by Robert Coles
Table of Contents
Title Page
Dedication
Acknowledgments
Preface
Introduction
PART ONE - Physicians Must Be Altruistic
OUTPATIENT
from FIRST SERMON ON REVERENCE FOR LIFE
LIKE A PRAYER
THE BODY FLUTE
CAN YOU TEACH COMPASSION?
1852: J. MARION SIMS PERFECTS A REPAIR FOR VESICOVAGINAL FISTULA
from THE NAZI DOCTORS
NOTES
THE LIE
THE WOUND DRESSER from Leaves of Grass
1
2
3
4
THE GOOD DOCTOR
EPISODE OF HANDS
from DEEP RIVER
PART TWO - Physicians Must Be Knowledgeable
THE CADAVER
I
II
III
IV
V
VI
VII
VIII
IX
X
XI
XII
ANYUTA
THE MAN WITH STARS INSIDE HIM
FROM THE HEART
THE SEDUCTIVE BEAUTY OF PHYSIOLOGY
NOTES
from PEOPLE LIKE THAT ARE THE ONLY PEOPLE HERE: CANONICAL BABBLING IN PEED ONK
ADMISSION, CHILDREN’S UNIT
THE VILLAGE WATCHMAN
from THE ELEPHANT MAN: A PLAY
LEECH, LEECH, ET CETERA
BAPTISM BY ROTATION from A Country Doctor’s Notebook
WHO OWNS THE LIBRETTO?
PART THREE - Physicians Must Be Skillful
THE TALLIS CASE
from MY OWN COUNTRY
WHAT THE DOCTOR SAID
THIS RED OOZING
FROM THE LISTENING END OF THE STETHOSCOPE
LARGE WOMAN, HALF
THE KNEE
from THE DIVING BELL AND THE BUTTERFLY
LETTER FROM THE REHABILITATION INSTITUTE
BREAST CANCER: POWER VS. PROSTHESIS from The Cancer Journals
A SMALL, GOOD THING
PIES
COMMUNION
THE NATURE OF SUFFERING AND THE GOALS OF MEDICINE
“Person” Is Not “Mind”
An Impending Destruction of Person
A Simplified Description of the Person
The Nature of Suffering
The Amelioration of Suffering
When Suffering Continues
REPOSE
THE GIRL WITH THE PIMPLY FACE
HEALERS: THE PHYSICIAN AND THE MORI
PART FOUR - Physicians Must Be Dutiful
from NOT ALL OF US ARE SAINTS
IN TERROR OF HOSPITAL BILLS
ANOTHER CASE OF CHRONIC PELVIC PAIN
from THE SCALPEL AND THE SILVER BEAR
UNWED
from A WISE BIRTH
from THE SPIRIT CATCHES YOU AND YOU FALL DOWN
HEALTH IS MEMBERSHIP
from AN UNQUIET MIND
A YOUNG PSYCHIATRIST LOOKS AT HIS PROFESSION from The Mind’s Fate
from THE TENNIS PARTNER
FACING OUR MORALITY: THE VIRTUE OF A COMMON LIFE
NOTES
PERMISSIONS
Copyright Page
To the memory of Dr. William Carlos Williams,
whose words and thoughts inspired and
helped so many of us in medicine;
and to my family with much love.
—ROBERT COLES
Acknowledgments
This book is the result of many people’s generous efforts and much grace. Accordingly, we thank Joe O’Donnell, Penny Armstrong, and Brownie Anderson for their wise assistance; Tom Mellers for permissions help; and Samita Sinha and Diane Wachtell at The New Press for their direction, help, advice, and humor.
