by Robert Coles
“You know we should have to part sooner or later, anyway,” said the student. “You’re a nice, good girl, and not a fool; you’ll understand. . . .”
Anyuta put on her coat again, in silence wrapped up her embroidery in paper, gathered together her needles and thread: she found the screw of paper with the four lumps of sugar in the window, and laid it on the table by the books.
“That’s . . . your sugar . . . ,” she said softly, and turned away to conceal her tears.
“Why are you crying?” asked Klochkov.
He walked about the room in confusion, and said:
“You are a strange girl, really.... Why, you know we shall have to part. We can’t stay together forever.”
She had gathered together all her belongings, and turned to say good-bye to him, and he felt sorry for her.
“Shall I let her stay on here another week?” he thought. “She really may as well stay, and I’ll tell her to go in a week”; and, vexed at his own weakness, he shouted to her roughly:
“Come, why are you standing there? If you are going, go; and if you don’t want to, take off your coat and stay! You can stay!”
Anyuta took off her coat, silently, stealthily, then blew her nose also stealthily, sighed, and noiselessly returned to her invariable position on her stool by the window.
The student drew his textbook to him and began again pacing from corner to corner. “The right lung consists of three parts,” he repeated; “the upper part, on anterior wall of thorax, reaches the fourth or fifth rib. . . .”
In the passage some one shouted at the top of his voice: “Grigory! The samovar!”
Jack Coulehan
THE MAN WITH STARS INSIDE HIM
A doctor’s attempt to diagnose and comprehend his patient Antonio’s pneumonia becomes an occasion for wonder at the body’s structure and functioning. This poem is a tribute to the body’s unique sounds and secrets—even in the midst of life-threatening disease.
JACK COULEHAN is a professor of medicine and preventative medicine, and co-director of the Medicine in Contemporary Society Program at Stony Brook Health Sciences Center. This selection is taken from his collection of poems titled The Knitted Glove.
Deep in this old man’s chest,
a shadow of pneumonia grows,
I watch Antonio shake
with a cough that traveled here
from the beginning of life.
As he pulls my hand to his lips
and kisses my hand,
Antonio tells me
for a man whose death
is gnawing at his spine,
pneumonia is a welcome friend,
a friend who reaches
deep between his ribs without a sound
and puff! a cloud begins to squeeze
so delicately
the great white image of his heart.
The shadow on his X-ray grows
each time Antonio moves,
each time a nurse
smoothes lotion on his back
or puts a fleece between his limbs.
Each time he takes a sip of ice
and his moist cheek shakes with cough,
the shadow grows.
In that delicate shadow
is a cloud of gas
at the galaxy’s center,
a cloud of cold stunned nuclei
beginning to spin,
spinning and shooting
a hundred thousand embryos of stars.
I listen to Antonio’s chest
where stars crackle from the past,
and hear the boom
of blue giants, newly caught,
and the snap of white dwarfs
coughing, spinning.
The second time
Antonio kisses my hand
I feel his dusky lips
reach out from everywhere in space.
I look at the place
his body was,
and see inside, the stars.
Rachel Naomi Remen
FROM THE HEART
A second-year medical student at the beginning of her study of pathology examines a human heart with a congenitally malformed anterior coronary artery. Rachel Naomi Remen makes this examination the basis of her cautionary story about the balance between scientific objectivity and responding “from the heart.”
RACHEL NAOMI REMEN is the co-founder and medical director of the Commonweal Cancer Help Program in Bolinas, California, and is currently a clinical professor of family and community medicine at San Francisco School of Medicine. She is the author of My Grandfather’s Blessings, from which this essay is taken, and the best-selling book Kitchen Table Wisdom.
Almost fifty-eight years ago, I attended preschool in the little park around the corner from our apartment in upper Manhattan. As the shy and timid only child of older parents it had taken me a long time to feel safe in the company of other children, and my mother or my nana often sat on a bench within eyesight to give me the courage to remain in the group.
Eventually I was able to stay there alone. One day close to Halloween, my nana left me at the park, and I spent the morning with the other four-year-olds making masks. Close to noon the teachers threaded string through our creations and helped us to put them on. I had never worn a mask and I was entranced. About this time, mothers began arriving to pick up their children, and as soon as I saw my own mother walking toward the class I stood and waved to her. She did not respond in anyway. She stopped just inside the door, her eyes searching the room. Suddenly I realized that she did not know who I was and I began to cry, terrified. All her efforts to soothe me and explain why she had not recognized me failed to comfort me. I simply could not understand why she had not known me. I knew who I was with my mask on. Why didn’t she? I never went back to the nursery school again. I felt too invisible, too alone, too vulnerable.
Most of us wear masks. We may have worn them so long that we have forgotten we have put them on. Sometimes our culture may even demand we wear them.
