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Tht?Joufnai of fmergency Medune, Vol 5, pp 233-240, 1987
Prlnted I” the USA
??
Copyright ‘c, 1987 Pergamon Journals Ud
KEEP IN TOUCH Richard M. Ratzan, MD AssIstant Professor of Medicine and AssIstant Professor of Surgery, Department of Medlclne, Department of Surgery, University of Connecticut School of Medicine, Farmington Repnnt address Richard M Ratzan, MD, 17 Concord Street, West Hartford, CT 061 19
“You must never again set your anger upon a patient. You were tired, you said, and therefore it happened.“’ Thus begins “Brute,” by Richard Selzer, a writer who recently retired from surgery to pursue writing full time. “Brute” is a confessional gem of a piece, barely four pages long. Yet it tells the tale of a doctor who lost control. Even while realizing it, he maliciously took advantage of a patient he was ostensibly helping. As with all of Selzer’s stories, it’s even more complicated than that. It’s 25 years ago. The doctor has been summoned to the emergency room at 2 AM to sew up a “hugely drunk” hulk of a man with a laceration in his forehead, “deep to the bone.” The man struggles like Samson to get free and will not cooperate. Restraints are applied. As the doctor begins to clean the wound, the man struggles even more. “Lie still,” Dr Selzer petulantly tells him, enraging him further. The man curses at him, angering the doctor. “Suddenly, I am in the fury with him. Somehow he has managed to capture me, to pull me inside his cage. Now we are two
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brutes hissing and batting at each other. But I do not fight fairly.” Doctor Selzer proceeds to sew the huge man’s ear lobes to the mattress with heavy silk (one imagines it to be 2-O), wipes the clots from his eyes so the man can see, taunts him with the same curse the man just hurled at him, and grins “the cruelest grin of my life. Torturers must grin like that, beheaders and operators of racks.” He finishes the job while the man, sensing defeat, holds still. “How sorry I will always be,” Selzer writes 25 years later “not being able to make it up to him for that grin.” There are many issues here: The rnost immediate is the “need” to use of force as opposed to other options (not discussed or tried in the story), for example, a sedative or waiting for sobriety or recruiting another health care worker with more rapport. Or Selzer could have elected not to sew the patient up at all. On a somewhat deeper and more interesting (intellectually, that is) level is the realization at the time that he was doing something wrong and enjoying it but not stopping. There is also
Humanities and Medicine provides a venue for essays, poems, and other expressions of the medical humanities. Readers are encouraged to submit articles. This section is coordinated by Richard M. Rattan, MD, University of Connecticut School of Medicine, Farmington, Connecticut.
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the discussion of his self-analysis that he had descended to the brutality of the patient and his identification with the patient and the latter’s fury. Perhaps the most interesting aspect of this story-as I’ve just discovered after what must be my tenth reading-is the physician-author’s remorse for the grin. Not the earlobe sewing, not the taunt, but the grin. The writer’s analysis of the evolution of his emotions is instructive. First there is respect (“There is a vast dignity about him.“) followed by an almost sexual fascination (“I am ravished by the sight of him, the raw, untreated flesh, his very wildness which suggests less a human than a great and beautiful animal.“). Next is anger (“Lie still.“) immediately giving way to fury. Revenge, borne of the necessity to sew up a wound too big to leave unmended, takes the form of a type of crucifixion. Despite its being a therapeutic crucifixion, the fastening of the body parts to the stretcher with cessation of activity and spiritual demise represents a subjugation of the patient’s will by the victorious surgeon. Finally, after the self-realization of the wrong he has committed, Doctor Selzer feels remorse. And that stays with him, returning “to peck among my dreams” 25 years later. Yet, is that the end of the story? I think not. For, like William Carlos Williams, Selzer has provided us with another view of this problem we all face: keeping in touch with our own feelings even when, or perhaps precisely because, they are painful feelings. In “The Use of Force,” Williams describes a physician going to the house of a girl, Mathilda, with a fever for three days.? Like Selzer, Williams admires her physical strength and beauty (“An unusually attractive little thing, and as strong as a heifer in appearance.“) Too, Mathilda, like the huge man in “Brute,” puts up a fight, knocking off the doctor’s glasses and embarrassing her parents, whom the
Richard M. Ratzan
doctor finds repulsive with their spineless threats (“If you don’t do what the doctor says you’ll have to go to the hospital.“). Enlisting the help of the father, the doctor decides to overpower Mathilda since he is worried that she might have diphtheria, which is going around. The doctor has “already fallen in love with the savage brat, the parents were contemptible to me. In the ensuing struggle they grew more and more abject, crushed, exhausted while she surely rose to magnificent heights of insane fury of effort bred of her terror of me.” The parallels to Selzer are interesting and worth noting. Finally the doctor engages in full-scale battle, acknowledging to himself that “now 1 also had grown furious-at a child. I tried to hold myself down but I couldn’t.” Mathilda reduces a tongue depressor to splinters. The doctor resorts to a spoon, examining Mathilda’s mouth which is bleeding from a lacerated tongue. He senses that there were alternatives but has chosen this course (“Perhaps I should have desisted and come back in an hour or more.), afraid even an hour’s delay in diagnosing diphtheria. Mathilda is now shrieking and fighting furiously. Like Selzer and his brute, the Williams’s doctor, identifies with his enraged patient: “But the worst of it was that I too had got beyond reason. I could have torn the child apart in my own fury and enjoyed it. It was a pleasure to attack her. My face was burning with it.” He rationalizes that the “damned brat must be protected against her own idiocy, one says to one’s self at such times. Others must be protected against her. It is social necessity.” Eventually, in “a final unreasoning assault I overpowered the child’s neck and jaws,” discovering her membrane. Mathilda, defeated, becomes truly furious, trying to get off her father’s lap to attack the doctor. The story apparently ends there, with no remorse, no introspection. The analogies with Selzer are clear.
