In the fourth year of medical school, I watched as, one by one, many of my classmates elected to specialize in less demanding areas (radiology or dermatology, for example) and applied for the residencies. Puzzled by this, I gathered data from several elite medical schools and saw that the trends were the same: by the end of medical school, most students tended to focus on “lifestyle” specialties — those with more humane hours, higher salaries, and lower pressures — the idealism of their med school application essays tempered or lost.
Several students argued for the removal of language insisting that we place our patients’ interests above our own. This kind of egotism stuck me as antiethical to medicine and, it should be noted, entirely reasonable. Indeed, this is how 99 percent of people select their jobs: pay, work environment, hours. But that’s not the point. Putting lifestyle first is how you find a job — not a calling.
Amid the tragedies and failures, I feared I was losing sight of the singular importance of human relationships, not between patients and their families but between doctor and patient. Technical excellence was not enough. As a resident, my highest ideal was not saving lives — everyone dies eventually — but guiding a patient or family to an understanding of death or illness. When a patient comes in with a fatal head bleed, that first conversation with a neurosurgeon may forever color how the family remembers the death, from a peaceful letting go (“Maybe it was his time”) to an open sore of regret (“Those doctors didn’t listen! They didn’t even try to save him!”). When there’s no place for the scalpel, words are the surgeon’s only tool.
The families who gather around their beloved do not usually recognize the full significance, either. They see the past, the accumulation of memories, the freshly felt love, all represented by the body before them. I see the possible futures, the breathing machines connected through a surgical opening in the neck, the pastry liquid dripping in through a hole in the belly, the possible long, painful, and only partial recovery — or, sometimes more likely, no return at all of the person they remember. In these moments, I acted not, as I most often did, as death’s enemy, but as its ambassador.
“Did anyone tell you what the MRI showed?” I asked.
“No.” The buck had been passed, as it often was with difficult news. Oftentimes, we’d have a spat with the oncologist over whose job it was to break the news. How many times had I done the same? Well, I figure, it can stop here.
By this point, I had learned a couple of basic rules. First, detailed statistics are for research halls, not hospital rooms. Second, it is important to be accurate, but you must always leave some room for hope. Rather than saying, “Median survival is eleven months” or “You have ninety-five percent chance of being dead in two years,” I’d say, “Most patients live many months to a couple of years.” This was, to me, a more honest description. The problem is that you can’t tell an individual patient where she sits on the curve: Will she die in six months or sixty? I came to believe that it is irresponsible to be more precise than you can be accurate. Those apocryphal doctors who gave specific numbers (“The doctor told me I had six months to live”): Who were they, I wondered, and who taught them statistics?
Patients, when hearing the news, mostly remain mute. (One of the early meanings of patient, after all, is “one who endures hardship without complaint.”) Whether out of dignity or shock, silence usually reigns, and so holding a patient’s hand becomes the mode of communication. A few immediately harden (usually the spouse, rather than the patient): “We’re gonna fight and beat this thing, Doc.” The armament varies, from prayer to wealth to herbs to stem cells. To me, that hardness always seem brittle, unrealistic optimism the only alternative to crushing despair. In any case, in the immediacy of surgery, a warlike attitude fit.
A resident’s surgical skill is judged by his technique and his speed. You can’t be sloppy and you cant’ be slow. From your first wound closure onward, spend too much time being precise and the scrub tech will announce, “Looks like we’ve got a plastic surgeon on our hands!” Or: “I get your strategy: by the time you finish sewing the top half of the wound, the bottom will have healed on its own! Half the work — very smart!” A chief resident will advise a junior, “Learn to be fast now. You can learn to be good later.” In the OR, everyone’s eyes are always on the clock. For the patient’s sake: How long has he been under anesthesia? During long procedures, nerves can get damaged, muscles can break down, kidneys can fail. For everyone else’s sake: What time are we getting out of here tonight?
I could see that there were two strategies to cutting the time short, perhaps best exemplified by the tortoise and the hare. The hare moves as fast as possible, hands a blur, instruments clattering, falling to the floor; the skin slips open like a curtain, the skull flap is on the tray before the bone dust settles. As a result, the opening might need to be expanded a centimeter here or there because it’s not optimally placed. The tortoise, on the other hand, proceeds deliberately, with no wasted movements, measuring twice, cutting once. No step of the operation needs revisiting; everything moves in a precise, orderly fashion. If the hare makes too many minor misstep and has to keep adjusting, the tortoise wins. If the tortoise spends too much time planning each step, the hare wins.
