“The Surge” republished

The problems are three in number. Two are skin deep; the third lies deeper…

Originally published in Dermanities online (October 7th, 2008; 5(3)), The Surge has been republished in the fall issue of the Journal of Dermatology for Physician Assistants (JDPA), Volume 7, Number 4, page 55.

Interested readers can also access this piece here.

Literary medical weblogs

Dear J.B.,

Your comment on my blog posting The stories we tell came in just as I was re-reading the first chapter of James Joyce’s Ulysses on the front porch.  Previously, I hadn’t run across the Joyce line you quoted about all novelists having only one story, which they tell again and again; but it certainly rings true.  Hemingway said that in crafting a piece of writing he could “cut the scrollwork or ornament out and throw it away and start with the first true simple declarative sentence” he had written. In my book, anyone who takes writing seriously has to start with a desire for truth and the stamina to pursue it, no matter where it might lead.

You also mentioned Dr. Robert Coles.  I too was fortunate to hear Dr. Coles speak two decades ago at a conference on medicine and the humanities.  I recently read Handing One Another Along, a collection of lectures from an undergraduate course which Coles taught at Harvard on literature and social reflection. (The title of the book comes from a line in Walker Percy’s The Moviegoer, one of Coles’ favorites.) Dr. Coles, of course, is an excellent resource for many good works on medicine and literature as well.

Decades ago I got interested in the idea of using story as a vehicle to explore the doctor-patient relationship.  Throughout my medical training (I am a practicing physician assistant) I was appalled at the insensitivity which many clinicians demonstrated in dealing with patients in their time of suffering.  I struggled to understand the source of this coarseness in bedside manner.  Had these clinicians always acted this way, or through years of training had their medical education squelched whatever empathy they might have once had?  Was this perhaps a defense mechanism they had developed over time to shield themselves from the suffering that they witnessed daily in practice?  If so, what could be done about it?  (It certainly wasn’t helping the patient to heal.)  Could empathy be taught, or was it an innate trait possessed by only a minority of individuals who opted for a career in medicine?

As I began to craft narratives of patient encounters, I discovered that the act of writing itself enhanced the way I related to patients.  Somehow writing the story down served to hone an empathetic response.  It also served to help me deal with my own emotions, guilt and grief which I experienced in encounters with patients.  As my perspective developed, I was fortunate to find several like-minded souls in the social ether along the way.  Over the years I worked with other colleagues to create several online sites which continue to function as forums for clinicians and patients alike, Cell2Soul and Dermanities among them.  After reviewing my book Patients Are a Virtue, Dr. Howard Spiro asked me to consider submitting a monthly piece—“Notes from a Healer”— for the Yale Journal for Humanities in Medicine; and I was also invited to write a bimonthly Humane Medicine column for the Journal of the American Academy of Physician Assistants.  I established this weblog to serve as a repository for my writings.

My hope has always been that with ongoing exposure to these sorts of narratives, more and more medical colleagues might come round to recognizing just how intimate and profound the doctor-patient relationship truly is, and come to an understanding that there is much more to the art of healing than just closing a surgical incision, dressing a wound or writing a prescription.  Medical practice is after all the stuff of life; and because literature historically has been an attempt to capture the essence of what it means to be alive, it is small wonder that the two complement each other so beautifully.  As you so aptly put it, medicine and storytelling go hand in hand.

None of us can be all things to all men; but we can certainly make some fumbling attempts to alleviate suffering in the world and bear one another’s burdens as best we can.  As Rilke so aptly put it, perhaps if we learn to love the questions themselves, we can one day live on into the answers.

The Naïve Narrative

In his recent column In Defense of Naïve Reading, Professor Robert Pippin speaks to the state of literary criticism as it is taught on university campuses. His contention is that, although the current trend is to scrutinize the literary arts through the lens of the natural scientific research model — with the ultimate end of developing a “science of meaning” — creative works themselves were never crafted to serve research. Rather, their authors penned them as works of art, works meant to speak to us at the deepest level of our being.