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235 ___
First is each’s use of force despite the possibility of alternatives. To be sure, although the other options were not good ones, neither doctor made an effort to try more creative ways rather than resorting to the tried and true method of force. Both realize their shameful enjoyment of overpowering the helpless patient and take comfort in the justification that the force was used for the patient’s own good. Each feels good about winning while wreaking revenge in the name of therapy, yet each feels bad about the method. Each faces his own feelings and becomes confused about their interpretation and resolution. (One wonders what Selzer would now do differently. Would he still sew the huge man’s ears to the mattress but not grin? Or would he have done something totally different?) Keeping in touch with one’s feelings in medicine is a necessary unpleasantness we all must face. We’ve all been in Selzer’s emergency department at 2 AM and in Mathilda’s house at one time or another. Each of us has his individual skeletons in the emergency department closet, skeletons we’d rather weren’t there. Some are big; some are small. They sometimes get easier to ignore, or explain away. But, like Seizer’s brutish surgeon, or the final floating hand in the movie “Deliverance”, they may continually surface at odd, inconvenient moments. What do we do at such moments, after such pecking dreams? If Selzer and Williams and many other authors have anything to tell us about such haunting memories, it is that honesty is the best policy. Recognition, self-recognition, is paramount. Treating one’s own skeletons is only possible after one first diagnoses them. Actually, diagnosing them is usually not the tricky part. Any physician with the usual amount of doctorly guilt senses such feelings of ambivalence when using force, when telling a lie (“therapeutic privilege” is the fancy term medical ethicists call it), when not being a\.ailable as one ought. Admitting to their
existence and letting them stay above the surface, not overpowering thern like Seizer’s huge man or Mathilda, is the dangerous and courageous act. Diagnosing their existence honestly as human traits-as physicians we arc? human-has been literature’s greatest gift to me when it deals with the seamy side of physician-patient relationships. Good literature that is. Recognizing these painful ambivalences and then railing against them, one’s patients, other physicians-in The short, the world -does no good. House of God teaches me nothing 1 didn’t learn during the first week of internship.’ The author’s anger at his emotions castrates that novel. It isn’t nourishing, cleansing like Seizer’s treatment of the wounds in his story - his patient’s physical one and his own psychic one. If Shem’s recognition of his anger is fruitless, anger recognized only by the reader and not the physician may, perhaps, be worse. A wonderful treatment of the explosive occurrence and lasting effect of anger is Chekhov’s story “Enemies”i (a story also known as “Two Tragedies”) in which the physician, Dr Kiriloff, having just lost his six year old child to diphtheria minutes earlier, answers the door to find a stranger beseeching him to come take care of his wife. Kiriloff demurs citing his grief. Abogin, the bourgeois stranger, finally convinces the despondent physician to come to his house to care for his wife whom Abogin feels is dying. Upon their arrival, they find that Abogin’s wife is gone and that it was all a ruse for her to run off with another man. Kiriloff becomes furious, his residue from the evening’s series of tragedies a lasting hatred of n/l the persons of Abogin’s class. Shem’s anger is self-diagnosed but is allowed to go to self-indulged seed. as it were. Kiriloff’s anger remains diagnosed only by the reader. Both angers, however. spill over, interfering with successful relations with patients, whether they are the source of the anger or not. (Interestingly,
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Shem’s anger interferes with his relationship with the reader. Chekhov’s separation of himself from Kiriloff obviates any writer-reader distress.) Nor will self-pity or self-righteousness do anyone any good. Hilfiker’s “Allowing the debilitated to die,“5 an account of his having discovered that physicians are often called upon “to play God” by not treating nursing home patients aggressively, as though he’d stumbled upon a social or professional obscenity only decoded by himself, leaves him as confused as he ever was, and us wondering how he made it this far and what he’s learned from it all. Such moral whining confuses despair for diagnosis. It were better not to diagnose if the treatment consists of throwing up one’s hands. Unadorned, unresolved, and unremitting guilt is likewise not the answer. It is destructive and, speaking in pragmatic terms, worthless, worthless. Hilfiker’s guilt over his past errors in “Facing our mistakes,“h although somewhat