Reflections in a Head Mirror

Recently, I have been helping guide the medical students’ dissections of the head and neck anatomy. The experience reminded me of a story I heard many years ago from one of my own teachers.  

A famous anatomy professor, austere and distinguished, was invited to a formal dinner party. After the cocktails and hors d'ouvres had been completed, the guests were seated for the meal. The host, acknowledging the stature of the anatomist, turned and asked him to provide the blessing for the meal.

The anatomist, who remained calm on the outside, was inwardly apprehensive. He had not attended a religious service since his youth and had placidly led a long, solitary, and completely agnostic life. He had no idea how to properly return thanks in such a formal setting.  

He stood slowly, bowed his head, and twitched his impressive moustache. The guests, in turn, quietly bowed their heads, anticipating his prayer. The anatomist, both sonorous and deliberate, slowly intoned: 

“Levator labii superioris alaeque nasi.”  

He raised his head, smiled gravely, and sat down. Several guests congratulated him on the perfectly chosen and powerfully delivered words. The remarkable incantation outlasted even the wonderful meal.

She’s a painter … beautiful stuff. She has painted murals on walls for homes and restaurants. Shortly after her cancer surgery, she brought in a photo album full of images of intricate patterns and floral designs. The work was stunning. Now, more than a year later, I ask her about her art. “Have you painted recently?”

“Oh, yes. I still paint murals for clients.”

“I mean, have you painted expressively? Have you painted anything about your cancer?”

She looks at me quizzically.

“No. I never felt like doing that,” she tells me. “I have been busy. Lots of deadlines. Not much time for creative work.”

She pauses. “I don’t know.”

She pauses again.

“Do you think I should?”

“Some people are able to use art as a form of expression after cancer treatment. It can be a way of processing the experience, but everyone is different. What do you think?”

“Wow. I guess I hadn’t thought of it. I can’t believe it has been a year since the surgery!”

She pauses again.

“Maybe I’m ready to try painting about my cancer now. I’m not certain. If I do, you will be the first to know.”

The poet, James Russell Lowell, once said, “Creativity is not the finding of a thing, but the making something out of it after it is found.” Maybe that is what is in play in this situation.

"Thanks," I tell her. I am looking forward to seeing what she creates.

When I was a medical student, I spent vacations working in a community hospital in the Chicago area. There were a few medical residents training there at the time, but, by and large, almost all of the care and teaching was provided by private practice physicians.  

My favorite physician was a soft-spoken, warm internist. He actually carried a “little black bag” as he made his rounds; he also carried and had read the latest issue of The Annals of Internal Medicine. In addition to expertly balancing an inpatient load and busy solo practice, he actively participated in conferences. He taught students and residents on the spot whenever the opportunity arose at the bedside or in the hallway. His teaching style was Socratic but non-threatening. His explanations were crystal clear and organized. He appeared to think, and teach, in paragraph-form.  

Interpersonally, he was an intent listener, humble, clever, and engaging. He always seemed unhurried for both patients and students.  

I believe compassion and caring are, to a great extent, hardwired. Nevertheless, I gained new insight into my role model’s character development when I read a book he wrote after retiring several years ago. The too short volume chronicles his time serving as a medic near the front lines in New Guinea and Luzon during World War II. His writing style, like his personal style, was clear, organized, self-effacing, and often funny. For much of his deployment, he was attached to the 36th Evacuation Hospital, working hard to support a war effort that was just miles (and often less) away.  

How might his military experience as a medic have made him a better physician later in life? He explains it in the book. While in New Guinea, he worked closely with the front-line combat troops and the experience moved him. He modestly writes:  

“This exposure to the lowest soldier, the foot soldier, the grunt, the GI who was, and knew he was, expendable but willingly bore the brunt, deeply impressed me; I acquired an appreciation of and a compassion for such men which persisted and, I think, guided me a bit, sometimes, as I practiced medicine.”

As a student, I found him to be a remarkable, compassionate role model. To this day, I can hear his voice as I tease details from a patient, wait patiently for a family member to come to the point, or try to pass on a concept to a trainee.   

There are some great teachers and role models in the big, academic medical centers. Fortunately, I met one such a physician in the halls of a community hospital in the very earliest days of my medical life and I have tried to emulate him ever since.      

During my first uncertain steps towards becoming a physician, I unconsciously searched for role models and mentors to emulate. First, as a nursing assistant and later, as a medical student and trainee, I had plenty of opportunities to observe doctors in their natural habitat. It was not always pretty.

Once, during my days as a nursing assistant, an older physician came to the hospital Outpatient Department accompanied by a woman with a small facial cyst. “Lie down!” he growled. She looked worried, but complied. I didn’t notice any attempt at informed consent.

