When I Die

On Friday the nurses and I were laughing hysterically together in the O.R. when I was describing the kind of "memorial" activity I wanted on the occasion of my death. No wake. No funeral (my ashes should have been disposed of privately by then). NO flowers; I still get sick at the scent of lilies because they bring back my grandmother's wake. No morose speeches. No lugubrious music. I want an ice cream sundae buffet.

There have to be waffle cones or waffle bowls available, the home-made kind, the kind you can get at Ben & Jerry's or used to get at Swensen's. I also want sugar-glazed, chocolate-frosted Krispy Kreme doughnuts, strawberries & cream, and Godiva chocolate there - all food to die for and die from - as the only reminder of DEATH in the room. I want 80's music blaring in the background (& if there's room for a Christmas area, where classical Christmas carols can be playing & some Christmas decorations up, I want that too). I want any irreverent thing I've written printed out in enormous letters and plastered on the walls. Maybe a children's book corner, movie marathon showing happy favorites like Elf (like, in the Christmas area), and a slide show of pictures. Goodie bags for the guests, of course, perhaps with recipe cards of our family favorites. There should be "real" food too - enough rouleaux from The Elephant Walk restaurant (or equivalent item) to choke a herd of elephants, mango rice from a good Thai place, a selection of Filipino and French eats, but not too much broccoli or garlic because I don't want anyone getting too gassy at my party, even if I'm going to miss it. That's the sad part for me: I'm gonna miss it! The nurses suggested I have a dry run so I can at least enjoy it once and fix any glitches. :) [Incidentally even our patient got in on the fun - she arrived in the O.R. just in time for it, joined the discussion right before I anesthetized her, and literally woke up from anesthesia saying, "You gotta have 80's music!" So that idea came from her!]

(spring rolls Photo: gildemax)

***

Last night one of my ninety-something patients developed significant post-op delirium and got combattive with us in the recovery room. Some elderly people are what we often describe as "pleasantly confused." Then there are those who are pleasant during the day but get downright nasty when the sun goes down, through no fault of their own. They swear, bite, punch, threaten. This is the type we were dealing with, and I always feel like a failure when this happens, but the truth is that anesthetics can do this in the very old - scramble the mind, or perhaps bring out the deep, dark side of it - and I always warn loved ones about this prior to surgery.

I thought this was interesting: when the nurse asked this patient from last night why she was so mad, the patient pointed to her chest and yelled, "Because I hold a lot of pain in here!" No, we didn't work her up for chest pain or a heart attack; there were many other signs that she wasn't referring to that kind of pain. I truly think she was referring to something less tangible.

It made me think: angry people really are hurting somewhere in there, and all it takes is a little disinhibition to reveal that underlying lack of peace. It also made me wonder: what if I'm the mean and nasty kind of demented when I get old, and sunset reveals my true nature to be a wad of resentment and bitterness? I confided these concerns to my husband, who'll be the one dealing with the mess when we get there, and he very kindly said, "No, you'll be sweet when you're demented, and still adorable." I dunno...I have some mean thoughts and resentments in there...they might come out...So my project now is to try to expurgate those from my psyche or whatever, and try to make my "true self" sweeter (at which I failed miserably last night when I got annoyed and snappish in the O.R. after hours and hours of annoyances and challenges ... sigh ...).

Do You Decry Your Doctor's Dyslexia?

The same op-ed section from the Boston globe that I quoted in my earlier post "Medicine Hates Moms" contained the following question from Janet James of Lunenburg, MA:

"Should students with dyslexia and attention disorders be allowed into medical school?"

The comments section under "Medicine Hates Moms" has taken an interesting turn thanks to a thoughtful, articulate reader who got me thinking about medicine and learning disabilities, particularly about the issues raised by James's question above. A lot of my thoughts on the subject can be found in that section, so I won't rehash those here, except to say that I think a lot of people erroneously equate "disability" with "inability," and I think this does people with learning disabilities and ADHD an injustice.

I'm interested in medical education and curious to know more about people''s thoughts on this. Please feel free to comment on the subject if you'd like, but please, please, please, in the wake of having had to delete a comment already due to obscenity and extreme disrespect, I ask that folks refrain from being acrimonious, disparaging, contemptuous, condescending, obscene, or insulting, even if offering criticism. Please express your opinions graciously, whatever they may be - with passion and even indignation if you feel them, certainly, but never without respect for fellow-readers and writers here.