more mature than the naive tone in his “Allowing the debilitated to die,” has caused him to “lapse into neurotic behavior to deal with my anxiety and guilt.” As a stimulus to a more honest dealing with such emotions, guilt serves a transitional purpose, as in Hilfiker’s instance. (His problem seems to be that he’s still stuck in the transitional mode.) In Pearl S. Buck’s “The Enemy”’ an American washes up on Japanese land during World War II. Dr Sadao wants very much not to care for the wounded foreigner. Yet Sadao has trained in America and feels a doubly edged guilt in not healing an injured person from the land that still holds cherished memories for him. After resolving to take him into his household, a dangerous act during wartime with soldiers in the nearby town, Sadao faces a silent mutiny from his household help, who leave the traitorous house. His wife is also torn. Finally Sadao tells the local military leader and plans to have the now recuperating soldier killed. But the plans go awry and the story ends with
Sadao helping the recovered American escape to an island to be picked up by foreign boats. The story of Sadao is an interesting examination of guilt and dual, if not multiple, loyalties-wounded humanity as a physician, one’s beleagured homeland, one’s family, one’s former host country where one has learned the skills he now practices as a surgeon. Although there’s no insight, Sadao faces these tensions nobly. Rather than quell all but patriotic loyalty, Sadao, if he does the “right” thing at all, does it because he allows conflicting emotions to pullulate in his consciousness striving all the while for an honest solution. A familiar literary pair also embodies the influence of guilt. Like Sadao, like Selzer’s and Williams’s physicians, Dr Jekyll faces a no-win situation.* If Dr Jekyll does not kill himself, Mr Hyde will continue with his destructive ways. If Jekyll does kill himself, he ends his own life and the benefit he can bestow as a physician on others. Although Dr Jekyll eventually kills himself for probably multiple reasons, one of which is to prevent Mr Hyde from killing anyone else, guilt plays a larger part in his motivation. Are there any other ways in which physicians have faced their mistakes and their conflicting reactions to them? Certainly one of the most charming depictions of a deplorable response-a total lack of concern-is Ben Hecht’s lovely spoof, “Miracle of Fifteen Murderers”.9 An organization of physicians calling themselves the X club in New York, these men gather quarterly. As one member:
of them
explains
to a new
‘The learned Hume,’ he went on, ‘has undoubtedly explained these forums to you on the psychiatric basis that confession is good for the soul. This is nonsense. We are not here to ease our souls but to improve them. Our real purpose is scientific. Since we dare not admit our mistakes to the public, and since we are too great and learned to be criticized by the untutored laity, and since such inhuman perfection as that to which we pretend is not good for our
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weak and human natures, we have formed this society. It is the only medical organization in the world where the members boast only of their mistakes.
Of course, by the time Hecht finishes his story, the laugh’s on them. But that’s for the reader to find out. Callous disregard for one’s mistakes or tensions in medical life is neither Hecht’s idea of the proper response nor is it likely to be anyone else’s, although the ending of another Williams short story, “Jean Beicke,“ro suggests just such an uncaring reaction by an ENT physician who, together with the physician-narrator, shares responsibility for missing a mastoid infection that kills an infant. Perhaps the other end of the spectrum from the Fifteen Murderers is Snake’s reaction in Vonda McIntyre’s “Of mist, and grass, and sand.“” A wandering healer in some futuristic yet primitive world, Snake attempts to heal a small boy with her snakes, Mist, Grass, and Sand. Despite the skepticism, distrust, and, finally, interference from the villagers, Snake succeeds in curing Stavin, the little boy, but at the cost of Grass’s life, which Stavin’s mother has literally cut in half. Although she has saved the boy’s life, Snake is crushed, guilt-ridden: ‘I can’t face their [the villagers’] guilt. What they did was my fault, Arevin [a friend]. I didn’t understand them until too late.’ ‘You said it yourself, you can’t know all the customs and all the fears.’ ‘I’m crippled,’ she said. ‘Without Grass, if 1 can’t heal a person, I cannot help at all. I must go home and face my teachers, and hope they’ll forgive my stupidity. They seldom give the name I bear, but they gave it to me-and they’ll be disappointed.’
Snake is too harsh on herself. Although she is facing disappointment and failure squarely, she is also failing to be reasonable. No one’s perfect. If the Fifteen Murderers confront their mistakes and care not at all, Snake cares too much.
