Reflections in a Head Mirror

In August 2008, I was honored to be the speaker at the White Coat Ceremony that welcomed the Medical College of Wisconsin class of 2012 . Here is a link to my talk. My suggestions to them at the time were to:

• Remember where you came from
• Listen to your friends and family
• Find a mentor
• Keep your white coat thin by letting patients' stories affect you and letting patients feel your compassion

Now, four years later, those students are graduating. Most of them forgot my talk long ago. It has been great to meet many of them during their time at MCW and I am proud that a few have chosen careers in otolaryngology! The world is in good hands. 

This week, I reflected on the differences between college commencement and medical school commencement on WUWM's Lake Effect.

Congratulations, Class of 2012!

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There is always a way to be honest without being brutal.
-Arthur Dobrin  

“The oncologist mentioned the possibility of some newer treatments,” his wife tells me.  

I look at him doubtfully. Placebo-light? I think to myself. Pretend-imab?

“Oh,” I say.  

He slumps in the exam chair, listing sideways, searching for an imaginary support that is not there. He occupies only a fraction of the space he filled four years ago when he first came to my office – before his first surgery, before radiation therapy, before the last round of salvage chemotherapy, before the latest frightening scans.  

He looks up, staring at me from the depths of his being. “Doc,” he whispers, “is this thing curable?”  

I move closer and rest my hand on his fragile arm. I have known him for a long time. “No.” I search their faces. “You will die with this cancer.”  

His eyebrows rise momentarily but there is a smile at the corner of his mouth. “Doc," he says, "Thank you.”  

I look at his wife. She shifts. “No one has told us that before.” She pauses then continues. “We talked about it ahead of time and we knew you would be straight with us.”

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The following is feedback received for this blog:

Your kindness to them required courage and integrity. Thank you for sharing this tender "moment".

We are already one. But we imagine that we are not. And what we have to recover is our original unity.
-Thomas Merton

I recently sat with a group of residents and students to discuss two fictional short stories that are classics in the Medical Humanities: “The Use of Force,” by William Carlos Williams (1938) and “Brute,” by Richard Selzer (1982). Both stories are difficult and violent.  

In “The Use of Force,” Williams tells the story of a home visit to see a sick child. The doctor must examine the child’s throat because he fears the child has diphtheria. Things do not go well. He tries to cajole the child and to enlist the help of the parents. The child resists and the parents are reluctant to force the child to cooperate. The doctor’s thoughts are transparent to the reader: he despises the parents for their weakness, admires the child for her strength and tenacity, and eventually loses his temper. “In a final unreasoning assault, I overpowered the child’s neck and jaws.” The doctor sees the tell-tale membranous discharge in the throat, thus sealing the diagnosis.  

In “Brute,” Selzer tells the story of a man brought to the emergency room in the middle of the night, roaring drunk and handcuffed. He has a deep gash across his forehead. The man is powerful and fights the doctor’s attempts to repair the cut. The doctor and patient are alone in the room, and the reader is privy to the doctor’s anger and exhaustion. In frustration, he finally grabs two large sutures and sews the man’s earlobes to the mattress. “I have sewn your ears to the stretcher,” I tell him. “Move, and you’ll rip ‘em off.”  Along the way, the doctor-narrator tells us of his rage.  

My discussion group reflected on the stories in ways I did not expect. They took the narrative conflicts personally. These residents and students have experienced long and difficult on-call nights and times of great frustration in patient-care settings. They have certainly had moments when interacting with patients was difficult and exhausting.  

Yet, some were very critical and unforgiving of the way the doctors in the stories reacted. “That’s just wrong!” they declared. “No one should ever treat patients that way!”  

The stories ARE difficult. The doctors get their tasks accomplished, but they are angry and sometimes profane in the process.    

It was an opening for me to talk about the difference between “Professionalism” and “Humanism.” We work to train professionals – people who have certain sets of attributes, skills and demeanors with which they will practice high-quality medicine with integrity and empathy. This is a good goal. “Humanism,” on the other hand, is broader than professionalism. These are qualities we hope every physician brings to the table from childhood. Humanism refers to a deep respect of humans individually and collectively, and concern for their general welfare and flourishing.    

In the examples we looked at, both doctors were, strictly speaking, professional. The child’s throat was examined and the man’s laceration was repaired. The spoken dialogue is, by and large, “professional” and focused on the medical issue at hand.

But, “humanism,” that is another story. Williams speaks of the doctor’s “fury” while Selzer speaks of his doctor’s “rage.” Both doctors overpower their patients. The inner dialogue is the focus.  

Both essays close with the doctor-narrator expressing shame and regret. A physician can be perfectly professional but lack humanism, depending on how he or she see patients and co-workers. Being attentive to our "inner dialogue" can tip us off to when we are in danger of losing our humanism. 

The discussion helped me see the difference. Great writing and great colleagues can do that.  

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References:
Williams WW, The Doctor Stories, New Directions, New York, 1984. MCW Library WZ 350 W728d

Selzer R, The Doctor Stories, Picador, New York, 1998. MCW Library WZ 350 S469d  

A wonderful discussion of the topic can be found at: Goldberg JL, Humanism or Professionalism? The White Coat Ceremony and Medical Education, Academic Medicine 2008; 83:715-722.

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“I will never forget that day.”

She smiled broadly.

“It was about a week after my cancer surgery and I had finally worked up the courage to look in the mirror. I knew you had rearranged things a bit, okay. Moved stuff around. Taken things apart and jammed them all back together, right?”
 
I probably would not have said it quite like that, but she was correct that her surgery had involved removing part of her tongue, a ridge of bone from the jaw, and some of the lymph nodes in her neck. She had been a bit swollen after the procedure but no more than expected, as I recalled. Things had gone well.
 
“So, I am standing in the bathroom and look up at myself in the mirror. Well, the face peering back WAS NOT ME! It just wasn’t me! I just kept staring. I wanted to know what had happened! Finally, I found something that looked familiar.”
 
“What was that?” I wanted to know.
 
“Finally, I recognized my left eye. I knew that face in the mirror was mine because it had my left eye! But that was the only thing I recognized! Only my left eye.”
 
Of course, at the time, I knew nothing of what she had discovered in the bathroom mirror. My daily rounds probably consisted of telling her she was recovering nicely and the cancer was gone. We would have talked about nutrition and what she would need to do once she was discharged from the hospital. I would have reminded her that her swelling would disappear gradually over a few weeks. I might have shared that the scars would fade steadily and would be almost invisible someday. I have had hundreds of similar discussions over the years.
 
She, on the other hand, must have been wondering, What the heck did this surgeon do to me?
 
I pressed her to go on. “So, what happened?” I asked. 

 “Well, gradually, I recognized more and more of my own face. After a while, I realized the unrecognizable person in the mirror had my nose, for instance. Then, over the course of a few days, I found my other eye, then my forehead, then my mouth. Finally, I recognized myself entirely. It was really weird, though! Now I know what it must be like to lose your memory or forget your childhood.”
 
“That must have been a scary experience,” I said.
 
She laughed. “I guess so. It all turned out fine. I’m doing
great now.”
 
I tried to imagine what else had run through her head at the time. Will I get better? Does this happen to everyone? Why didn’t the doctor warn me about this? What if it gets worse?
 
Now, several years of cancer-free existence later, she still tells the story with great enthusiasm. Those days when her memory did not work remain very fresh in her mind.

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