In particular I'm interested to know

-Do you know professional people with learning disabilities?

-Do you think people with learning disabilities should be excluded from any particular profession? Why/why not?

-What about neuropsychological disorders?

-Where do you draw the line in terms of excluding people with shortcomings from the medical profession?

-What measures are appropriate for predicting whether someone will be a good physician or not? Or IS a good physician or not?

Birthday Cake with a Side of Deep Thoughts

My daughter turned 10 yesterday. I am aghast and delighted and wistful and excited. She looks every bit her ten years. I mourn and rejoice all at once.

We celebrated at the home of good friends who spend some summer weekends in Truro, on Cape Cod. The kids sang songs from Wicked which blared from a karaoke machine. The grown-ups drank chardonnay and talked about being parents. The women made birthday cake. The girls braved the chilly Atlantic. The boys flew a kite. I read Anil's Ghost; my son was engrossed in Jennifer Morgan's poetic three-volume series for children about The Big Bang and ensuing history of life on earth (quote of the week: "I'm on my first eukaryote."). We had delicious sandwiches at PJ's Seafood in Wellfleet on the way home. All in all a refreshing weekend on the shore.




***

We spent part of the weekend discussing an article in The New Individualist, an objectivist publication. It decried conventional altruism and extolled Ayn Rand's philosophy of "rational self-interest" as the highest moral standard. It highlighted reason and individualism as two great themes of Rand's novel Atlas Shrugged.

I have a couple of problems with the idolization of reason. I think reason is one of humankind's most important tools, a defining one at that. But I also cry at old movies, love mountain views, enjoy chocolate, and prefer blue to orange. Reason can't define all of my self, nor do I think human cognitive faculties supreme enough for us to be able to claim that the universe is completely knowable through them. I think reason is put to good use as a way to rise above emotional reactivity, violence, and hedonism, as well as to make sense of observation and experience. But I don't think it's the be-all and end-all.

I have mixed feelings about individualism as delineated in the article: a way of being in which one's own happiness is the ultimate ethical end. I do believe we are ultimately responsible for our own happiness. I also believe, however, that we are not always in control; we can only exert that responsibility under conditions of real freedom, and there are many things that can physically, practically, or psychologically abridge that freedom. It's so in-vogue to talk of empowering oneself these days that there's a real danger of failing to recognize or acknowledge that things that take power or control from people are real and valid obstacles. I'm all for not whining about one's sorry plight, not being needy or playing the role of the victim - poor me, poor me, look what society did to me - and I think we should pull ourselves up by the bootstraps when we are down, to the extent that we can. I just think those bootstraps are genuinely defective or out-of-reach for some people, and that some never got boots to begin with.

To say that we are not responsible for others or to others may in a sense have some truth to it, but I don't really buy it. Individuals exist in relationships and communities. I won't accept responsibility for another's emotional responses, but I am responsible for the way I treat him or her. We are responsible for our own happiness, certainly, but I don't agree that we should fail to choose some responsibility for noticing and correcting injustices within relationships and communities. I believe we should strive to be generous, given that life deals people some unequal hands, whereas the objectivist, as I understand from this article, would criticize generosity as silly.

I'm no philosopher. I'm sure the authors of the articles in the publication have bigger brains than I do. But I don't want to have a smaller heart.


***

My husband and I were watching the PBS miniseries The War and my daughter caught part of it with us, the part about the Philippines. Perhaps knowing her grandparents were survivors of the Japanese occupation magnified its emotional impact, but she grieved for the dead soldiers and civilians as only a child can grieve, completely vulnerable, open-hearted, full of love. "It's not fair!" she wept. "So many people died! Why do people keep doing it?" What's a mother to murmur, except that all we can do is try to be kind and peaceable in our own lives, with one another, try to reject violence, try to choose ways of love and live in the hope that that energy is never wasted? How many mothers over thousands of years have sat stupefied wondering how to console their sweet children over this very thing?

She is at the cusp, my young girl. Old enough to know the painful stories of history, young enough to hug her teddy bear close at bed time. Which she did.

Learning to Play; or, Two Steps Forward, One Step Back II

I think a capacity for silliness or playfulness is important. I find that people who don't seem to have one either are miserable or tend to make other people miserable, or at the very least extremely annoyed.

In med school I wrote a contemplative poem about my cadaver. That was not playful. But the little verse below, also penned during medical school, was meant to be, another self-check to make sure I wasn't taking everything so seriously all the time. In the wake of my recent ranting and raving, I include it as a way of stepping back and lightening up a little.