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She has crippled
herself. Such introspection does no one any good-not Snake, not her patients. Why deal with these unpleasant emotions? Why not simply describe them as part of the job description, a kind of hazardous duty risk, and shrug them off? What will happen if, like the Fifteen Murderers, we just go onto the next patient? Or, conversely, how likely is it that we will become crippled, like Snake, haunted by pecking dreams twenty-five years from now? If the answer to the last question is “likely,” or even “remotely possible,” why do we do it? Why not sell Maytag washers and face a life of conflict-free ease? We must face these problems and yuestions, like the reactions to our mistakes and our tensions, honestly. Anything less will lead to even more problems. A physician who thinks medicine is tough and risky and full of conflicts only has to play ostrich with his or her feelings for an hour or two to find just how more tough, more risky, more full of conflicts it can be. We compound our problems when we don’t face them honestly and come up with mature answers. Kiriloff has not only not resolved his individual conflict with Abdgin; he now hates an entire class of innocent people. Selzer’s surgeon now has bad dreams. Hilfiker has traded confusion for guilt because he didn’t do his medical ethical homework in “Allowing the debilitated to die.” Had he done so, he would have found out that others have faced the same problem just as honestly but more bravely, have stuck it out rather than whine impotently at the uncaring gods of injustice. Faulty responses to our feelings have a cascade of effects: not only do we cripple ourselves like Snake, kid ourselves like the Fifteen Murderers, delude ourselves like Abogin, and box ourselves into a corner of anger like Shem, we also cheat our patients of an honest physician who will not only face both our problems and theirs honestly, but will face all problems resolutely and courageously. If there’s no an-
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swer to medical life’s horrid injustices and ambiguities, so be it. Admit it, plow on and heal. Such is the admirable lesson of Dr Rieux in Camus’s The Plague.‘? Toward the end of that remarkable book, when Rieux waxes philosophic, he tells Rambert, a Parisian journalist, “‘For nothing in the world is it worth turning one’s back on what one loves. Yet that is what I’m doing, though why I do not know,“’ referring to his own personal sacrifice in not going with his wife in order to care for people during the plague. Yet again, shortly thereafter, when both Rieux and the priest, Paneloux, have just witnessed a child’s terrible, prolonged and painful death by plague, Paneloux says to . . . That sort of Rieux, “‘I understand thing is revolting because it passes our human understanding. But perhaps we should love what we cannot understand.’ Rieux gathers his strength and shakes his head. “‘No Father. I’ve a very different idea of love. And until my dying day I shall refuse to love a scheme of things in vvhich children are put to torture.“’ As Rieux said earlier, “‘a man can’t cure and know at the same time. So let’s cure as quickly as we can. That’s the more urgent job.“’ The brutal honesty of the existentialists may not be for every one. Yet there is something to be said for it. What is more important than the particular philosophy or religion one espouses is the confrontation of those troublesome spots in medicine and the brave and intelligent attempt to resolve them. Where and how does one “bravely and intelligently” resolve one’s conflicts? I obviously find great solace and wisdom in
M. Ratzan
literature. It’s always there. It doesn’t charge me a psychiatrist’s fees. It changes, like the transcendalists’ concept of Nature, with my moods and my aging. There’s always more around so that I am continually adding to my personal library of bibliotherapy. I also have my mentors, my wailing walls who have to listen to me from time to time because of a mutual relationship based on respect and friendship. I don’t go to them with every day’s laundry list of failed intravenous attempts. If the disability resulting from tensions is great enough, professional help is not only warranted, it becomes an obligation. I hinted above that Selzer’s story might not have ended with the last sentence and that Williams’s story was only apparently finished. What I find fascinating is the possibility that each writer may have exorcised his guilt by writing about it, by teaching others, reducing the hurt to the huge man and Mathilda. Of course writers of the caliber of Selzer and Williams do not need guilt and personal experiences that match up, one to one, with their stories in order to create. Yet the avenue of writing is one method of dealing with these tensions that we shouldn’t belittle too quickly. Letters, poems, stories, essays, diary entries-all can assuage personal hurt. I’m sure one of Dr Hilfiker’s motivations was just this confessional gesture. What one writes in honesty is never wasted effort. And, if that honesty is blessed with the grace of talent, it can help not only one’s self and possibly his next patient; it can also help unknown others, turning a bad memory into healing art.
REFERENCES I. Selrer R: The brute, in Lerrers To A Young Docfor. New York, Simon and Schuster, 1982, pp 59-63. 2. %‘illiams \VC: The use of force, in The Farmer’s Daughters: The Collected Stories of William Carlos U’illiams. Ne\s York, New Directions, 1961, pp 131-135.
3. Chekhov A: Enemies, in The World’s Best Docror Stories. New York, Garden City Books, 1951, pp 255-267. 4. Hilfiker D: Allowing the debilitated to die. NEngl JMed 1983; 308:716-719. 5. Hilfiker D: Facing our mistakes. N Engl J Med 1984; 310:118-122.
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Keep In Touch __-6. Buck PS: The enemy, in: 7. Hecht B: Miracle of the fifteen murderers, in The World’s Best Doctor Stories. New York, Garden City Books, 1951, pp 89-105.
8. McIntyre V: Of mist, and grass, and sand, in Fireflood and Other Stories. Houghton Mifflin. 9. Camus A: The Plague. New York, Modern L.ibrary, 1948.
