Wednesday, May 13, 2009

The Cadaver Room and Other Memories: a blogiversary reminiscence

Two Views of a Cadaver Room by Sylvia Plath

The day she visited the dissecting room
They had four men laid out, black as burnt turkey,
Already half unstrung. A vinegary fume
Of the death vats clung to them; 
The white-smocked boys started working.
The head of this cadaver had caved in, 
And she could scarcely make out anything
In that rubble of skull plates and old leather.
A sallow piece of string held it together.

In their jars the snail-nosed babies moon and glow.
He hands her the cut-out heart like a cracked heirloom.

In Brueghel's panorama of smoke and slaughter
Two people only are blind to the carrion army:
He, afloat in the sea of her blue satin
Skirts, sings in the direction
Of her bare shoulder, while she bends,
Fingering a leaflet of music, over him,
Both of them deaf to the fiddle in the hands
Of the death's-head shadowing their song.
These Flemish lovers flourish; not for long.

Yet desolation, stalled in paint, spares the little country
Foolish, delicate, in the lower right-hand corner.


Every year in the month of May - the month in which I graduated from medical school - I think back to those years before I encountered patients face to face.  Med students are in some ways like Bruegel's Flemish lovers - oblivious to the carnage, not yet involved in it, in fact quite shielded from it, yet with a front row seat and hearts full of interest. 

At some point we have to enter into the fray.  We have to see blood spilled, watch people die in front of us, take part in a person's very first moments, hear people's hidden thoughts and fears, see and touch parts to which even their most intimate loved ones haven't had access.

How do we prepare for that kind of intensity and intimacy?

We do it in stages.  Our first patient, our cadaver in anatomy lab, doesn't risk suffering harm at our hands.  Through this generous individual we confront death, the signs and scars of disease, internal organs.  We place our fingers into the portals of the human heart.  We trace the paths of nerves both delicate and tough, touch the glossy surfaces of liver and spleen, dissect the structures of the head and larynx.

We start seeing live patients as observers standing awkwardly behind seasoned preceptors.  We learn to take a medical history and perform an exam, and we start doing a few. (Embarrassingly, my salient memory from my earliest preceptorship is of my turning visibly green and almost wretching when my preceptor had to lance an abscess in her office.  I held it together...but just barely.)

Then there's the first time we have to deal with someone else's private parts. Tears and suffering I wasn't afraid of...but I felt very shy about invading others' bodies. At my school we were guided through our first pelvic exams by trained models, male and female, who would permit us to examine them and give us feedback on our technique in order to provide us with a greater degree of competence and comfort when we ventured to examine real patients.  We all tried to be cool, almost nonchalant, as we inserted digits and metal objects for the first time into the orifices of strangers.  Predictably, we uttered awkward things. But we learned.  We learned to be careful without being afraid, and to be correct and professional.  I can't say I found this training experience enjoyable, but I certainly found it extraordinarily helpful.

Eventually we are turned loose in the hospitals, to learn how to gather information from and about real patients, examine them well, and make judgments about their needs.  In the end our patients are our most valuable teachers.  We learn from them the mechanics of our profession, but we also learn the things that can't be taught in a classroom, except by simulation - how to discuss bad news; how to console someone who's weeping; how to convey sympathy, to touch people in comforting ways that don't involve percussing or applying a stethoscope. How to feel a portion of someone else's pain without being distracted or destroyed by it.

For most of us, these are recurring lessons to which we'll return for the rest of our careers.  The word doctor in Latin means teacher, and perhaps the best doctors are those who are great teachers.  But no doctor can ever be a great doctor without being a committed life-long learner, and being open to the teaching treasures other people and their lives have to offer.  If this is true, then no doctor can be really good without being genuinely humble - not with the false modesty of someone whose insecurity causes constant self-deprecation, but with the true humility of someone who acknowledges that knowledge and power must be constantly earned and shared.


Christine said...

Wow, great post. I start my clinical preceptorships in about six weeks, so things like this are very much on my mind. I'm excited and horrified, and I know I have a LONG way to go. You write well.

Thanks for sharing. :)

Resident Anesthesiologist Guy (RAG) said...

Excellent post. I have thought about that first patient encounter a lot over the years and wonder why, over so many years, that anatomy is one of the first things we learn. There are times when I think that, now that I understand some of medicine, anatomy would be far more appreciated and more likely remembered than it was the first semester of first year. I guess it's a time-honored tradition and it acts like a catalyst towards your move from undergrad to medical school. Staying awake long hours, tending to your "patient", learning from them. It all has a very real feel to it now, though at the time I didn't appreciate it that way.