A Life or Death Decision

Her father is sick, again—but this time she’s asked to choose.

The will of the father; the wishes of the daughter.

His body is spent; and intuitively, he knows it. Still he clings to life by one thin thread of hope.

She’s become the designated caregiver.  Emotionally exhausted, she has no energy left for family and friends.  Her career has suffered, and she wants her life back.

Suddenly, she has been charged with making a decision on his behalf:  to intervene or not to intervene, knowing full well that intervention will ultimately only prolong her father’s suffering.

It would be so easy to say: “No, don’t intubate; let’s end this folie a deux right now and get on with our lives.”

Yet for him, that is not the right thing to do.

As his daughter, she respects his will to live.

In this case, technology is a curse. If we didn’t have ET tubes and ventilators, life would take its natural course. We have created our own demons, and they constantly come back to taunt us: in this case, six additional months of ventilator dependence, dialysis and a feeding tube before death from heart failure.

What a pity this whole scenario could not have been discussed with the father during one of his more lucid moments! Perhaps then he could have made a more rational decision.

But then, death is never rational, is it?

Wounded Healers

Henri Nouwen coined the phrase the wounded healer in reference to individuals who have developed the ability to empathize with the sufferings of others through sufferings that they have experienced themselves.

The other morning I greeted a woman who had recently had a total hip replacement. I was surprised to see her out and about so soon after the surgery. Another woman who had had a tumor removed from her lung last month approached the woman with the artificial hip and asked how she was faring. “Don’t get up,” she said, but the woman rose from the bench; and I watched these two elderly women embrace—two wounded healers reaching out through their individual pain to comfort one another.

Freud said: “Wherever I go, I find a poet has been there first.” To be a poet in this day and age is to have a broken heart. Here are the beautiful words of the poet Naomi Nye in an excerpt from her poem entitled Kindness.

Before you know kindness as the deepest thing inside,
You must know sorrow as the other deepest thing.
You must wake up with sorrow.
You must speak to it till your voice
catches the thread of all sorrows
and you can see the size of the cloth.

Then it is only kindness that makes sense anymore, only kindness that ties your shoes
and sends you out into the day to mail letters and purchase bread,
only kindness that raises its head
from the crowd of the world to say
it is I you have been looking for,
and then goes with you everywhere
like a shadow or a friend.

Aftershocks

I listened to the initial reports of the devastation caused by the earthquake in Haiti while driving home from work Tuesday evening.  Later, I tried to read the lead articles at the New York Times website.  I had a great deal of trouble making it through the first several paragraphs.  Even at the outset the carnage was too much to comprehend—50,000 to 70,000 feared dead in the worst earthquake to hit the country in 200 years.

Normally, when disaster strikes, rescue workers transport the injured to emergency medical facilities for care.  In Haiti the hospitals themselves were leveled by the quake.  The infrastructure of the country had crumbled.  There was no medical care available, no food, no water, little transportation; and chaos reigned in the streets.

Today I scanned photographs of bulldozers dropping dead bodies into dump trucks; piles of corpses lying in the streets; faces looking up holding empty buckets to be filled with fresh water; a bag of IV fluid hung from the branches of a tree infusing into the arm of a woman reclining on a mattress on the grass; faces of pain, faces of grief.

This week one of the women at the office returned from a vacation in the Caribbean.  She brought back a nice tan, stories of the exotic life and stacks of color photographs.  Co-workers oohed and aahed over the sandy beaches, the turquoise waves, the plush hotel accommodations.  It was a dream getaway.  For three days it was the talk of the office.

“Did you see the photos?” someone asked me late one afternoon.  “You have to see them—what a lovely place!”

“Guess she didn’t go to Haiti,” I mused matter-of-factly.

“Oh—why?  Did something bad happen there?”

Auden had his finger on it when he penned his poetic treatise on suffering:

About suffering they were never wrong,
The Old Masters: how well they understood
Its human position; how it takes place
While someone else is eating or opening a window or just walking dully along….

                                    —Musée des Beaux Arts,  W. H. Auden

Through the Looking Glass

“Jackie, stop!” I say in my most authoritative voice.  “Stop it now—stop barking!”

I gather the struggling terrier into my arms and try to calm her down while my wife trucks bags of groceries into the kitchen from her car in the driveway.  Still holding the dog, I walk into the parlor, away from the kitchen commotion, where the dog catches sight of herself in the mirror on the wall above the antique settee.  Immediately she cues in, cocks her head, then raises her tiny black nose to sniff the dog in the mirror.  She begins to whine, insisting that I bring her closer.  She gets so excited that she jumps out of my arms and runs back into the kitchen, only to return momentarily and leap up on the sofa, where trembling, she stands on her hind legs and proceeds to paw at the base of the mirror, repeatedly jumping up to see if the other dog is still there.

Later, my wife stacks cushions on the settee so the dog can hop on top of them to catch a glimpse of her reflection.  It appears that she still thinks there’s another dog in there somewhere, through the looking glass, and she’s frustrated that she can’t gain access to it.

A friend of mine, an expert on these matters (he has had at least two dogs in his household at one time or another over the course of the past three decades), tells me that he has witnessed dogs acting in a similar manner when they catch sight of another canine on TV.  They see the dog, they hear him bark; but baffled, they can’t seem to break through into his world.