He glowered at me, “Get me a set of instruments.” I got out what he would need and began to wash up her forehead.  “Where’s the razor?” He shaved a wide swath well up into her hairline. “Gimme the local!” Without warning, he jabbed her several times, infiltrating the burning anesthetic into her forehead, completely oblivious to her discomfort.

He clumsily draped her head, leaving towels covering her mouth and nose. She tried to move the drapes so she could breathe. “Don’t touch that! It’s sterile!” he yelled. Her hand dropped submissively to her side.

As he made an incision, she withdrew. “Yeouch!” she cried. Blood dripped down the side of her scalp.

“Hold still!” he ordered. He made no attempt to add more anesthetic. Despite the small size of the cyst, the procedure took a painfully long while. After the cyst was removed, he placed a few thick, uneven sutures. “Don’t get it wet AT ALL for five days! Meet me here next week and I will take out the stitches!” I tried to clean up the blood, but she shot off of the bed and bolted for the door without saying a word. I doubt she came back.  

Albert Schweitzer once noted, “Example is not the main thing in influencing others. It is the only thing.” I admit that at least a part of my career was heavily influenced by a cranky, old general practitioner on that day almost 35 years ago.

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The following is feedback received for this blog:

Wow! I have always found talking to patients as a great way to distract them from the uncomfortable things we sometimes have to do to them (i.e. needle injections to place the local, etc). - RL Bates I encountered a doctor--and I use the word with a wince--who was like that, 20 years ago. Brought the needle tip to my eye, as I laid there, and fiercely demanded that I not blink. (I had a squamous-celled growth on the inside of my eyelid.) Thank you for learning from your own encounter not to ever be that kind of a doctor. Thank you for being a compassionate one. - Alison Hyde http://www.spindyeknit.com

“Will you be my doctor? The other doctor didn’t look me in the eye, kept checking his watch, and told me that I needed surgery. He didn’t answer my questions and never called me back. We just did not connect.”  

I hear this occasionally (and I am certain that my former patients’ new doctors hear it, as well). Getting the elements of communication “right” between patient and physician is tricky, especially in the context of cancer surgery. The issues are not new.  

Over Labor Day weekend, I immersed myself in several of the stories in the collection, Chekhov’s Doctors (Jack Coulehan, ed. The Kent State University Press, 2003). Anton Chekhov, the noted writer and playwright, was a practicing physician; doctors figure prominently in many of his wonderfully crafted, timeless, and very readable stories. He brings to life physicians who display mixtures of compassion, cruelty, tenderness, greed, sensitivity, saintliness, arrogance, depression, despair, immorality, and existential conflict — in short, his doctors are flawed. Doesn’t that sound familiar!

In a story entitled “Ionitch,” Chekhov’s physician protagonist begins as a poor energetic doctor who is welcomed to town by an artistic family; he soon falls in love with the beautiful daughter. Early in the story, she rebuffs his marriage proposal. He recovers, but the seeds of isolation and irritability have been planted.

Over the years, Ionitch focuses on working hard and making money. He becomes increasingly haughty, refusing all gestures of friendship. He grows rich.

By the end of the story, despite being a respected consultant, he is also corpulent and ill-tempered; when seeing patients, he raps his walking stick on the floor and shouts, “Be so good as to confine yourself to answering my questions! Don’t talk so much!” Chekhov’s doctor has become a success, but his quest for wealth has left him detached and bitter. Chekhov focuses more on the relationships between the doctor and others than on the medical care rendered and he cleverly leaves most interpretation to the reader.  

Transformations from eager neophyte to bitter dinosaur still happen today, believe it or not. Can doctors be taught to be compassionate? Or at least MIMIC it? How do we pass these cautionary tales on to our next generation of physicians?  

How do we get students to absorb the lessons they will need to avoid becoming The Someone they never intended to be?  

Instructive examples are abundant in classic and modern literature. However, during medical school and residency, there are persistent demands from hard sciences and overwhelming clinical duties. When I examine our medical school library's collection of medical fiction, poetry, and reflective essays, I notice that some of the volumes haven’t been checked out for months or even years.  

Medical schools, including ours (I am proud to say), are developing Medical Humanities programs to find other ways to expose students to this “softer” aspect of Medicine. It is critical that we find ways for physician-writers like Williams, Chekhov, Maugham, Percy, and Coles to teach students the following lesson: We, as doctors, are in danger of becoming complacent and arrogant when too many patients, parents, friends and acquaintances tell us that we are something special.  

Because it just ain’t so.  

That lesson won’t be on the final exam this year in medical school, but it might be important much, much later to our patients, our families, and ourselves.

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The following is feedback received for this blog:

Thanks for this nice post. - RL Bates http://rlbatesmd.blogspot.com/