—ROBERT COLES AND RANDY TESTA
Preface
A beginning medical student struggling to obtain a medical history is delighted by the story his elderly patient tells him instead. A mother whose child has just been diagnosed with cancer walks into the pediatric oncology unit for the first time and the ground drops out from under her. A nurse/poet meditates on the secret moments she has shared with patients, just before and just after their deaths. This anthology collects moments like these, gleaned from a life in medicine, moments rendered poignant through stories, poems, and essays. Each in its own way examines the relationship between patients and health care professionals. Some pieces are by doctors, nurses, and residents; others are by laypeople. Some pieces are filled with outrage, others with gratitude. Some offer prescriptions. All offer perspective.
In the literature and medicine courses taught by those of us compiling this anthology, we frequently hear students of our disciplines complain bitterly that, although they love reading literature, they don’t really have time for it. They must learn “hard science,” they insist, and they become fearful that time spent with literature is time spent away from medicine. Sadly, this view often originates with their teachers, who are not only entrusted with teaching medicine, but with determining the very structure of medical education.
Dr. Rita Charon of Columbia University’s College of Physicians and Surgeons points out that, for all its emphasis on scientific knowledge, “the work of medicine in considerable part rests on the doctor’s ability to listen to the stories that patients tell; to make sense of these often chaotic narratives of illness; to inspect and evaluate the listener’s personal response to the story told; to understand what these narratives mean at multiple (and sometimes contradictory) levels, and to be moved by them.” Ron Carson, director of the Institute for Medical Humanities at the University of Texas Medical Branch, Galveston, offers further justification for literature in the education of health care professionals: learning to read with care stories about patients helps health care professionals become careful readers of their patients.
In 1996 the Association of American Medical Colleges (AAMC) embarked on a major new initiative to assist medical schools in their efforts to educate medical students more fully. Titled the Medical School Objectives Project (MSOP), it identified altruism, knowledge, skill, and duty as the four attributes necessary for medical school graduates to thrive in the current and future health care environment.a We have organized the selections in A Life in Medicine using these four objectives as section headings, and have provided the AAMC’s full definition of each objective at the opening of each section of readings. It is our hope that multiple perspectives will allow for deeper insight into the implications of the four objectives, as well as what Dr. Coles has described as a moral education.
One goal of the MSOP is to provide a blueprint or framework upon which medical schools and educators can build unique approaches to medical education. Our goal is to offer narrative knowledge as a means for examining with fresh perspective the daily responses we have to those on whose behalf we work. We hope this book represents a fundamental tool—for dialogue, debate, insight, and clarification—for all of us who find ourselves engaged by a life in medicine.
INTRODUCTION
The Moral Education of Medical Students
ROBERT COLES
In Middlemarch, George Eliot’s greatest novel, she remarks at one point that “character is not cut in marble—it is not something solid and unalterable.” She pointedly amplifies that observation with a medical simile (in a novel that tells, among other things, of a doctor whose moral values go through a marked transformation): “It is something living and changing, and may become diseased as our bodies do.” Indeed, throughout her writing career, Eliot struggled hard with moral questions—she was constantly posing them to her fictional protagonists and, thereby, to her readers. The p
hysician, Dr. Lydgate, who figures prominently in Middlemarch, starts out as an intensely idealistic young man, determined to use his professional skills on behalf of needy people, no matter their background, and determined, as well, to advance his profession’s knowledge, through research, as best he can. Yet, in a few short years, he is a society doctor, all too cynically catering to those who can buy his time. “He had gained an excellent practice,” we are told at the story’s end, “alternating, according to the season, between London and a Continental bathing-place; having written a treatise on Gout, a disease which has a good deal of wealth on its side. His skill was relied on by many paying patients, but he always regarded himself as a failure: he had not done what he once meant to do.”