The funny thing about time in the OR, whether you race frenetically or proceed steadily, is that you have no sense of it passing. If boredom is the awareness of time passing, then surgery felt like the opposite: the intense focus make the arms of the clock seem arbitrarily placed. Two hours could feel like a minute. Once the final stitch was placed and the wound was dressed, normal time suddenly restarted. You could almost hear an audible whoosh. Then you started wondering: How long until the patient wakes up? How long until the next case is rolled in? And what time will I get home tonight?
As a chief resident, nearly all responsibility fell on my shoulders, and the opportunities to succeed — or fail — were greater than ever. The pain of failure had led me to understand that technical excellence was a moral requirement. Good intentions were not enough, not when so much depended on my skills, when the difference between tragedy and triumph was defined by one or two millimeters.
Neurosurgery requires a commitment to one’s own excellence and a commitment to another’s identity. The decision to operate at all involves an appraisal of one’s own abilities, as well as a deep sense of who the patient is and what she holds dear. Certain brain areas are considered near-inviolable, like the primary motor cortex, damage to which results in paralysis of affected body parts. But the most sacrosanct regions of the cortex are those that control language. Usually located on the left side, they are called Wernicke’s and Broca’s areas; one is for understanding language and the other for producing it. Damage to Broca’s area results in an inability to speak or write, though the patient can easily understand language. Damage to Wernicke’s area results in an ability to understand language; thought the patient can still speak, the language she produces in a stream of unconnected words, phrases, and images, a grammar without semantics. If both areas are damaged, the patient becomes an isolate, something central to her humanity stolen forever. After someone suffers a head trauma or a stroke, the destruction of these area often restrains the surgeon’s impulse to save a life: What kind of life exists without language?
It felt to me as if the individual strands of biology, morality, life, and death were finally beginning to weave themselves into, if not a perfect moral system, a coherent worldview and a sense of my place in it. Doctors in highly charged fields met patients at inflected moments, the most authentic moments, where life and identity were under threat; their duty included learning what made that particular patient’s life worth living, and planning to save those things if possible — or to allow the peace of death if not. Such power required deep responsibility, sharing in guilt and recrimination.
- It’s Jeff. He killed himself.
- What?
- He apparently had a difficult complication, and his patient died. Last night he climbed onto the roof of a building and jumped off. I don’t really know anything else.
I searched for a question to bring understanding. None was forthcoming. I could only imagine the overwhelming guilt, like a tidal wave, that had lifted him up and off that building.
I wished, desperately, that I could’ve been walking with him out the door of the hospital that evening. I wished we could’ve commiserated as we used to. I wished I could have told Jeff what I had come to understand about life, and our chosen way of life, if only to hear his wise, clever counsel. Death comes for all of us. For us, for our patients: it is our fate as living, breathing, metabolizing organisms. Most lives are lived with passivity toward death — it’s something that happens to you and those around you. But Jeff and I had trained for years to actively engage with death, to grapple with it, like Jacob with the angel, and, in so doing, to confront the meaning of a life. We had assumed an onerous yoke, that of mortal responsibility. Our patients’ lives and identities may be in our hands, yet death always wins. Even if you are perfect, the world isn’t. The secret is to know that the deck is stacked, that you will lose, that your hands or judgment will slip, and yet still struggle to win for your patients. You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.
If I were a writer of books, I would compile a register, with a comment, of the various deaths of men: he who should teach men to die would at the same time teach them to live.
At Lucy’s insistence, we began seeing a couples therapist who specialized in cancer patients.
“Well, you two are coping with this better than any couple I’ve seen,” the therapist said at the end of our first session. “I’m not sure I have any advice for you.”
I laughed as we walked out — at least I was excelling at something again. I turned to Lucy, expecting to see a smile; instead, she was shaking her head.
“Don’t you get it?” she said, taking my hand in hers. “If we’re the best at this, that means it doesn’t get any better than this.”
The bulk of my week was spent not in cognitive therapy but in physical therapy. I had sent nearly every one of my patients to physical therapy. And now I found myself shocked at how difficult it was. As a doctor, you have a sense of what it’s like to be sick, but until you’ve gone through it yourself, you don’t really know. It’s like falling in love or having a kid. You don’t appreciate the mounds of paperwork that come along with it, or the little things. When you get an IV placed, for example, you can actually taste the salt when they start infusing it. They tell me that this happens to everybody, but even after eleven years in medicine, I had never known.
In physical therapy, I was not even lifting weights yet, just lifting my legs. This was exhausting and humiliating. My brain was fine, but I did not feel like myself. My body was frail and weak — the person who could run half marathons was a distant memory — and that, too, shapes your identity.
