Reflections in a Head Mirror

Question: What do you call physicians who write?
Answer: Physicians.
- Jay Baruch, MD  


I sit in the office and listen as she tells me her story. Her cancer treatment had impacted her family in nearly unimaginable ways. Personal demons are everywhere. Just as she recovered from surgery, her marriage disintegrated. Her life has been and would always be completely different from my own. I am riveted.  

As I sit transfixed, my mind starts working … is this a story I can turn into an essay?    


In a piece entitled, “Thin Walls,” Jay Baruch writes about a woman who leaves college and lives with her grandparents, becoming part of their lives in the months before her grandfather succumbs to a slow and debilitating death from cirrhosis. The story careens dangerously through drug dealing to child neglect to the physical effects of liver failure to suicide to death. We watch proud, angry, and stubborn people collapse. We wonder at the effect on the young woman — a character created by Dr. Baruch, an emergency physician and bioethicist at Brown University. The narrative is breathtaking and is only one of the remarkable fictional essays in his book, Fourteen Stories.  

As an accomplished physician-writer, Dr. Baruch has chosen to work in fiction and he does so for a reason: the stories really belong to the patients. In an essay entitled, The Story Always Comes First, he confesses that “[w]riting about ‘real events’ and ‘real people’ from my roles as a physician makes me feel like a thief … [because] [t]he physician-patient relationship is tender and complex, charged with issues of vulnerability and power.”    

As I listen to my patient run through the latest disasters, I wonder how I could share her story, honestly and reflectively, in a way that betrays nothing of the patient’s private experience. Like Dr. Baruch, I write to “understand particular human behavior and to effectively communicate that which surprises and disturbs me.”  

I decide to pass on turning this woman's difficult struggles into an essay. Maybe a small piece of it will end up in a work of fiction someday. In the meantime, I will continue to admire writers like Jay Baruch.

Froedtert & The Medical College of Wisconsin will participate in the 2009 Oral, Head and Neck Cancer Awareness Week (OHANCAW) by hosting free screenings, an information fair, and some brief talks. Screenings will be performed next Tuesday, April 28 from 4:00 pm to 6:00 pm. Screening requires an appointment; the exams can be scheduled at (414) 805-3666. Even after the screening schedule is full, everyone is invited to come and learn more about head and neck cancer. More information can be obtained in the media release. 

Several of us have performed the screenings over the past several years. We rarely find anything worrisome, but it is always great to answer some questions and put someone’s mind at ease.  

This year’s event is much more ambitious than usual! We will have speakers including cancer survivor and blogger Jay Walt. We will also be featured on Fox 6 Wake Up News on Tuesday morning, April 28!  

If we can ease just one person’s mind or catch just one early cancer, it will have been worth the effort. We will post some photos after the event. Special thanks to Kathy Myers, RN, who is coordinating the event and to all of our wonderful volunteers.

Children have never been very good at listening to their elders, but they have never failed to imitate them.
-James Baldwin

I calculated backwards and figured that her granddaughter must have been about 10-years-old when my patient first developed cancer. Few of my patients have had such a difficult run.

Nothing has come easily. Her cancer was difficult to control and she required radiation and then extensive surgery and more radiation. The side effects led to additional treatments, a feeding tube, and expensive pain medications. She had battles with both her employer and her insurance company. She cannot gain weight. I suspect she has lost friends because of her difficulty with communication. Many of her old friends no longer spend time with her since she quit smoking and does not like to be around smoke.

Of course, to hear her tell the story, she is doing fine. She feels well and has adjusted reasonably well. She celebrates her freedom from cancer every single day.

I was worried, therefore, when she arrived for a follow-up visit. She looked distracted. I moved into position to perform the examination.

“What’s this?” I blurted out. “Have you started smoking again?”

“Oh, no!” She was adamant. “Quitting was the best thing I ever did!” She looked quizzically and then realized that I had smelled tobacco smoke on her clothing. “Doctor, my family still smokes in front of me. They know how I feel but they smoke anyway.”

She paused.

“Even my 17-year-old granddaughter! She just started smoking. Despite growing up watching what I have been through, she smokes.”

My patient sat silently and shook her head.

“Doctor, it is just absolutely unbelievable.”

Of course, raising kids is tough. When my own children were very small and my oldest son was acting up, a favorite teacher once told me, “Remember: your sons will wreck your cars, but your daughters will break your heart.” My teacher’s half-joking comment came to mind again as my patient struggled to land on an argument that would induce her granddaughter to see what smoking could potentially mean for her own future. Was there something that the girl had somehow missed watching her grandmother’s ordeal over that last seven years? We came to no conclusions and both suspected that getting through to the girl would be neither quick nor easy.