That second sentence is especially important. Eliot had no interest in being a scold. Rather, she meant to explore the manner in which, not rarely, we disappoint our own selves, forsake certain ideals or principles that helped shape our lives at crucial moments—only to relinquish their hold on us. She wondered why—how it comes about that we lose our moral moorings, shift the moral direction of our lives, end up doing things we once regarded as unworthy of our own standards of behavior. A half-century later an American novelist, F. Scott Fitzgerald, worried over the same matter. He gave us, in Tender Is the Night, the physician Dick Diver, whose last name conveys the essence of the novel’s action: a steep decline in a person’s self-respect, never mind his responsibility to the ethical norms of his chosen profession. Like Eliot, Fitzgerald had no great interest in wagging his finger at his readers or at doctors in general. He was a talented storyteller who knew that moral irony abounds in our lives; that we can claim an integrity which we gradually let slip by us, an integrity undermined in small, day-by-day ways that may seem inconsequential—until, in their sum, they have had their unmistakable effect. Not that either Dr. Lydgate or Dr. Diver suffers any great pangs of conscience as a result of the personal change that befalls each of them—and therein lies the unnerving reminder to us who get to know them, page by page: we, too, have agile minds that are quite capable of fooling us, that spin webs of rationalizations and selfdeceptions, to the point that we’re unself-consciously caught in a life whose implications we have long ago stopped examining, never mind judging.
How to call upon such novelists (they at times become moral visionaries) in our lives, in our work, if we are doctors at medical schools who are trying to teach the young men and women in our classes what it means to be a good doctor? To be sure, factual knowledge counts a lot; we have to impart it constantly, and our students are mightily challenged by the demands on their memory as they absorb blackboards full of information, textbooks full of explanations, and as they try to keep in mind what they have learned in long laboratory sessions. All too often, though, those students will wonder what the point of such an experience is, especially in the first two years of their medical school education, and they will resort to gastrointestinal imagery as they try to gain any possible perspective on a relentlessly demanding, exhausting, unnerving experience: ingestion, regurgitation. Some students will utter terse lines of poetry that stress the attitude of utter compliance required (“ours not to reason why, ours but to do and die”) or stress the desired outcome as a justification for what seems to be an arbitrary kind of force feeding meant to test tenacity (“survival is all”).
But medical school need not be an episode worthy of Tennyson’s well-known description in “The Charge of the Light Brigade,” nor a spell of melancholy resignation such as Rilke evoked in one of his elegies. Some medical schools have tried hard to emphasize ideas and ways of thinking, so that an ever-expanding mass of detailed information can be fitted to a broad understanding of how things work in our bodies. Of course, such efforts of reform have had to contend with the so-called Boards, the gateway to certification for state licensing. And so, despite curricular reforms, medical students will still have to cram and cram in order to get through multiple-choice tests that are not exactly designed to do justice to the complexity of things, nor to encourage independent or reflective thinking. Indeed, in medicine especially, with its emphasis on human particularity and on individual idiosyncrasy (the old refrain “each patient is different”), the use of multiple-choice tests, with their frequent emphasis on yes or no, right or wrong, is both ironic and not likely to encourage medical students to think broadly, make connections across various academic fields of inquiry, or develop any kind of wide-ranging, openeyed responsiveness to patients in all their puzzling, surprising variation. One of my medical students, thrilled to be discussing ideas and examining trends, excited to be asked to write thoughtful, probing essays that connect concepts taught in various courses, stirred by the chance to contemplate apparent inconsistencies or paradoxes, the mysteries that science only gradually and incompletely banishes, at the end of her second year of medical school had this to say: “To turn from the New Pathway [Harvard’s effort at curriculum reform] to learning lists and more lists (it’s rote learning, and you forget what you’ve memorized five minutes after you take the exam)—that’s very sad, and very confusing.”
I mention such familiar aspects of medical school education because they are not without moral implications. Students told to stuff their heads with information, the more obscure the more likely to be queried, students told they are in a rock-bottom sense competing against one another on one “curve” after another, are not being encouraged to think about the truly consequential or to do so in alliance with one another. Moreover, in the course of teaching at seven medical schools in different parts of this country, and in doing many interviews with medical students, I have heard the usual stories about certain teachers, their displays of arrogance, condescension, mean-spiritedness, even vengefulness; and, too, the usual stories about students, their extreme competitiveness, their decline into a dog-eat-dog attitude—a continuation, alas, of what not uncommonly occurs among pre-medical students (whose professors of chemistry, physics, and biology are not always sensitive, thoughtful, let alone kindly or inspiring individuals).