Prlnted I” the USA
??
Copyright ‘c, 1987 Pergamon Journals Ud
KEEP IN TOUCH Richard M. Ratzan, MD AssIstant Professor of Medicine and AssIstant Professor of Surgery, Department of Medlclne, Department of Surgery, University of Connecticut School of Medicine, Farmington Repnnt address Richard M Ratzan, MD, 17 Concord Street, West Hartford, CT 061 19
“You must never again set your anger upon a patient. You were tired, you said, and therefore it happened.“’ Thus begins “Brute,” by Richard Selzer, a writer who recently retired from surgery to pursue writing full time. “Brute” is a confessional gem of a piece, barely four pages long. Yet it tells the tale of a doctor who lost control. Even while realizing it, he maliciously took advantage of a patient he was ostensibly helping. As with all of Selzer’s stories, it’s even more complicated than that. It’s 25 years ago. The doctor has been summoned to the emergency room at 2 AM to sew up a “hugely drunk” hulk of a man with a laceration in his forehead, “deep to the bone.” The man struggles like Samson to get free and will not cooperate. Restraints are applied. As the doctor begins to clean the wound, the man struggles even more. “Lie still,” Dr Selzer petulantly tells him, enraging him further. The man curses at him, angering the doctor. “Suddenly, I am in the fury with him. Somehow he has managed to capture me, to pull me inside his cage. Now we are two
B
brutes hissing and batting at each other. But I do not fight fairly.” Doctor Selzer proceeds to sew the huge man’s ear lobes to the mattress with heavy silk (one imagines it to be 2-O), wipes the clots from his eyes so the man can see, taunts him with the same curse the man just hurled at him, and grins “the cruelest grin of my life. Torturers must grin like that, beheaders and operators of racks.” He finishes the job while the man, sensing defeat, holds still. “How sorry I will always be,” Selzer writes 25 years later “not being able to make it up to him for that grin.” There are many issues here: The rnost immediate is the “need” to use of force as opposed to other options (not discussed or tried in the story), for example, a sedative or waiting for sobriety or recruiting another health care worker with more rapport. Or Selzer could have elected not to sew the patient up at all. On a somewhat deeper and more interesting (intellectually, that is) level is the realization at the time that he was doing something wrong and enjoying it but not stopping. There is also
Humanities and Medicine provides a venue for essays, poems, and other expressions of the medical humanities. Readers are encouraged to submit articles. This section is coordinated by Richard M. Rattan, MD, University of Connecticut School of Medicine, Farmington, Connecticut.
RECEIVED: 23 December
1986; ACCEPTED: 20 January
233
1987
0736-4679/87
$3.00 t .OO
234
the discussion of his self-analysis that he had descended to the brutality of the patient and his identification with the patient and the latter’s fury. Perhaps the most interesting aspect of this story-as I’ve just discovered after what must be my tenth reading-is the physician-author’s remorse for the grin. Not the earlobe sewing, not the taunt, but the grin. The writer’s analysis of the evolution of his emotions is instructive. First there is respect (“There is a vast dignity about him.“) followed by an almost sexual fascination (“I am ravished by the sight of him, the raw, untreated flesh, his very wildness which suggests less a human than a great and beautiful animal.“). Next is anger (“Lie still.“) immediately giving way to fury. Revenge, borne of the necessity to sew up a wound too big to leave unmended, takes the form of a type of crucifixion. Despite its being a therapeutic crucifixion, the fastening of the body parts to the stretcher with cessation of activity and spiritual demise represents a subjugation of the patient’s will by the victorious surgeon. Finally, after the self-realization of the wrong he has committed, Doctor Selzer feels remorse. And that stays with him, returning “to peck among my dreams” 25 years later. Yet, is that the end of the story? I think not. For, like William Carlos Williams, Selzer has provided us with another view of this problem we all face: keeping in touch with our own feelings even when, or perhaps precisely because, they are painful feelings. In “The Use of Force,” Williams describes a physician going to the house of a girl, Mathilda, with a fever for three days.? Like Selzer, Williams admires her physical strength and beauty (“An unusually attractive little thing, and as strong as a heifer in appearance.“) Too, Mathilda, like the huge man in “Brute,” puts up a fight, knocking off the doctor’s glasses and embarrassing her parents, whom the
Richard M. Ratzan
doctor finds repulsive with their spineless threats (“If you don’t do what the doctor says you’ll have to go to the hospital.“). Enlisting the help of the father, the doctor decides to overpower Mathilda since he is worried that she might have diphtheria, which is going around. The doctor has “already fallen in love with the savage brat, the parents were contemptible to me. In the ensuing struggle they grew more and more abject, crushed, exhausted while she surely rose to magnificent heights of insane fury of effort bred of her terror of me.” The parallels to Selzer are interesting and worth noting. Finally the doctor engages in full-scale battle, acknowledging to himself that “now 1 also had grown furious-at a child. I tried to hold myself down but I couldn’t.” Mathilda reduces a tongue depressor to splinters. The doctor resorts to a spoon, examining Mathilda’s mouth which is bleeding from a lacerated tongue. He senses that there were alternatives but has chosen this course (“Perhaps I should have desisted and come back in an hour or more.), afraid even an hour’s delay in diagnosing diphtheria. Mathilda is now shrieking and fighting furiously. Like Selzer and his brute, the Williams’s doctor, identifies with his enraged patient: “But the worst of it was that I too had got beyond reason. I could have torn the child apart in my own fury and enjoyed it. It was a pleasure to attack her. My face was burning with it.” He rationalizes that the “damned brat must be protected against her own idiocy, one says to one’s self at such times. Others must be protected against her. It is social necessity.” Eventually, in “a final unreasoning assault I overpowered the child’s neck and jaws,” discovering her membrane. Mathilda, defeated, becomes truly furious, trying to get off her father’s lap to attack the doctor. The story apparently ends there, with no remorse, no introspection. The analogies with Selzer are clear.