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The following is feedback received for this blog: My husband was forced to give up smoking in late Nov 2006 because of a severe sore throat. Some 7 weeks later when it had practically improved, he'd "gone off" smoking, much to my delight. Recently, I've discovered that he's taken it back up again. He tells me that it's only 1 a day, but I know it's more ... Sadly there is just no telling some folk. And even more sadly, nothing we can do to stop them. - Jabulani

I was delighted to have an essay accepted for this week’s “A Piece of My Mind” section of the Journal of the American Medical Association (JAMA). For those of you with access to JAMA online, you can find the essay here.

The editors of JAMA have been kind enough to publish three of my essays (10-10-2007, 2-27-2008, 4-8-2009). Before they would accept this essay, however, Associate Senior Editor Roxanne Young gave me a tough assignment. The journal wanted the family’s permission. After all, if the family happened to see the article, might they not recognize themselves?  

At first, I was resistant to calling the family. Couldn’t we just change a few of the details of the story? Maybe we could change the patient’s gender. I worried: what if the family refused to grant permission to publish?  

Most of all, though, I realize that contacting the family would be uncomfortable for me. The essay was about a failed resuscitation attempt. The experience was traumatic to the staff, the residents, and the nurses; I could not begin to imagine the potential effect it had on the family. Furthermore, it had been a long time since the events chronicled in the essay had occured. 

I realized, of course, that the editors were correct. I worked up the courage and called the family member who I had known best. It was a wonderful conversation.  

We talked about the patient and about how each of the family members had coped with the events and his death. She was surprised to learn how much the physicians had been affected. We talked about how much all of us missed him. Permission was granted and soon the essay was accepted.  

I had a similar experience with a previous essay. When I called the patient, a man whose religious beliefs affected his medical care, he was delighted to share his thoughts and provide additional resources. After the contact, I realized how much I had enjoyed talking to him again.  

In both cases, the conversations had offered each of us a moment to remember an event that had been very important to us.  

Medical bloggers like me often write stories about their patients. As bloggers, we do not routinely obtain written consents like the one required to publish in JAMA. Some bloggers change identifying details. Others leave out important data. Sometimes, however, people spot themselves in the essay and, occasionally, this lack of formal permission has gotten bloggers into hot water.  

For me, these moments of contact have been wonderful experiences. In each case, they have allowed me to better understand the patients, the families, and, of course, the final chapter of the stories I am trying so hard to tell. 

To choose what is difficult all one's days, as if it were easy, that is faith.
-W. H. Auden   


"They want to operate on your grandmother."

Dad was shook.  I shuddered. This was one of those dreaded moments when my family looked to me for medical advice. 

“What should we do? What should I tell them?”  

I was still in training. I tried as best I could to think objectively.

“Who wants to operate?” I asked. “What did they tell you?”  

My dad had received a phone call. My grandmother was in her 90s and confined to a healthcare facility six hundred miles away. For years, she had adamantly insisted that her boys never put her in “one of those places.” However, after a rapid deterioration in mental and physical status, she had passively allowed herself to be moved to the local nursing home. For two years, she had shared a room with a woman who had spent her entire life on a neighboring farm. Although they had known each other for decades, my grandmother no longer recognized her old friend.  

“What surgery are they suggesting?” I asked.  

“Her foot is turning black. They say she needs an amputation soon.”  

We had visited the family farm just a few months before. When we spent time at the nursing home, my grandmother had not recognized us even once. She had smiled pleasantly when we spoke to her but the vigorous farmer’s wife of the past had long since faded away. This remarkable woman who had weathered the Great Depression saving pennies, selling eggs, worrying about rain, raising cattle, and butchering chickens no longer knew who anyone was. Her eyes were empty.  

“Why do they want to operate? Will it make her better?”  

“No. They said the foot is getting infected. They said surgery might help her live longer.”  

Dad and I talked about our visits to the farm. In my memory, I could taste the home-cooked meals around the kitchen table, gaze at the sunsets from the front porch, smell the fresh-plowed Ozark soil, and feel the clean sheets of the upstairs bedroom. I could hear the boards creak beneath my feet and touch the bare plaster as I climbed the stairs.  

“I don’t think surgery will make her feel better, Dad.”   

There was a long pause. “Could you talk to the doctor?”  

“Sure.”  

A few minutes later, as I hung up the phone after talking to my grandmother’s physician, I felt an unfamiliar heaviness in my chest. To this day, that heaviness returns whenever one of my patients presents me with a choice that I would rather not have to make.