No wonder, in the 1970s, Lewis Thomas (in “How to Fix the Pre-Medical Curriculum,” a chapter in The Medusa and the Snail) was prompted to such intellectual alarm, such moral indignation, as he surveyed pre-medical life on our campuses: “The influence of the modern medical school on liberal arts education in this country over the last decade has been baleful and malign, nothing less.” He documented that assertion with many observations made while working at Yale Medical School as its dean, and talking with undergraduates in New Haven and elsewhere. He wanted the MCAT test done away with, and an emphasis put on literature and history and philosophy (and yes, the study of Latin and Greek) as a means of broadening and deepening the inner life of men and women who, after all, hope one day to attend their fellow human beings, understand and connect with them heart, mind, and soul. Perhaps he exaggerates when he describes the “premeds” as “that most detestable of all cliques eating away at the heart of the college”; and perhaps he is similarly a little overwrought when he describes “today’s first-year medical students” as already “surfeited by science”—not out of an ardent love for it, but a fiercely contentious desire to prevail over others, and at all costs “get in” to this or that or any medical school. Still, I suspect that many of us continue to read his brilliantly provocative essays (which graced the New England Journal of Medicine for many years) with nods of recognition—and especially so those essays in which he kept worrying about the ethical consequences of the undergraduate and graduate education of late-twentieth-century American physicians.
All the time we medical school teachers send moral signals to our students. As Lewis Thomas kept insisting, we let them know by our admissions practices what kind of person (educated in which way) we desire. Once those young people are admitted, we let them know (by how we teach what we teach) the kind of people we are, never mind the kind of people we expect them to be. Another physician who wrote (novels as well as essays), Walker Percy, also
addressed in a moral and philosophical way the matter of scientific education. His essay “The Delta Factor” in The Message in the Bottle reminds us how bored and jaded and drearily submissive we can become as we take in a subject mindlessly, fearfully, in order to “get in,” or “get by,” those clarion-call phrases that inform so much of what gets called “pre-med” and then medical school education. He wryly suggests strategies of surprise—efforts to undermine the juggernaut of resigned compliance, of anxious boredom that informs so much of university life. He would have our students coming to a laboratory, now and then, to find Shakespeare or the words of a novelist, a moral philosopher such as William James (another physician who worried about the way science is taught to doctors and others). He worries, really, about the stifling of the moral imagination—which is our capacity to assume responsibility for what we learn, fit it into our notion of how we ought live, what we ought do (and in what manner) with what we have come to know.
We can, of course, surprise not only our students but ourselves. We can, for instance, take passages from George Eliot’s Middlemarch to heart—follow Dr. Percy’s advice, put those moments of wisdom in our laboratories for our students, but also ponder them in our own minds and hearts, let them influence the way we teach, what we have to say to, or better, ask of our students. Dr. Percy was, however, as wary of literature as he was of science—he knew that we can pay mere lip service to either (rote memorization, clever interpretations, then a hurried consignment to oblivion, so that new “stuff” can be “imprinted” on those poor brain cells). He would have us putting ourselves on the line, connecting what we read and believe to how we act, a kind of “medical ethics” that is expressed, for example, in community service. He would have us integrating Middlemarch or Tender Is the Night or Raymond Carver’s “A Small Good Thing” or Chekhov’s “Anyuta” or William Carlos Williams’s constantly challenging “Doctor Stories” into the entire range of medical school education. He would have us connect those serious “texts” to clinical teaching so that they might have an impact on how we address and regard and respond to the people we aim to heal—so that a patient’s presence before us in a hospital or office setting becomes for us a moral occasion, a measure of our moral life as it is lived moment to moment.