Ode to a Mitochondrion; or,

a medical student's homage to Ogden Nash

Cristae, cristae curling 'round,

In your matrix have we found

A clue to evolution's jaunt?

Are you an endosymbiont?

:)

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My son started taking violin lessons with my daughter's best friend's mom. Naturally when he brought home his little rental violin we all wanted to try it. No one sounded as screechy and awful as I did. It was pitiful. Best of all was our little boy, who produced a rich, mellow tone from it right from the start. I asked his teacher how this was possible - we had all been expecting to have to plug our ears during practice time to get through the squeaky beginning phase - and her explanation was eye-opening. Without a relaxed grip on the bow, it can't vibrate against the strings properly, and you get that awful scraping noise, whereas if one just eases up a little and "goes" with it - "goes with the bow," as it were - a nice tone comes out. The moral of the story is I am way too tense, and I need to learn to be more like my child who, despite a bit of an anxious nature, is still relaxed enough to be open to his experiences and just let the music flow through him. Maybe that's what's meant in part by "the kingdom of God belongs to such as these."

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That being said, I have to confess my annoyometer registered a pretty high reading this afternoon when I was dealing with someone from a local oboe reed manufacturer on the phone. This manufacturer charges $4.00 for delivery even though the same box sent through the mail by another manufacturer shows postage for MUCH less (like, by about 300%). Already this was irritating the first time I ordered from them. At that time I asked if I could pick the reeds up in person because I live so close by. They agreed, and it turned out the pick-up spot was two streets over from my house. Today I called and asked if I could do the same, and the woman made reluctant noises before saying finally, "We really don't like to do it that way."

"Why not?!" I asked, unable to imagine a powerful enough reason for her to object to such a sensible arrangement.

"Well, it's just coordinating everything..."

"But there's nothing to coordinate. The last time you let me know when they were ready, and I walked over, opened the front door, and picked them up from the foyer."

"Well...we like the orders to all to go out at once."

Eventually she agreed I could come on foot the two ridiculous little blocks, not worth $4.00, and pick up the reeds on Monday, but this whole exchange struck me as silly - not the kind of silliness I was advocating when I first started writing this post, but the ANNOYING kind, the kind of bad PR that makes you never want to call the company back or order from them ever again.

The problem is, their reeds are REALLY good, and I still haven't gotten to the point of learning how to make my own. Sigh...that's the trouble with getting attached to a brand. The only thing worse than your favorite pen or ice cream flavor or lip gloss getting discontinued is it remaining available but at the hands of people you don't really want to deal with!

First lesson of the fall is next week. Between my travels and my call schedule, not to mention my kids' activities, I may have to start from square one. This summer oboe hiatus has gotten pretty worrisome. I can feel my gains slipping away. I need to remember the lesson from my son's violin: I gotta just relax and go with the flow.

Medicine Hates Moms

Speaking of opening old wounds...I need to vent about Sophie Currier's battle against the National Board of Medical Examiners.

A few days ago an article in The New York Times told the story of a medical student, Sophie Currier, who requested accommodation for her need to express breast milk for her child during her board exams. Her request was denied because breast-feeding doesn't constitute a condition covered by the Americans With Disabilities Act.

Never mind that a mother's act of nourishing her young is one of the most natural and important activities in the world.

Never mind that doctors are duty-bound to inform patients and the public that "breast is best," at least in early infancy.

None of this matters, you see, because there are rules about how you're supposed to be as a medical student or resident, the most revered one being that if you're weak, you don't deserve to be involved in medicine. And if you've chosen to be a mom and a physician, in many medical minds, you're weak. Because now they'll be asked to actually acknowledge and be considerate of your needs instead of treating you like chattel - what a pain!

What else makes you weak, in the world of medical training?

Needing 8 hours of sleep every night. Needing to eat breakfast, lunch, and dinner and not gulp it down in 15 minutes. Needing bathroom breaks. Needing to take sick time off. Needing to sit down during rounds because you have multiple sclerosis or are nine months pregnant with sciatica. Being pregnant. Having children and needing reasonable time away from work to care for them. Having a learning disability. Having a physical disability. Not knowing how to do something without being taught. Not knowing answers to esoteric questions. Sometimes, even taking time to be kind to patients.

What makes you earn the coveted phrase of praise, "strong work," during medical training?

Being fast. Being slick. Having an assertive personality. Always knowing the answer, or at least expounding upon it with confidence even if you don't know what you're talking about.