In Pippin’s words: “Literature and the arts have a dimension unique in the academy, not shared by the objects studied, or ‘researched’ by our scientific brethren. They invite or invoke, at a kind of ‘first level,’ an aesthetic experience that is by its nature resistant to restatement in more formalized, theoretical or generalizing language.”

Pippin goes on to say: “Likewise ─ and this is a much more controversial thesis ─ such works also can directly deliver a kind of practical knowledge and self-understanding not available from a third person or more general formulation of such knowledge.”

I was reminded of these words during small group discussion at our recent Cell2Soul gathering on Nantucket. One of the presenters, a young physician, published author and director of a narrative medicine course, put forth his observations on illness. Illness, he maintained, separates us from our bodies. Illness diminishes us physically and morally. Illness alters the way we perceive the world and our place in it. Illness threatens us at the core of our being.

This young physician examined illness in various spheres of influence: illness and the self, illness in the doctor-patient relationship, illness and the family unit, illness and the community. He is working to formulate a theory of illness and its impact on the individual, the family, the community and society, in part to provide a framework for and justification of the study of narrative medicine in the medical school curriculum.

I applaud his efforts. In academic settings it is always necessary to justify what students need to learn to become competent in their chosen careers. A well-developed theory lends credence to academic study — and ultimately, acceptance of the particular discipline. In Pippin’s words: “We certainly need a theory about how artistic works mean anything at all, why or in what sense, reading a novel, say, is different than reading a detailed case history.”

When I engaged him in further discussion, the young physician maintained that the illness narrative could not stand alone by itself. It is too soft a subject to garner academic recognition.

Personally, I believe that narrative, like art, whether in written, cinematic, poetic or visual format, is sufficient to speak by itself. Although narrative understandably deals with the particular, it encompasses the universal, and so becomes relevant on a profound level.

Simple vignettes, simple narratives, in the hands of a skilled teacher, can be used to impart universal truths — scientific or moral — which every clinician needs to learn.

The Poetry of the Commonplace

In her recent New York Times column, Compelling Stories, If Not Literature, Dr. Abigail Zuger bemoans the recent outpouring of health-related memoirs. “Few of these efforts rise to the level of great literature,” she writes. “None of these books comes close to succeeding according to the usual standards. The language is clumsy and full of clichés; the dialogue is stiff and unreal; the pacing is way off.”

Dr. Zuger also has something to say about doctors who have taken to writing their own stories: “the great majority are sentimental and predictable, and a few manage to be as pedantic, self-important and annoying as, one ventures, their authors must be in person.” Her conclusion? “Most of these books aren’t great literature either.”

Still, Dr. Zuger confides, she has a soft spot in her heart for such books. In the face of all of her prior criticism, you have to ask yourself why. Is Dr. Zuger merely being sentimental? Or does she identify with the sentiments of her patients and colleagues?

In my opinion, what Dr. Zuger fails to recognize is that the patient’s story, no matter how ineptly told, becomes an integral part of the healing process itself.

Medicine’s great 19th century humanitarian physician William Osler remarked that, dealing as he does with poor suffering humanity, a good doctor has to keep his heart soft and tender, lest he develop too great a contempt for his fellow creatures. Osler reflects on what he terms “the poetry of the commonplace”—the ordinary man, the plain, toil-worn woman, their love and their joys, their sorrow and their griefs.

According to Osler, such tales serve to sustain the weary-worn clinician in his daily work. They also serve to sharpen his compassion for his fellow creatures.

My collection of clinical tales in the art of medicine, Patients Are a Virtue, might not be great literature. Few practicing clinicians and fewer patients will ever read it. Most likely it will eventually be relegated to the dustbin of narrative medical writing. And yet I take heart when I receive that occasional communication from cyberspace, such as a brief e-mail from a doctor in rural western Pennsylvania, who wrote that, after reading my book, he felt energized and renewed in his commitment to his patients. He felt so strongly about it that he purchased additional copies for his colleagues and encouraged them read it as well.

Is every patient and practitioner a poet? Dr. Zuger asks. In his consideration of the poetry of the commonplace, I believe that Dr. Osler would answer her rhetorical question in the affirmative.