A young woman named LaVera told me of something that happened when she was a first-year medical student. Those were anxious times, and it was not uncommon for people to work and study eighteen hours a day for weeks on end. In the evening, members of her class were in the habit of releasing the day’s tension by playing basketball on the court in the basement of the medical students’ residence. No one kept score, and people would drop in and out of the game for fifteen minutes or a half hour—however long it was before their anxiety about needing to study took them back upstairs to their desks. Often the game went on for hours, and the two teams that called it quits had no players in common with the teams that had started the game.
About four months into the year, in the midst of one of these games, one of her classmates had suddenly collapsed and died surrounded by other freshman students who had no idea how to help him. He was twenty-one years old.
Although many of the students were deeply shaken by the event, nothing further was said about the matter. The school made no opportunity to acknowledge either the tragedy of the death or the feelings of the class. The young man’s belongings had been packed up and sent to his parents who lived in another state. No one from his class or from the school had attended his funeral, which was held near his home.
The pace of the first year was intense and the competition fierce. Despite their shock and distress, the members of the class simply went on. Few talked about their classmate even at first, and by the spring of the year, the incident seemed almost forgotten.
At the beginning of their second year, the class began the study of pathology. In one of the laboratory sessions on congenital anomalies the instructor began passing around trays, each holding a preserved human specimen that demonstrated a specific birth defect. Wearing gloves, the students examined each specimen and then passed it on.
One of these specimens was a heart with a congenitally malformed anterior coronary artery. As it was being passed hand to hand through the class, the instr
uctor commented in a casual way that it was the heart of the young man who had died the year before.
Without lifting her head, LaVera looked out of the corner of her eye. No one around her seemed to react. All her classmates wore expressions of detached scientific interest. A wave of panic rose up in her until she realized that she, too, was wearing a mask of professional detachment. No one could possibly know the terrible distress she was feeling. She was flooded with relief. She remembers thinking that she was going to be able to DO this. She was going to be able to become a real physician.
LaVera closed her eyes as she finished her story and sat in silence for a moment. She rocked back and forth slightly and began to cry.
After more than thirty-five years as a physician, I have found at last that it is possible to be a professional and live from the heart. This was not something that I learned in medical school.
Medical training instills a certain scientific objectivity or distance. Other perspectives may become suspect. In particular, the perspective of the heart is seen as unprofessional or even dangerous. The heart with its capacity to connect us to others may somehow mar our judgment and make us incompetent. Such training changes us. We may need to heal from it. It has taken me years to realize that being a human being is not unprofessional.
My training encouraged me to give away vital parts of myself in the belief that this would make me of greater service to others. In the end I found that abandoning my humanity in order to become of service made me vulnerable to burnout, cynicism, numbness, loneliness, and depression. Abandoning the heart weakens us.
The heart has the power to transform experience. No matter what we do, finding fulfillment may require learning to cultivate the heart and its capacity for meaning in the same way that we are now taught to pursue knowledge or expertise. We will need to connect intimately to the life around us. Knowledge alone will not help us to live well or serve well. We will need to take off our masks in order to do that.
Jeffrey R. Botkin
THE SEDUCTIVE BEAUTY OF PHYSIOLOGY
In this piece, Jeffrey R. Botkin suggests that physiology provides the organizing structure for the study of medicine. This structure, he contends, helps mitigate the uncertainties of clinical medicine, thereby providing a measure of comfort for the medical student—a false comfort if the student does not recognize that the complexities and uncertainties of clinical medicine are not so easily pigeonholed. Rather, it is the study of cultures, behavioral sciences, ethics, anthropology, and health care systems that, taken together, contribute to the student’s understanding of the context of illness and provide a necessary addition to the structure of the basic sciences.
JEFFREY R. BOTKIN is an associate professor in the Department of Pediatrics of the University of Utah, Salt Lake City.
Physiology has become the leading intellectual interest in clinical medicine. The influence physiology has in contemporary medicine stems, in part, from the power afforded by knowledge, but also by the process of contemporary medical education. Bright students adept at biology and organic chemistry are self-selected to pursue the profession of medicine. The formal introduction to medicine then proceeds through a flood of factual detail channelled through discrete scientific disciplines. These basic sciences are intended to be the fundamental building blocks of the medical mind. A few cross threads connecting these disciplines may be apparent to the perceptive student, but, as a rule, the effort is one of accumulating raw materials for later development.
It is physiology that provides the grand design for these disparate elements. The pieces begin to form relation to one another as the fascinating processes of life become increasingly apparent from the dissections, the Giemsa-stained tissues, and the detailed biochemical pathways. There is a compelling beauty to the flow and regulation of life processes—the maintenance of sodium balance, the homeostasis of blood glucose, the response to novel invaders, and so forth. Yet these processes are not mystical in their beauty; when adequately understood they are logical and elegant. With the fundamental building blocks in place, physiology makes sense. The development of this conceptual structure can be intellectually exciting, like the thrill of the scientist when the pieces suddenly fit—a quiet “Eureka!” on a grand scale. Rational rules appear to govern organic function.