I need to get off my chest some incidents from my own training that Sophie Currier's story brought to mind.

Comment from the chief resident in OB/Gyn (no less!) as she walked into the residents' lounge while I was discreetly, under a blanket, expressing milk for my son: "Anyone can just walk in here and see you, you know. You really shouldn't be doing that in here."

Underlying messages I heard in her hostile tone: Breast-feeding should be hidden from view. Women shouldn't bring their motherhood into medical territory.

Comment from a female faculty member in the presence of my pregnant friend: "It's irresponsible for women to have children during residency."

Message: medicine is more important than your family. You should rearrange your "normal life" around medicine. Women shouldn't bring their motherhood into medical territory.

Catcalls from surgery residents as I was expressing breast milk behind closed doors in the surgery call room: "Do it out here! Come on!"

Message (albeit facetious): even if you're doing something sacred, like being a mother to your infant child, ultimately to us you're just an object for our entertainment or use.

Request from me to the chief resident in surgery during an operation for which I was holding retractors: "May I scrub out to pump some breast milk for my son? I'm in a lot of pain."

Resident: "You really need to stay and finish the case."

A few minutes later: "This is really hurting a lot and I'm losing some milk onto my scrubs. I really need to scrub out."

Resident: "Oh, all RIGHT."

Message: well, forget about getting a fair or decent evaluation for the rotation. Oh yes, and please don't bring motherhood into medical territory.

Warning from OB anesthesia fellow to me: "When there's a lot of down-time between epidurals, you need to be careful what you're seen doing. Stick to reading anesthesia. When people see you addressing birthday party invitations for your kids...it doesn't look good."

Me: "Because that's somehow more offensive than sitting around and watching baseball or action movies, the way the guys do between epidurals?"

OB fellow: "I know it's not fair, but that's just the way it is. It's ok for them to do that, but it's not seen as ok for you to do activities that belong at home. I'm just trying to warn you about the way people see things in this department."

Message: Women shouldn't bring their motherhood into medical territory. It's WEAK (see weakness criteria above).

That department later tried to claim on written evaluations that I was a weak resident because my fund of knowledge was inadequate. I wrote back with a copy of the results for a standardized (read: objective) test of our progress that we had to take periodically, pointing out that my scoring above both the national average AND that hospital's average for OB anesthesia seemed to belie their claim: one cannot be simultaneously ahead of one's peers and behind them. After that they left my "fund of knowledge" alone but they tried many times on subsequent evaluations to claim deficiencies which I felt I did not have, and which I rebutted in writing with concrete examples. The bottom line was that I knew what I was doing and my patients were well-cared for. I am glad that stupid fight is behind me.

I passed all my boards, written and oral, on the first try, despite a diagnosed learning difficulty for which I couldn't get accommodations because I had done well enough in school and on past standardized tests. Clinically, I am careful and competent; my patients can trust me. I got through my training with two kids who are happy and healthy. I nursed both of them, not as long as I wanted to, but as long as I could. I was able to nurse my first child longer than my second, who was born during medical school; I was unable to express milk for him as regularly as I needed to during the rotations described above, and to my great sadness, my milk dried up early. (Message from the medical world: your physical and mental health, and that of your children, is not our concern - but excel in providing for the health of others nevertheless.) I wonder if medicine will ever pull its head out of it proverbial derriere someday and take measures to actively support mothers in their task of learning to become good physicians. It's too late for me, but I hope changes come, both in terms of breast-feeding education, which should be part of high school health curricula, and for women entering medicine now. If Sophie Currier's story is any indication, there's still a long way to go.

_______________________________________________________

Addendum, c. 9pm: I found examples of anti-Sophie-Currier posts, for instance at Parlancheq and at Don Surber's blog, that made me realize the breadth and depth of ignorance, sarcasm, and hostility that exists over women professionals, doctors, and nursing mothers out there. Posts like these sound like they're written by authors who have absolutely no idea what taking the boards is like, and/or no idea what nursing entails. To authors that fit this description I say the same thing I said on a recent post to people who pass judgment against Mother Teresa without having lived an equally generous life. To those who actually know what they're talking about, from experience, but still find Sophie Currier's actions objectionable, I would say I can understand why using litigation to make a point as well as to effect reform might be off-putting to some, but I also hold that the medical profession has been unfriendly to family life, for both men and women, long enough and could use some very real and lasting changes, and perhaps a swift kick in the pants once in a while. (Incidentally, for the MANY people who have asked on other sites why she can't just pump the milk before the test, I have to ask: what is she supposed to do when the milk rapidly reaccumulates, as it would in any healthy nursing mother, and causes extremely painful engorgement during the first couple of hours of the exam, with another seven hours of testing to go, reaccumulating milk all the while?)

