July/ August 2008

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CONTENTS SAN FRANCISCO MEDICINE July/August 2008 Volume 81, Number 6

Literature and Medicine

FEATURE ARTICLES

MONTHLY COLUMNS

10 The Permanent Patient: The Life of Marcel Proust Thomasine Kushner, PhD

4 On Your Behalf 5 Upcoming SFMS Events

12 Sniffing the Same Air: Using Lear and Loman to Teach Future Doctors about the Human Condition Larry Zaroff, MD, PhD

7 President’s Message Steven Fugaro, MD

13 Seized by the Muse: Dostoevsky’s Convulsive Poetics in The Idiot Dennis Patrick Slattery, PhD

9 Editorial Mike Denney, MD, PhD

15 Shakespeare’s Doctors: A Medical Lesson from Literature Mike Denney, MD, PhD

32 Hospital News

17 The Starving Artist (An Excerpt) Ashley Skabar

33 In Memoriam Nancy Thomson, MD

20 Losing the Ability to Create: Amy Tan on Lyme Disease Amy Tan 23 Medicine as Muse: Writing My Way through Medical School Craig Chen 24 Learning from Literature: Literature, Medicine, and the Good Doctor Lawrence J. Schneiderman, MD 26 Reflective Writing: Providing a Useful Tool to Medical Students Gail Ellison, PhD 28 South Wing: A Medical Mystery Written by the Editorial Board of San Francisco Medicine 30 The Poetry Corner 31 Book Review: Aging, Time, and Love in the Time of Cholera Ashley Skabar

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July/August 2008 San Francisco Medicine

July/August 2008 Volume 81, Number 6

ON YOUR BEHALF A sampling of activities and actions of interest to SFMS members

Editor Mike Denney Managing Editor Amanda Denz Copy Editor Mary VanClay Cover Artist Amanda Denz Editorial Board Chairman Mike Denney Obituarist Nancy Thomson Stephen Askin

Shieva Khayam-Bashi

Toni Brayer

Arthur Lyons

Linda Hawes Clever

Terri Pickering

Gordon Fung

Ricki Pollycove

Erica Goode

Kathleen Unger

Gretchen Gooding

Stephen Walsh

SFMS Officers President Steven H. Fugaro President-Elect Charles J. Wibbelsman Secretary Gary L. Chan Treasurer Michael Rokeach Editor Mike Denney Immediate Past President Stephen E. Follansbee SFMS Executive Staff Executive Director Mary Lou Licwinko Director of Public Health & Education Steve Heilig Director of Administration Posi Lyon

SFMS Supports Antisuicide Barrier for Golden Gate Bridge San Francisco Medical Society board of directors is in support of an effective and appropriately designed barrier to deter attempted suicides from the Golden Gate Bridge. Our board, which represents many medical specialties from all around our city, heard arguments from various perspectives and collectively agreed with the strong evidence that many, if not most, such suicides are impulsive and can be prevented by making jumping from the bridge more difficult. We also believe that an effective barrier need not be unduly expensive nor pose too great an impact on the visual beauty of the bridge.

The SFMS therefore urges the Golden Gate Bridge District to begin implementing an effective physical barrier to those who would consider jumping from the bridge.

We also urge our members to submit their comments on the matter; you can do so via www.ggbsuicidebarrier.org/getinvolved.asp —Steven Fugaro, MD, President

Director of Membership Therese Porter Director of Communications Amanda Denz Board of Directors Term: Jan 2008-Dec 2010

Jordan Shlain

George A. Fouras

Lily M. Tan

Keith Loring

Shannon Udovic-

William Miller

Constant

Jeffrey Newman

Term:

Thomas J. Peitz

Jan 2006-Dec 2008

Daniel M. Raybin

Mei-Ling E. Fong

Michael H. Siu

Thomas H. Lee

Term:

Carolyn D. Mar

Jan 2007-Dec 2009

Rodman S. Rogers

Brian T. Andrews

John B. Sikorski

Lucy S. Crain

Peter W. Sullivan

Jane M. Hightower

John I. Umekubo

Donald C. Kitt CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Robert J. Margolin, Alternate Delegate

SFMS Annual General Meeting Monday, September 8, 2008 6:00 p.m. – 7:30 p.m.

Commodore Room, Golden Gate Yacht Club Tentative speakers include, Gavin Newsom, Mayor of San Francisco (invited) and Richard S. Frankenstein, MD, CMA President. The Nominations Committee report will also be presented. Dinner will be provided, RSVP is required. Please RSVP no later than noon on September 1, 2008.