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235 ___
First is each’s use of force despite the possibility of alternatives. To be sure, although the other options were not good ones, neither doctor made an effort to try more creative ways rather than resorting to the tried and true method of force. Both realize their shameful enjoyment of overpowering the helpless patient and take comfort in the justification that the force was used for the patient’s own good. Each feels good about winning while wreaking revenge in the name of therapy, yet each feels bad about the method. Each faces his own feelings and becomes confused about their interpretation and resolution. (One wonders what Selzer would now do differently. Would he still sew the huge man’s ears to the mattress but not grin? Or would he have done something totally different?) Keeping in touch with one’s feelings in medicine is a necessary unpleasantness we all must face. We’ve all been in Selzer’s emergency department at 2 AM and in Mathilda’s house at one time or another. Each of us has his individual skeletons in the emergency department closet, skeletons we’d rather weren’t there. Some are big; some are small. They sometimes get easier to ignore, or explain away. But, like Seizer’s brutish surgeon, or the final floating hand in the movie “Deliverance”, they may continually surface at odd, inconvenient moments. What do we do at such moments, after such pecking dreams? If Selzer and Williams and many other authors have anything to tell us about such haunting memories, it is that honesty is the best policy. Recognition, self-recognition, is paramount. Treating one’s own skeletons is only possible after one first diagnoses them. Actually, diagnosing them is usually not the tricky part. Any physician with the usual amount of doctorly guilt senses such feelings of ambivalence when using force, when telling a lie (“therapeutic privilege” is the fancy term medical ethicists call it), when not being a\.ailable as one ought. Admitting to their
existence and letting them stay above the surface, not overpowering thern like Seizer’s huge man or Mathilda, is the dangerous and courageous act. Diagnosing their existence honestly as human traits-as physicians we arc? human-has been literature’s greatest gift to me when it deals with the seamy side of physician-patient relationships. Good literature that is. Recognizing these painful ambivalences and then railing against them, one’s patients, other physicians-in The short, the world -does no good. House of God teaches me nothing 1 didn’t learn during the first week of internship.’ The author’s anger at his emotions castrates that novel. It isn’t nourishing, cleansing like Seizer’s treatment of the wounds in his story - his patient’s physical one and his own psychic one. If Shem’s recognition of his anger is fruitless, anger recognized only by the reader and not the physician may, perhaps, be worse. A wonderful treatment of the explosive occurrence and lasting effect of anger is Chekhov’s story “Enemies”i (a story also known as “Two Tragedies”) in which the physician, Dr Kiriloff, having just lost his six year old child to diphtheria minutes earlier, answers the door to find a stranger beseeching him to come take care of his wife. Kiriloff demurs citing his grief. Abogin, the bourgeois stranger, finally convinces the despondent physician to come to his house to care for his wife whom Abogin feels is dying. Upon their arrival, they find that Abogin’s wife is gone and that it was all a ruse for her to run off with another man. Kiriloff becomes furious, his residue from the evening’s series of tragedies a lasting hatred of n/l the persons of Abogin’s class. Shem’s anger is self-diagnosed but is allowed to go to self-indulged seed. as it were. Kiriloff’s anger remains diagnosed only by the reader. Both angers, however. spill over, interfering with successful relations with patients, whether they are the source of the anger or not. (Interestingly,
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Shem’s anger interferes with his relationship with the reader. Chekhov’s separation of himself from Kiriloff obviates any writer-reader distress.) Nor will self-pity or self-righteousness do anyone any good. Hilfiker’s “Allowing the debilitated to die,“5 an account of his having discovered that physicians are often called upon “to play God” by not treating nursing home patients aggressively, as though he’d stumbled upon a social or professional obscenity only decoded by himself, leaves him as confused as he ever was, and us wondering how he made it this far and what he’s learned from it all. Such moral whining confuses despair for diagnosis. It were better not to diagnose if the treatment consists of throwing up one’s hands. Unadorned, unresolved, and unremitting guilt is likewise not the answer. It is destructive and, speaking in pragmatic terms, worthless, worthless. Hilfiker’s guilt over his past errors in “Facing our mistakes,“h although somewhat