________________________________________________________

One more thought by Dr. Nancy Terres of Boston, from the Boston Globe op/ed section on boston.com: "It is one thing for the healthcare system to endorse a health behavior such as breast-feeding, but quite another to change our own behaviors to make the goals possible for our patients. As a representative of the medical establishment, the NBME is sending the message to the public that we as healthcare providers are not all that serious about our health recommendations."

It takes energy and conscientious effort to do the right thing. It'll be hard for anything about the system of medical training in the U.S. to change without personal transformation, insight, compassion, and courage from the individuals running the show - those who are "teaching" the residents and controlling credentials. I hope it's not too much to ask.

Wicked

Last night we saw the national tour production of Wicked at Boston's beautiful Opera House. What an incredible show! I was riveted from the moment the red eyes in the dragon's head above the curtain (with its map of Oz) began to glow, and a "monkey" climbed down onto the stage hand-over-hand on a vine, to the moment all secrets were revealed and that same curtain came down on the magical world that had told us its story in song and dance. Composed by Stephen Schwartz, who also wrote Godspell, Pippin, and the songs from The Prince of Egypt, with a witty book by Winnie Holzman, based on the novel by Gregory Maguire, Wicked is everything a Broadway / West End musical is expected to be: a stunning visual spectacle with sumptous sets and special effects; interesting characters; a gripping story; a complex, compelling, imperfect but heroic protagonist (here perfectly portrayed by Victoria Matlock); high dramatic stakes; and clever treatment of themes near and dear to all our hearts...

...or at least, to my heart. I was surprised at what Wicked reminded me of. It reminded me of my residency.

Ordinarily that would be a strong case of wound-picking and I would want to avoid such a reminder, but I loved the show, and I think it was because Elphaba was able (literally!) to rise above the external forces she felt were bringing her down, cast off their hold on her, and find within herself a power that couldn't be assailed - not even by the stubborn prejudices and judgments of those around her, or by their need to cling to the false idol of their perception of her. She learned the truth about herself, and it outshone their misperceptions and lies.

Someone asks in the beginning where wickedness comes from - are people born with it, or do they become wicked because their experiences apply layers of negativity, arrogance, self-interest, and bitterness to them that seep in so deeply that their very natures are changed? As the story unfolds one suggested answer seems to be that evil comes from people's judgment of each other - especially when judgments are made based on appearances, incomplete perceptions, and unswerving but poorly founded beliefs.

The friend who came with me (we both brought our daughters) pointed out that Gregory Maguire's backstory for the characters in the Wizard of Oz (and how they got to where they got to - the cowardly lion, the tin man, the monkeys, all of them) achieved the same effect created when the curtain was pulled back in Baum's original story, and the truth about the wizard was revealed. The musical, which is so much about correcting perceptions and learning new perspectives, gives us, the audience, a whole new way of seeing a familiar story, and does it with more multi-dimensional characters, who themselves learn new ways of seeing their own story, each other, and themselves. They also learn about the true nature of power - where it comes from, its ability to corrupt, how the misuse of it can rob people of their freedom and ability to express themselves and communicate with each other, and how clawing for it with wicked means, like spying and tyranny, is ultimately a demonstration of humanity at its weakest.

In the end Elphaba doesn't need the truths or untruths others have constructed in order to embrace her own. I saw Wicked as ultimately a morality play in which the heroine dies to her old self and rises again, escapes her encumbrances, and perfects her faith. With that learned faith and its components - courage, freedom, and peace - Elphaba comes to know who she is and is able to know real love. Great, great show.

Wound Care

Not too long ago I had to counsel a family about a surgical procedure their loved one needed in order to have a chance at survival but which, at the same time, she might not survive. I told the family I needed to place a breathing tube for the surgery but that I was also unlikely to be able to remove it afterward. Our conversation was long and quiet but intense, and in the end I could offer no better news for them. "Thanks for explaining it to us, doc. You do what you gotta do." What I was able to do for that patient was very little. She survived the surgery and was in guarded condition when I left the hospital for the day, but she died later that night.