In his book The Art Spirit, Robert Henri writes:

There are moments in our lives, there are moments in a day, when we seem to see beyond the usual.  Such are the moments of our greatest happiness.  Such are the moments of our greatest wisdom.  If one could but recall his vision by some sort of sign.  It was in this hope that the arts were invented.  Sign-posts on the way to what may be.  Sign-posts toward greater knowledge.

Like dogs discovering another dimension through a looking glass, we momentarily glimpse miracles.  Sometimes, struggle though we might, we are unable to make sense of them.  But if we are fortunate, sometimes the light breaks through—and in an epiphany we see truly, face to face.

Such are the sign-posts toward greater knowledge; such are the sign-posts of wisdom.

The Emerging Science of Narrative Medicine

Last week’s Education Life section of the New York Times carried an article outlining a new offering at Columbia’s College of Physicians and Surgeons: a one-year graduate degree program in narrative medicine.

The offering is the brain child of Dr. Rita Charon, clinical professor of medicine at Columbia, and a leading advocate in this “emerging field” that “aims to treat the whole person, not just the illness.”

For the paltry sum of $50,000, participants can pursue courses in “philosophy, literary theory, psychoanalytic theory, and autobiography,” culminating with a “reading of literature that involves experiences of illness.”

This academic year 28 professionals have matriculated in the course.  At $50,000 per student, that’s a whopping $1,400,000 added to Columbia’s coffers per annum.  To me that seems rather outlandish, even if Dr. Charon does possess a Ph.D. in English in addition to her M.D. degree.

The gist of the program is to produce better doctors—those who can relate with a higher degree of empathy to patients—as well as leaders who can set up similar programs in other institutions of higher learning.

Anyone who has spent any time wrestling with literature will recognize the concept of irony, one of the dominant themes in the discipline.  To my humble way of thinking, as one who has spent untold hours delving into the writings of past medical authors and mentors, the concept of a $50,000 graduate degree program to learn the art of narrative medicine is, well, rather ironic in itself.

My father was a teacher.  He spent most of his career in the classroom, teaching students.  (He eventually rose to the rank of department chairman, a position which required more administrative duties in his final work years.)  I remember his words one afternoon in quiet conversation:  “The only ones who know anything about teaching are those who work in the field.” (Lest readers accuse me of nepotism, let me add that I’ve heard the same sentiment echoed by any number of other teachers worth their salt.)

If I read former physicians like William Osler, Francis Peabody, William Carlos Williams and Albert Schweitzer, as well as any number of literary types such as Tolstoy, Chekhov, Cronin, et. al., I find that the “emerging discipline of narrative medicine” has been emerging for quite some time—decades, I’ll warrant, if not centuries; perhaps millennia.

Personally, over a thirty-year career in clinical medicine, I became involved in “narrative medicine” by listening to patients and trying to make some sense of their stories as I melded them with my own.  I frequently visited with mentors (both living and dead) and learned from them as best I could. I started to write for my own edification—to put things into perspective, to learn from my mistakes, to identify what was important in caring for my patients. I published pieces to share what I learned with others, who likewise were searching for fulfillment in their roles as healers.  All of this I did with no expectation of monetary reward—I did it for the love of it, and an amateur I remain.

Now that narrative medicine has become the “in thing,” entrepreneur types are capitalizing on it, generating big bucks through workshops and programs like Dr. Charon’s at Columbia.  Eventually, it will become tainted. (As Mark Twain said, ‘Taint yours and ‘taint mine.)

But for the time being, those of us who work in the field, listening to the stories of our patients every day, can continue to ride the common waves for as long as the surf’s up.

Voice Recognition

“It’s for you,” my wife says, handing me the telephone.

I raise the receiver to my ear and speak the word: “Hello?”

“Hey, how’re you doing?”  The voice sounds muffled, a bit hollow; somehow I can’t quite place it.  I’m about to show my ignorance by asking the obvious question when the voice identifies itself as that of a friend with whom I haven’t spoken in a while.

“Oh, hey!” I say, conscious that my own voice has perked up.  “What’s new?”

“Just kicking back a bit after my recent surgery.  Thought I’d give you a call to say thanks for the loan of your crutches.  Your wife brought them over the other week.  They’ve come in handy.”

As he speaks, a mental image forms in my head of him standing by the telephone in his kitchen, resting on the set of aluminum crutches that had supported me for two months a year ago.  I marvel at how the spoken word triggers a thread of snapshots stored in the photo album of my brain.

Voice recognition:  we know it when we hear it; we cue into the familiar sound, even though we might not have heard it for quite a while.

All of us can pick out the particular voices of those significant others in our lives:  family, friends, co-workers; radio announcers, TV personalities, politicians.  Each human voice is unique, as demonstrated by voice identity patterns in the sound laboratory.

In voice biometrics a person’s speech is digitized to produce a voice print. Spoken words are reduced to segments composed of several dominant frequencies.  Each of these segments consists of several tones captured in digital format, which collectively identify the speaker’s unique voice print.

There are those who have the ability to mimic the voices of others in a most convincing manner.  Although they might be able to fool listeners most of the time, they can’t fool modern voice recognition technology.  I’ve never actually tried it, but I suspect that, if you play the voice of a mimic beside the voice of the real person, the human ear would most likely be able to discriminate between the two.

Sometimes it’s that way in our lives.  We hear a voice that at first sounds convincing, yet we intuit that it’s not the real McCoy.  As we begin to attend to it, we recognize it to be fraudulent.

It takes a great deal of work to discern that still small voice which speaks from the heart.  Yet when we hear it, we know it to be true.