You are also invited to attend the regular meeting of the Board which immediately follows the General Meeting. This is a good opportunity both to meet with SFMS leadership and to learn firsthand what SFMS and CMA are involved in on behalf of physicians in San Francisco and California.

Please RSVP to Posi Lyon by phone at 415-561-0850 extension 260 or email, plyon@sfms.org.

San Francisco Medicine July/August 2008

Candidates Night You are cordially invited to participate in a Board of Supervisors Candidates’ Interview Night on Wednesday, September 24, 2008 from5:15 p.m. to be held in the SFMS offices at 1003A O’Reilly Avenue in the Presidio. As many of you know, this is a great way to get to know the candidates early on in their political careers. The format for this event will be a series of informal interviews with each of the invites candidates. Candidates will be interviewed by small groups of physicians. We have prepared a list of interview questions which will be sent in advance to the candidates.

If you are interested in attending, please contact Posi Lyon by phone at (415) 5610850 extension 261 or by e-mail at pylon@ sfms.org. Make sure to include your phone number and email address so we can provide you with directions to the event.

Notes from the Membership Department The real estate seminar “Buying a Home in San Francisco,” held on June 28, was a tremendous success. The Medical Society hopes to produce more events of this type. If you have an idea for a seminar or event, please contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org.

Back and Better Than Ever—The Jazz Mixer at the Togonon Gallery!

Thursday, August 28 from 6:00 to 8:00 p.m. – Enjoy beverages, hors d’oeuvres, great jazz, and exciting art while mingling with your fellow physicians. The Togonon Gallery is located at 77 Geary Street, just blocks from Union Square in San Francisco (www. togonongallery.com). This popular event is always a great time for members and their guests, and it also provides a terrific way to introduce nonmembers to the San Francisco Medical Society. The cost is just $20 for members, $25 for nonmembers and guests.

Please RSVP by August 21.

New members who join at this event www.sfms.org

will have their event cost deducted from their already discounted first year’s dues!

A Family-Friendly Matinee at the San Francisco Lyric Opera!

Sunday, September 21, 2008 – A performance of Aida at 2:00 p.m. at the Cowell Auditorium at Fort Mason, followed by a postperformance reception and an opportunity to meet some of the singers. The Lyric Opera offers a fun and accessible way to enjoy opera for all ages. The cost is just $45 for an afternoon of top-notch musical entertainment, and it includes the postperformance reception. Children under 12 get in free! Space is limited, so be sure to RSVP

by September 17. Visit the Lyric’s website at www.sflyricopera.org.

To RSVP for events, or for more information, contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org.

Be sure to watch for the next SFMS Night at the Symphony coming this fall, and the return of the popular Night at the SF Ballet Nutcracker performance in December. More information will be available soon.

An Opportunity to Reach Out to the Next Generation of Medicine On Thursday, September 25, members of the San Francisco Medical Society are invited to a pizza party mixer with first- and second-year medical students at the UCSF campus. Exact time and location to be announced. This event will be sponsored

by Epocrates and will provide a wonderful chance to meet and talk with the next generation of doctors, who are equally eager to meet those already established in the profession. Don’t miss it! For more information about these and future events, or to RSVP, contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org.

Other Opportunities for Our Members

to the San Francisco Medical Society: Interested in sharing your perspectives on the financial realities of medicine with first- and second-year medical students?

UCSF is looking for physicians from small and large group practices, unusual practice scenarios, and community-based practices to share their knowledge and advice in a two-hour evening panel at UCSF’s Parnassus campus. Please contact nolan.caldwell@ ucsf.edu or alison.silvis@ucsf.edu if interested. The students are currently on vacation but should be back by mid-August.

SFMS Seminar Schedule Advance registration is required for all SFMS seminars. Please contact Posi Lyon at plyon@sfms.org or (415) 5610850 extension 260 for more information. All seminars take place at the SFMS offices, located in the Presidio in San Francisco.

October 3, 2008 Customer Service/Front Office Telephone Techniques This half-day practice management seminar will provide valuable staff training to handle phone calls and scheduling professionally and efficiently.

9:00 a.m. to 12:00 p.m. (8:40 a.m. registration/continental breakfast) $120 for SFMS/CMA members and their staff ($99 each for additional attendees from the same office); $159 each for nonmembers.

November 4, 2008 “MBA” for Physicians and Office Managers 9:00 a.m. to 5:00 p.m. (8:40 a.m. registration/continental breakfast) This one-day seminar is designed to provide critical business skills in the areas of finance, operations, and personnel management. $250 for SFMS/CMA members and their staff ($225 each for additional attendees from same office); $325 for nonmembers.