There's a lot that's hard in medicine. The hours. The demands. The stresses. These are merely exhausting or frustrating, but confronting our own impotence - that has something else to it. Something really humbling, a kind of sadness.

So why do it? Why did I? How did I end up in med school at all?

I was an English major in college, and a good one. I loved to read great books and write good papers. I was into music and dance, medieval and Renaissance history, ancient languages, modern languages, scripture exegesis, art history. I dabbled in theater and even performed the role of Connie in A Chorus Line. Later I would get interested in social psychology and anthropology. In short, I was a humanities student through and through, not an ounce of the science geek in me, nor the aptitude of one. I was fascinated and awed by science - especially molecular biology and astrophysics - but I had no facility with it. If I managed to get through a science class at all, it was with a lot of tears and sweat.

In my last year of college, while I was writing my English thesis, I took an EMT class for fun. Should I have or shouldn't I have? I ask, facetiously, because in the middle of that course a voice in my mind said, "Uh-oh. I think I want to be a doctor. I love taking care of people, and using clinical skills and science to do it." Here was science that had the breath of life in it! Physiology, the logic of the body, was a tantalizing intellectual pleasure. I wanted to learn all I could about it, and use it to be of service to people. The first (and, intially, the only) person I admitted this to at the time was the man I would eventually marry (at a time when we were "in neutral," between fitful bouts of dating). His reaction then is what it still is: whole-hearted, affirming, faithful support. We would wind up marrying and starting a family before I ever set foot in medical school, but set foot I did, for better or worse.

I wasn't always going to be an anesthesiologist, though. I was going to be a pediatric specialist and spent most of my electives in medical school preparing for a life in pediatrics. I took a special course in an inner city hospital in New York on the evaluation of victims of child abuse. I was attracted to the field of medical genetics because of its integration of child development, in which I had a master's degree, and counseling, and I had the chance to spend several stimulating weeks at the National Institutes of Health learning the ropes in its division of medical genetics. They wanted to hire me as a resident and fellow, in fact, but sometimes life takes its own circuitous path. Choosing anesthesia involved a "voice in my head" kind of moment too: after mask-ventilating a child for the first time, I knew I wanted to be the doc that was doing that every day. So here I am.

Sitting here on the eve of the anniversary of 9/11 I realize that though my life was left intact by those dramatic moments in our history, I was not entirely untouched by those events. When the planes hit the towers I was in New York, completing another elective in medical genetics at Mount Sinai Medical Center. The first nail in the coffin of my dream of becoming a medical geneticist was hearing one of the medical geneticists comment, "Should we go and help? Oh, wait, we can't really...unless they need IVs or something..." I was bothered by that. I wanted to be a doctor who COULD help in that situation, and even though I knew the ongoing care given by medical geneticists to their patients was irreplaceable to those patients, I also knew how abstract it could be, and I realized I wanted to be able to see the help I was giving. I'm a lot like Doubting Thomas in many ways.

Academic activity was suspended that day, but all fourth-year medical students were asked to assemble in one place and offer assistance if needed. Someone had the presence of mind to make a note of anyone who was multilingual. It was all for naught, as we now know: there were few if any survivors to help, and rescue workers needing medical attention would go to hospitals downtown, where some of my classmates were on rotation, not uptown.

That day was the most intense example of what for many physicians is one of the worst aspects of medicine: its limitations. When I look back on the times in medical school or residency that left me feeling utterly disconsolate, I remember moments when I or the clinician next to me would have to say some variation of "I'm sorry, but there's nothing I can do."

I recall a beautiful young girl who had been maimed somehow and who came to the orthopedist's office with the hope of restoring some function to her arm, the upper part of which had been shattered and faultily repaired in some foreign country. She couldn't lift her arm to the side, so when I asked her to extend it she had to unfold it in a broken-winged sort of move. The orthopedist was using my imperfect Spanish to communicate with this lovely girl and her mother, and I felt stupid, frustrated, and helpless telling them we couldn't do anything for them.

Another time in the ear/nose/throat clinic I examined an African American woman with downcast eyes whose eardrum was blown wide open.

"How did this happen?" the ENT fellow asked.
Her bottom lip started to quiver. "My boyfriend..."
We remained silent, hoping to give her space to tell the story.
"We got into a fight..." Large tears started to roll down her cheeks.
"He hit you," the fellow said quietly.
"Will I be able to go back to my job?"
"What sort of work do you do?"
"I'm a..." The woman was laboring to suppress a sob, but couldn't. "I'm a telemarketer."
"Oh," said the fellow. His manner was serious but gentle, like his voice. "The injury is quite severe. We could attempt a surgical repair, but I can't guarantee that surgery would help."
"But it don't feel right. Can't you do nothin'?"
"I'm sorry..."