more mature than the naive tone in his “Allowing the debilitated to die,” has caused him to “lapse into neurotic behavior to deal with my anxiety and guilt.” As a stimulus to a more honest dealing with such emotions, guilt serves a transitional purpose, as in Hilfiker’s instance. (His problem seems to be that he’s still stuck in the transitional mode.) In Pearl S. Buck’s “The Enemy”’ an American washes up on Japanese land during World War II. Dr Sadao wants very much not to care for the wounded foreigner. Yet Sadao has trained in America and feels a doubly edged guilt in not healing an injured person from the land that still holds cherished memories for him. After resolving to take him into his household, a dangerous act during wartime with soldiers in the nearby town, Sadao faces a silent mutiny from his household help, who leave the traitorous house. His wife is also torn. Finally Sadao tells the local military leader and plans to have the now recuperating soldier killed. But the plans go awry and the story ends with
Sadao helping the recovered American escape to an island to be picked up by foreign boats. The story of Sadao is an interesting examination of guilt and dual, if not multiple, loyalties-wounded humanity as a physician, one’s beleagured homeland, one’s family, one’s former host country where one has learned the skills he now practices as a surgeon. Although there’s no insight, Sadao faces these tensions nobly. Rather than quell all but patriotic loyalty, Sadao, if he does the “right” thing at all, does it because he allows conflicting emotions to pullulate in his consciousness striving all the while for an honest solution. A familiar literary pair also embodies the influence of guilt. Like Sadao, like Selzer’s and Williams’s physicians, Dr Jekyll faces a no-win situation.* If Dr Jekyll does not kill himself, Mr Hyde will continue with his destructive ways. If Jekyll does kill himself, he ends his own life and the benefit he can bestow as a physician on others. Although Dr Jekyll eventually kills himself for probably multiple reasons, one of which is to prevent Mr Hyde from killing anyone else, guilt plays a larger part in his motivation. Are there any other ways in which physicians have faced their mistakes and their conflicting reactions to them? Certainly one of the most charming depictions of a deplorable response-a total lack of concern-is Ben Hecht’s lovely spoof, “Miracle of Fifteen Murderers”.9 An organization of physicians calling themselves the X club in New York, these men gather quarterly. As one member:
of them
explains
to a new
‘The learned Hume,’ he went on, ‘has undoubtedly explained these forums to you on the psychiatric basis that confession is good for the soul. This is nonsense. We are not here to ease our souls but to improve them. Our real purpose is scientific. Since we dare not admit our mistakes to the public, and since we are too great and learned to be criticized by the untutored laity, and since such inhuman perfection as that to which we pretend is not good for our
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weak and human natures, we have formed this society. It is the only medical organization in the world where the members boast only of their mistakes.
Of course, by the time Hecht finishes his story, the laugh’s on them. But that’s for the reader to find out. Callous disregard for one’s mistakes or tensions in medical life is neither Hecht’s idea of the proper response nor is it likely to be anyone else’s, although the ending of another Williams short story, “Jean Beicke,“ro suggests just such an uncaring reaction by an ENT physician who, together with the physician-narrator, shares responsibility for missing a mastoid infection that kills an infant. Perhaps the other end of the spectrum from the Fifteen Murderers is Snake’s reaction in Vonda McIntyre’s “Of mist, and grass, and sand.“” A wandering healer in some futuristic yet primitive world, Snake attempts to heal a small boy with her snakes, Mist, Grass, and Sand. Despite the skepticism, distrust, and, finally, interference from the villagers, Snake succeeds in curing Stavin, the little boy, but at the cost of Grass’s life, which Stavin’s mother has literally cut in half. Although she has saved the boy’s life, Snake is crushed, guilt-ridden: ‘I can’t face their [the villagers’] guilt. What they did was my fault, Arevin [a friend]. I didn’t understand them until too late.’ ‘You said it yourself, you can’t know all the customs and all the fears.’ ‘I’m crippled,’ she said. ‘Without Grass, if 1 can’t heal a person, I cannot help at all. I must go home and face my teachers, and hope they’ll forgive my stupidity. They seldom give the name I bear, but they gave it to me-and they’ll be disappointed.’
Snake is too harsh on herself. Although she is facing disappointment and failure squarely, she is also failing to be reasonable. No one’s perfect. If the Fifteen Murderers confront their mistakes and care not at all, Snake cares too much.
