the throes of cancer, dementia, and more. Physicians will begin to feel anxious themselves, and this anxiety can get in the way of giving excellent care. It can get in the way of perspective-taking so there’s a sort of vicious cycle. Too much feeling erodes empathy.
Halpern seeks a more practical middle ground: It’s not that physicians should have a deeply emotional relationship with patients, or show deep personal affection … patients want something simpler. They want the physician to see their suffering, really see it. To understand it as real, and to acknowledge that the situation is meaningful, and merits attention.
This process of empathizing has measurable benefits, according to Halpern. An empathetic physician is more likely to be trusted. And patients who trust their physicians, apparently, are more likely to follow a prescribed treatment plans. So in theory, empathy can lead to better health.
I look forward to hearing your thoughts on this, Hippo. Down here, the sun is setting and putting on an amazing display – it is, after all, time for our daily walk.
But how can I disturb my poor old friend? He has not taken to the barley gruel, I’m afraid.
There will be other sunsets.
All the best,
PS … Your neighbor sounds both charming and terrifying. Why do I picture her holding a musket, or tamping a cannon?
PPS .. regarding my dog – he is an Icelandic sheepdog, aged 12 years and ten months.
Your last letter reminds me of a patient, someone I had known since childhood. Allow me to explain.
My friend Lydus had summoned me because of acute pain in his side. I saw immediately that he was critically ill – he no longer resembled himself, and his eyes were hollow.
It was obvious he would die within seven days, so I sought out the finest of barley for his gruel and the purest of drinking water. But only after asking extensive questions about his lifestyle: how many meals did he typically take? What sort of exercise? How much wine did he normally drink? I realized how little I actually knew of Lydus the adult.
As we spoke, I drifted back to the old days, saddling up two chestnut mares with young Lydus and riding up through the hills. The more I drifted, the more I felt the pull of his hollow eyes. As if the edges of my body were beginning to soften, and for a moment, it was me, lying on that bed, my bowels burning, the hot moisture of my body bursting through my flesh and beading on my skin. I averted my eyes from the bedside, but this strange connection to his body would not bend.
After that I could not leave his side; I ate and drank nothing, slept not at all, and sent my students to my other patients.
This would be the last time I attended a friend.
The poor fellow died on the seventh day, as predicted, his breath floating free of his body. I thought I was alone when I shed that tear for him, but no, the man’s servant was behind me in the darkness and he then ran about Athens telling everyone of the physician who felt so deeply for his patients. The physician who sacrificed his own sleep for the well-being of a friend. I was horrified to discover that this made me feel … good.
And I later wondered. Why did I do this? Why did I bend myself into Lydus’s bed? Did the ache of my own bones make me feel like a better physician? A more caring friend? Was I trying to alleviate my own distress upon seeing a suffering friend?
But I must dash – I feel I should set down a few words about Lydus.
By all the gods and more,
PS … I have researched the matter, and the Icelandic sheepdog often reaches the age of 15 – more if indulged with healthy diet and exercise.
PPS … Try sweetening the dog’s gruel with pomegranate.
How wonderful that you’re writing about Lydus. I recently read an article by Rita Charon on the relationship between narrative and medicine. She talks about that feeling of being absorbed by a work of art, like your feeling of being swallowed up by the Homer passage, or lying on Lydus’s bed, and she compares that to the act of opening yourself to the experience of the patient – absorbing their story, if you will. She thinks that reading and writing can help physicians listen, and pay close attention to the situations of patients.
Novelist Zadie Smith talks about literature forcing people to wake up from the sleepwalking of their lives. It can make the familiar seem strange enough that we stop and notice. Like Homer, with the sensation of longing. He stretches it out, extends it into an image that makes you ache, like the exhausted swimmer. Maybe you can add a little Homer when you write about Lydus, or Olive.
But for now I must be off – my dog has a new spring in his step and is asking for another walk. It must be the pomegranates.
As for our conversation about empathy – what can we conclude about our slippery friend? I feel like it was good for both of us to exercise our curiosity and wonder a bit about each other.
This task of wondering recalls the task of Sisyphus.
Hauling the boulder up the hill only to watch it slide back down. It’s difficult, and imperfect.
And yet he keeps on.
Go in peace, Hippocrates, my friend. Go visit your neighbor, brew a delicious gruel, and enjoy your moments of solitude.
All the best,
On narrative medicine:
Charon, Rita Narrative Medicine: Honoring the Stories of Illness.(Oxford UP, 2006). Available through U of C library at https://ebookcentral-proquest-com.ezproxy.lib.ucalgary.ca/lib/ucalgary-ebooks/detail.action?docID=3053606
I pulled information from an excellent anthology on empathy and medicine titled Empathy: From Bench to Bedside (MIT Press, 2014, Ed. Jean Decety). Available at U of C library at https://ebookcentral-proquest-com.ezproxy.lib.ucalgary.ca/lib/ucalgary-ebooks/detail.action?docID=3339367
Individual chapters from From Bench to Bedside:
- On defining and unpacking empathy: “The Nature of Empathy” by Abigail Marsh
- On the role of empathy in clinical settings: “Clinical Empathy in Medical Care” by Jodi Halpern
- Definitions of empathy and its implications to health care professionals: “The Costs of Empathy among Health Professionals” by Ezequiel Gleichgerrcht and Jean Decety
- Unpacking the affective and cognitive sides of empathy: “How Children Develop Empathy: The Contribution of Developmental Affective Neuroscience” by Jean Decety and Kalina J. Michalska
On empathy and literature / empathy & reading as basis for moral citizenship:
Poetic Justice: The Literary Imagination and Public Life by Martha Nussbaum (Beacon Press, 2004). Available in print form at the U of C library.
On empathy and power / the politics of empathy:
Feeling Power: Emotions and Education by Megan Boler. (Taylor & Francis, 1999). Available at U of C library: https://ebookcentral-proquest-com.ezproxy.lib.ucalgary.ca/lib/ucalgary-ebooks/detail.action?docID=214511
Compassion: The Culture and Politics of an Emotion by Lauren Berlant (Taylor & Francis, 2014). Available at U of C library: https://ebookcentral-proquest-com.ezproxy.lib.ucalgary.ca/lib/ucalgary-ebooks/detail.action?docID=3423752
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.