When something of ourselves rips or breaks, there is grief, a futile yearning for things to be as they were, unhurt, unchanged. Healing is an astonishing process, as is our capacity for it; but there is a melancholy aspect to it: we are forced to learn to live with scar tissue, with changed selves, and to accept that things can never be as they were before a blow was dealt, whether with words or ideas or fists or fortune. Perhaps in the end our scars are meant to teach us that while in some respects "there is nothing we can do" but let things be, and find new ways of accepting and transforming imperfection, it's also true that we can do more than we realize, especially when we recognize, get involved with, and learn from the wounded around us, and the wounded within.

Doctors Who Write

Last week I read the following poem, by Warner V. Slack, M.D., on the blog kept by Paul Levy, President and CEO of Beth Israel Deaconess Medical Center. Dr. Slack kindly gave me permission to share it here. It's arresting, inspiring, and profound. I am grateful for writers (and doctors) like him, who stop and think, and who make the effort to see, the first task of any artist (or physician).

ENCOUNTER ON THE STAIRS
By Warner V. Slack, MD

Next to Children’s Hospital, in a hurry
Down the stairs, two at a time
Slowed down by a family, moving slowly
Blocking the stairway, I’m in a hurry
I stop, annoyed, I’m in a hurry
Seeing me, they move to the side
A woman says softly, “sorry” in Spanish
I look down in passing, there’s a little boy
Unsteady in gait, holding onto an arm
Head shaved, stitches in scalp
Patch over eye, thin and pale
He catches my eye and gives me a smile
My walk is slower for the rest of the day

***

One of my most sacred "academic" values is a reverence for story and language. As in the case of being a "person of faith," being a person with a deep love of the arts and humanities can sometimes be marginalizing in the medical world. Medical training, in fact, can be a desert for those who thirst for really good writing, as a Time article once affirmed, so when I find a poet like Dr. Slack, I feel like someone who has taken a long-awaited cold drink of water on a scorching day, or who has found a breezy spot under shade trees in an otherwise arid landscape.

I especially admire those who can write poetry. Of all literary forms, I think this distilled form is the most challenging - all that meaning to cram into an itty bitty space! Not a word out of place! Next hardest, I think, is the short story, also a distillation of meaning without the wider "wiggle room" afforded by novellas and novels.

I found this wonderful paragraph by Stephen J. Dubner on the subject of doctors who write:

"So why do these doctors write so well, and so much better (to my mind, at least) than other non-writers? Perhaps there are elements of doctoring that lie in harmony with writing: peeling back the layers to get to the core of an issue; confronting the obvious but being willing to look beyond it; learning where to 'cut in,' of course; and, more than anything, recognizing that this object before you – in one case a human body, in the other a manuscript – is on a certain level a miraculous object with the power to astound, and on another level is a complex, dynamic system which can (and must be) reduced to a schematic, laid out on paper or x-ray film."

We learn as medical students that the most important resource for our healing efforts is a thorough history of our patient. Story, story, story: it's not only what makes us human, but also what drives us and helps us excel at our humanity. I thank Dr. Slack, and his intellectual / artistic / spiritual ancestors and colleagues: Anton Chekhov, William Carlos Williams, W. Somerset Maugham, A. Conan Doyle, A.J. Cronin, Walker Percy, Ethan Canin, Sid Schwab, and so many other doctors who write (or writers who doc!), for their gifts, and their balm.

The Illusionist

Who doesn't love a good mystery, or a good ghost story? I think the most captivating stories are, in some way, one or the other, or both.

Neil Burger is a genius. I've just watched The Illusionist, which I've been wanting to see for a year, since its release, and I was completely mesmerized by it.

Steven Millhauser's original story "Eisenheim the Illusionist" is spare by comparison, a catalog of achievements by the protagonist, whose motives and character are never really explored. In one memorable line Millhauser compares story tellers to conjurers, hinting at themes that are never fully incarnated.

Burger's film adds STORY to the story, human drama, emotional stakes (forbidden love, my fave). Coupled with evocative production design and cinematography, the themes and motifs of art v. life; illusion v. reality; disguised truths; missing pieces; belief, disbelief, and suspension thereof; power, and its sources; and penetration of mystery are all brought to life in a fascinating period piece expertly acted by one of the greatest actors of this generation, Edward Norton.