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She has crippled
herself. Such introspection does no one any good-not Snake, not her patients. Why deal with these unpleasant emotions? Why not simply describe them as part of the job description, a kind of hazardous duty risk, and shrug them off? What will happen if, like the Fifteen Murderers, we just go onto the next patient? Or, conversely, how likely is it that we will become crippled, like Snake, haunted by pecking dreams twenty-five years from now? If the answer to the last question is “likely,” or even “remotely possible,” why do we do it? Why not sell Maytag washers and face a life of conflict-free ease? We must face these problems and yuestions, like the reactions to our mistakes and our tensions, honestly. Anything less will lead to even more problems. A physician who thinks medicine is tough and risky and full of conflicts only has to play ostrich with his or her feelings for an hour or two to find just how more tough, more risky, more full of conflicts it can be. We compound our problems when we don’t face them honestly and come up with mature answers. Kiriloff has not only not resolved his individual conflict with Abdgin; he now hates an entire class of innocent people. Selzer’s surgeon now has bad dreams. Hilfiker has traded confusion for guilt because he didn’t do his medical ethical homework in “Allowing the debilitated to die.” Had he done so, he would have found out that others have faced the same problem just as honestly but more bravely, have stuck it out rather than whine impotently at the uncaring gods of injustice. Faulty responses to our feelings have a cascade of effects: not only do we cripple ourselves like Snake, kid ourselves like the Fifteen Murderers, delude ourselves like Abogin, and box ourselves into a corner of anger like Shem, we also cheat our patients of an honest physician who will not only face both our problems and theirs honestly, but will face all problems resolutely and courageously. If there’s no an-
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swer to medical life’s horrid injustices and ambiguities, so be it. Admit it, plow on and heal. Such is the admirable lesson of Dr Rieux in Camus’s The Plague.‘? Toward the end of that remarkable book, when Rieux waxes philosophic, he tells Rambert, a Parisian journalist, “‘For nothing in the world is it worth turning one’s back on what one loves. Yet that is what I’m doing, though why I do not know,“’ referring to his own personal sacrifice in not going with his wife in order to care for people during the plague. Yet again, shortly thereafter, when both Rieux and the priest, Paneloux, have just witnessed a child’s terrible, prolonged and painful death by plague, Paneloux says to . . . That sort of Rieux, “‘I understand thing is revolting because it passes our human understanding. But perhaps we should love what we cannot understand.’ Rieux gathers his strength and shakes his head. “‘No Father. I’ve a very different idea of love. And until my dying day I shall refuse to love a scheme of things in vvhich children are put to torture.“’ As Rieux said earlier, “‘a man can’t cure and know at the same time. So let’s cure as quickly as we can. That’s the more urgent job.“’ The brutal honesty of the existentialists may not be for every one. Yet there is something to be said for it. What is more important than the particular philosophy or religion one espouses is the confrontation of those troublesome spots in medicine and the brave and intelligent attempt to resolve them. Where and how does one “bravely and intelligently” resolve one’s conflicts? I obviously find great solace and wisdom in
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literature. It’s always there. It doesn’t charge me a psychiatrist’s fees. It changes, like the transcendalists’ concept of Nature, with my moods and my aging. There’s always more around so that I am continually adding to my personal library of bibliotherapy. I also have my mentors, my wailing walls who have to listen to me from time to time because of a mutual relationship based on respect and friendship. I don’t go to them with every day’s laundry list of failed intravenous attempts. If the disability resulting from tensions is great enough, professional help is not only warranted, it becomes an obligation. I hinted above that Selzer’s story might not have ended with the last sentence and that Williams’s story was only apparently finished. What I find fascinating is the possibility that each writer may have exorcised his guilt by writing about it, by teaching others, reducing the hurt to the huge man and Mathilda. Of course writers of the caliber of Selzer and Williams do not need guilt and personal experiences that match up, one to one, with their stories in order to create. Yet the avenue of writing is one method of dealing with these tensions that we shouldn’t belittle too quickly. Letters, poems, stories, essays, diary entries-all can assuage personal hurt. I’m sure one of Dr Hilfiker’s motivations was just this confessional gesture. What one writes in honesty is never wasted effort. And, if that honesty is blessed with the grace of talent, it can help not only one’s self and possibly his next patient; it can also help unknown others, turning a bad memory into healing art.
REFERENCES I. Selrer R: The brute, in Lerrers To A Young Docfor. New York, Simon and Schuster, 1982, pp 59-63. 2. %‘illiams \VC: The use of force, in The Farmer’s Daughters: The Collected Stories of William Carlos U’illiams. Ne\s York, New Directions, 1961, pp 131-135.
3. Chekhov A: Enemies, in The World’s Best Docror Stories. New York, Garden City Books, 1951, pp 255-267. 4. Hilfiker D: Allowing the debilitated to die. NEngl JMed 1983; 308:716-719. 5. Hilfiker D: Facing our mistakes. N Engl J Med 1984; 310:118-122.
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Keep In Touch __-6. Buck PS: The enemy, in: 7. Hecht B: Miracle of the fifteen murderers, in The World’s Best Doctor Stories. New York, Garden City Books, 1951, pp 89-105.
8. McIntyre V: Of mist, and grass, and sand, in Fireflood and Other Stories. Houghton Mifflin. 9. Camus A: The Plague. New York, Modern L.ibrary, 1948.