I began to look forward to my meetings with Emma. In her office, I felt like myself, like a self. Outside her office, I no longer knew who I was. Because I wasn’t working, I didn’t feel like myself, a neurosurgeon, a scientist — a young man, relatively speaking, with a bright future spread before him. Debilitated, at home, I feared I wasn’t much of a husband for Lucy. I had passed from the subject to the direct object of every sentence of my life. In 14th century philosophy, the word patient simply meant “the object of an action,” and I felt like one.
“Will having a newborn distract from the time we have together?” she asked. “Don’t you think saying goodbye to your child will make your death more painful?”
“Wouldn’t it be great if it did?” I said. Lucy and I both felt that life wasn’t about avoiding suffering.
Lost in a featureless wasteland of my own mortality, I began reading literature again — anything by anyone who ever written about mortality. I was searching for a vocabulary with which to make sense of death, to find a way to begin defining myself and inching forward again. The privilege of direct experience had led me away from literary and academic work, yet now I felt that to understand my own direct experiences, I would have to translate them back into language. Hemingway described his process in similar terms: acquiring rich experiences, then retreating to cogitate and write about them. I needed words to go forward.
And so it was literature that brought me back to life during this time. The monolithic uncertainty of my future was deadening; everywhere I turned, the shadow of death obscured the meaning of any action.
The tricky part of illness is that, as you go through it, your values are constantly changing. You try to figure out what matters to you, and then you keep figuring it out. It felt like someone had taken away my credit card and I was having to learn how to budget. You may decide you want to spend your time working as a neurosurgeon, but two months later, you may feel differently. Two months after that, you may want to learn to play the saxophone or devote yourself to the church. Death may be a one-time event, but living with terminal illness is a process.
Grand illnesses are supposed to be life-clarifying. Instead, I knew I was going to die – but I’d known that before. My state of knowledge was the same, but my ability to make lunch plans had been shot to hell. The way forward would seem obvious, if only I knew how many months or years I had left. Tell me three months, I’d spend time with family. Tell me one year, I’d write a book. Give me ten years, I’d get back to treating diseases. The truth that you live one day at a time didn’t help: What was I supposed to do with that day?
Yet the paradox is that scientific methodology is the product of human hands and thus cannot reach some permanent truth. We build scientific theories to organize and manipulate the world, to reduce phenomena into manageable units. Science is based on reproducibility and manufactured objectivity. As strong as that makes its ability to generate claims about matter and energy, it also makes scientific knowledge inapplicable to the existential, visceral nature of human life, which is unique and subjective and unpredictable. Science may provide the most useful way to organize empirical, reproducible data, but its power to do so is predicated on its inability to grasp the most central aspects of human life: hope, fear, love, hate, beauty, envy, honor, weakness, striving, suffering, virtue.
Yet I returned to the central values of Christianity — sacrifice, redemption, forgiveness — because I found them so compelling. There is a tension in the Bible between justice and mercy, between the Old Testament and the New Testament. And the New Testament says you can never be good enough: goodness is the thing, and you can never live up to it. The main message of Jesus, I believed, is that mercy trumps justice every time.
Struggle toward the capital-T Truth, but recognize that the task is impossible — or that if a correct answer is possible, verification certainly is impossible.
In the end, it cannot be doubted that each of us can see only a part of the picture. The doctor sees one, the patient another, the engineer a third, the economic a fourth… Human knowledge is never contained in one person. It grows from the relationships we create between each other and the world, and still it is never complete. And Truth comes somewhere above all of them, where, as at the end of that Sunday’s reading,
the sower and reaper can rejoice together. For here the saying is verified that “One sows and another reaps.” I sent you to reap what you have not worked for; other have done the work, and you are sharing the fruits of their work.
I thought back to med school, when a patient had told me that she always wore her most expensive socks to the doctor’s office, so that when she was in a patient’s gown and shoeless, the doctor would see the socks and know she was a person of substance, to be treated with respect.
Verb conjugation has become muddled, as well. Which is correct: “I am a neurosurgeon,” “I was a neurosurgeon,” or “I had been a neurosurgeon before and will be again”? Graham Greene once said that life was lived in the first 20 years and the remainder was just reflection. So what tense am I living in now? Have I proceeded beyond the present tense and into the past tense? The future tense seems vacant and, on other’s lips, jarring.
Everyone succumbs to finitude. I suspect I am not the only one who reaches this pluperfect state. Most ambitions are either achieved or abandoned; either way, they belong to the past. The future, instead of the ladder toward the goals of life, flattens out into a perpetual present. Money, status, all the vanities the preacher of Ecclesiastes described hold so little interest: a chasing after wind, indeed.