Burger's additional characters, dramatic scenes, and philosophical musings about time and power are all added gems embedded in a script with no awkward or unnecessary sentences, nothing extra. The scene with the sword, the passionate revelation of Eisenheim the man behind the enigmatic facade, his darker ghost-conjuring toward the end of the film, as well as smaller moments - his first recognition of a long-lost love, his distraction in the workshop after an evening performing in front of her, the illusions themselves - all cast their spell on me. As Eisenheim works his machinations in the world of the story, the film-maker is doing the same in the world of my own mind - a brilliant double-play, illusion upon illusion creating reality upon reality.

"He has proven to be more than a magician, your highness," says Chief Inspector Uhl in the movie. The real magic was that Eisenheim's audience, his "readers," drew and voiced their own conclusions with no need for explicit direction from him. He was a puppeteer without strings. Eisenheim got under people's skin, transformed the way they saw reality, recreated their thoughts. That's ultimately what any great writer or artist or teacher becomes: no mere conjurer, or illusionist, or performer, but someone who actually transfigures the world. Heady stuff for a Labor Day weekend on-call! The power of story triumphs once again. In the end the film itself is the ultimate magician's masterpiece, an intricate box of secrets and delights, a play of smoke and mirrors that reveals its characters (and our own) in bits and pieces and lingers in one's thoughts long after its scenes have vanished from view.
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(Images from the Lexikon der gesamten Technik (dictionary of technology), 1904, by Otto Lueger

What's a "High Pay-off" Kid?

Recently, my husband and I sought help for one of our kids from a professional who specializes in evaluating children's academic and behavioral skills. During the "results meeting" we heard very little that was surprising - our kid was bright, our kid had this or that personality trait, our kid would benefit from this type of parenting style and that type of external aid, etc. After some suggestions which we generally found helpful - the evaluator was an experienced, caring professional whom we liked and respected - I was struck by the way the evaluator phrased one observation, said almost in passing: "Your child's got a lot of talents and will probably be on the honor roll in school, so I wouldn't worry about academics - your kid's going to be a pretty high-payoff kid."

"High pay-off" kid? What is that?

Am I supposed to feel rewarded if my kid aces grammar school, or gets the state trophy in knot-tying, or something? What kind of parent has kids to get a kind of pride "pay-off?"

I honestly don't think this lovely psychologist meant any harm by the way he phrased his statement, but it hit a nerve. It reminded me of an ad I heard on the radio for an Ivy League summer program for high school students, inviting young people who were intelligent, talented, motivated, with "good leadership" qualities, etc. etc.: all the superficial characteristics this society sees as gifts that make people valuable, and "worthy" of attention, and which turn this culture into the meritocracy and beauty contest that it so often is.

Let me state here and now, just to get my opinion off my tachycardic chest, even if no one really cares to know it:

MY CHILDREN ARE HIGH PAY-OFF CHILDREN BY THE VERY FACT OF THEIR EXISTENCE.

They could be "above average," "average," "below average," whatever, but as long as they were doing their best to be kind and to work hard, we would delight in their efforts. We find deep joy in their presence, and loving them is the most fulfilling experience of our lives.

My entire life has been a stream of lessons about human worth. The older I get, the more I realize that most of what we're often told about human worth is completely wrong. I may not be what many Christians in the U.S. would consider a real Christian, but I do try to contemplate and act on the teachings of Jesus. One of the reasons I appreciate those teachings is his frequent attempts to speak out against and overturn some of this faulty thinking about the value of human beings, sometimes quietly like a gardener turning earth over in his hands, and sometimes with the force of pushing money-changers' tables to the ground. I love the passages in the New Testament in which Jesus tells the arrogant, self-important Pharisees to their faces that the poorest wretches might reach the "Kingdom of Heaven" before they do. That must have really stuck in their craws somethin' awful, and good for them, and for any of the "high and mighty" in any society who fancy themselves to be worth the world but their neighbors not.

I think Jesus lived, and probably also died, for the conviction that people are worth the world but their trappings - achievement, social status, talent, wealth, beauty, and the like - are immaterial. I think if we as a society had the kind of faith in our own intrinsic dignity that he had, there would be much less unrest in our hearts. I hope my husband and I can transmit to our children this genuine and profound sense of peace, and thus set them totally free.