But the contrasting realities of clinical medicine soon become apparent to the young physician as he or she is first challenged by patients. Students are (or should be) struck by the pervasive uncertainty in clinical medicine. The anxiety produced by this uncertainty is intense. There are two types of uncertainty that must be distinguished: the uncertainty of the physician’s individual knowledge of medicine and the uncertainty of our collective knowledge.1 The first is a reflection of individual limitations; we simply cannot remember everything we have been taught, and we cannot digest the mass of information that overwhelms us daily. However, we may believe that the brighter we are, the harder we work, and the more experience we have, the more this uncertainty will diminish. In truth, experience and hard work may also serve to clarify the limits of our uncertainty and lead to a wiser use of our limited knowledge. But if this route to wisdom escapes the physician, it may become increasingly difficult with time to admit uncertainty to patients or to colleagues. This uncertainty may be seen as an embarrassing admission of modest intellectual powers, inadequate study, and/or insufficient experience. It is when physicians conceal their uncertainty, whether consciously or unconsciously, that they become a significant threat to the welfare of patients.
The uncertainty created by our human limitations must be contrasted with the intrinsic uncertainty of science and medicine. This latter type of uncertainty is composed of two related components. The first is simply our current state of knowledge: there is a vast body of knowledge to be acquired and a vast body of knowledge to be revised. We shall not see the end of this process. Second, there is the problem of applying our knowledge to the individual patient. The clues of the careful history, the basics and the subtleties of the physical exam, the use of technical tests and probes, and a comprehensive knowledge of physiology and pathology may not tell us why this patient is ill. Katz has observed that physicians will readily admit this type of uncertainty to one another,2 but that we are frequently reluctant to reveal uncertainty to patients. Socrates took a certain pride in proclaiming his ignorance, but most of us do not. We are perhaps afraid that such honesty will diminish our power with patients, and indeed it might. Our traditional reluctance to admit our ignorance and the popular glorification of “medical miracles” lead some patients to confuse the origins of uncertainty. Patients may search in vain for a “better doctor” to provide them information that simply cannot be provided.
These pervasive uncertainties are intellectual irritants. In the midst of this uncertainty remains a solid core of practical knowledge—the rational rules of the human organism. Herein lies the seductive power of physiology. Knowledge of physiologic rules provides the ability to control physiologic processes. There is that psychological surge of power when the blood gases normalize from our astute manipulations of the ventilator, or when the heart’s erratic rhythm smooths to a sinus beat. The power is afforded not only from our capabilities, but through a perceived understanding of our capabilities. We know what should work and why it should work—physiology is in our hands. The profound satisfaction this produces is compelling and provides safe refuge from pervasive uncertainties. This leads not so much to a “technological imperative”—the need to use technology for its own sake—but to a “physiologic imperative”—the desire to take control over those life processes susceptible to our technology. As residents, when death for our patients seemed inevitable, we strove for what we termed a “Harvard Death”—in which the body’s electrolytes remained in balance. This was a pointless exercise of power from the perspective of the patient, but a satisfying exercise for those of us unable to deal with death on other terms.
The pursuit of normal physiology defines much of
modern clinical medicine. Obviously this is good and right in the majority of clinical circumstances where normal physiology serves the interest of the patient. But reestablishing normal physiologic processes is obviously a narrow goal—a goal that serves only the portion of the human organism amenable to physiologic description and control. Despite the advances afforded by experimental medicine, humans have yet to be explained or understood in the vocabulary of physiology. This ignorance of ourselves and our mutual unpredictability is a fundamental element of self-perception and social relations. At the present time, at least, we can continue to believe that we, as individuals, are more than the sum total of our physiologic processes. Whether this is due to a soul or is only biology at a higher order of complexity remains to be determined.
When an individual is in good health, organic function is only background noise. For an individual in poor health, organic function becomes relevant in two ways. One is the intrinsic value of normal function, apparent when disease causes pain or suffering. The second is the instrumental value of health. Normal or adequate organic function is a primary good through which we pursue our other goals.3 If medicine is to serve us as individuals, it must address organic function on both levels.
As the science of organic function, physiology must be seen as the servant of our other goals and thus of the human values that determine those goals. For better or worse, human values often lie well within the realm of uncertainty. Even our own personal values may be frequently uncertain—at least in the context of illness, where complex choices may be layered on pain and fear. The values of our patients are all the more remote from our grasp. It is little wonder that physicians may seek refuge in the science of the organism, and that our patients are often eager followers of our firm—but perhaps misguided—lead on technical adventures.