Other Local Events September 17, 2008 From Cure to Quality of Life: The Shifting Nature of Hope at the End of Life A Palliative Care Conference with guest speaker David Feldman, PhD at CPMC St. Luke’s Campus Cafeteria, 3555 Cesar Chavez. Dinner and drinks at 6 p.m., program at 6:30 p.m. The program will explore how the meaning of hope shifts for patients from cure to quality of life as they confront the end of life. RSVP by September 8 by calling (415) 600-7450 or emailing hallse@ sutterhealth.org.

September 25, 2008 In the Heart of the Mission Gala Cathedral of Saint Mary of the Assumption, 11 Gough St., San Francisco. Celebrate the 40th anniversary of the Mission Neighborhood Health Center with champagne, sangria, and a Latino food festival. This fund-raiser will honor Dolores Huerta, cofounder of United Farmworkers, and Antonia Sacchetti, MD, retiring medical director of thirty-eight years. Please call (415) 552-3870 for more information, to buy tickets, or to reserve a table for ten.

September 27, 2008 CMA Foundation’s Obesity Prevention Cultural Competency Training Symposium 9:00 a.m. to 12:00 p.m. at the Airport Hilton in Oakland. Please visit www. calmedfoundation.org/projects/ obesityProject.aspx. For additional information, please contact Jennifer Caulfield, Obesity Prevention Project Assistant, at (916) 779-6631 or by e-mail at jcaulfield@thecmafoundation.org.

October 2–3, 2008 California Primary Care Association Annual Conference DoubleTree Hotel Ontario Airport, Ontario. Contact Carole Loeb at (916) 440-8170 extension 206 or cloeb@cpca.org, or visit www.cpca.org for more information.

The medical student leadership of UCSF has sent the following announcement www.sfms.org

July/August 2008 San Francisco Medicine

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The Power of Words It seems a soft bargain—you tell, I listen, you suffer, I listen. You confess your life is limited, your pain incessant, your suffering meaningless, and your body a betrayer of self, and I listen. So why are so few doctors or nurses … able to listen when ill people try to speak fully and bravely about what they go through? What is the barrier against absorbing these words of rage and grief and resignation? The listening, we have to allow, might not be without its own burdens of shame and fear. You tell, I listen so as to comprehend the limitations, the incessancy, the meaninglessness, and the betrayal of life lived in a body.

—Rita Charon and Maura Spiegel, “On Conveying Pain/On Conferring Form,” Literature and Medicine, 24.1 (2005)

W

hat do sick people think about? What order can they bring to the random events of illness? How do they continue to coexist with their diseases? How can their physicians help them find meaning and accept the inevitability of death? The asking and answering of these queries should be an integral part of medical treatment, yet it was not until recently that formal medical training began to confer on physicians the skills to grapple with these issues.

Literature was introduced to modern medical education in 1972 and is taught to some extent in a third of all medical schools in the United States. Poetry has developed an important niche in two of the major medical journals, The Journal of the American Medical Association and The Lancet. The study of literary and cultural texts enables the exploration of the resonance between literary understanding and medical knowledge.

There are several goals that may be met by including the formal study of literature in medical education and medical schools.

For one, literature is a remarkable tool for the teaching of ethics.

Through portrayal of both of ethical dilemmas and of their resolution, students may explore the consequences and implications of a particular ethical stance. This narrative approach to ethics allows a physician to fully evaluate and understand the entire context of an illness. Furthermore, a reader has the opportunity to experience empathically viewpoints that may be contrary to his or her own.

Another benefit of literary study is to enable physicians to better grasp their own personal stake in medical practice and to better understand a patient’s story of illness. Although we can understand www.sfms.org

diseases by reading scientific literature and texts, actually comprehending illness with its emotional and contextual responses requires something more. Each illness is a highly individual and unique event that is experienced in a particular way by each patient and provider. Medical narratives, texts, and books all can stretch our imagination by allowing us to enter into unfamiliar situations or see other points of view. As T. S. Eliot said, “we read many books because we cannot know enough people.”

Finally, critical reading and appraisal are not just meant to relate to the scientific literature. The formal study of literature can clearly enhance one’s skills in interactive interpretation and deconstructionism, both of which can mirror the complex doctor-patient discussion. Literature also facilitates expressing emotion through art and provides a healthy outlet for the powerful emotions elicited in our daily professional lives as we face, with our patients, some of the most powerful feelings encountered as humans.

This issue of San Francisco Medicine has an array of articles exploring the various aspects of literature and medicine. Please enjoy these wonderful essays and reviews—they reinforce the critical role of arts in medical education and the role of literature in bridging the scientific terrain of twenty-first-century medicine with the wonderfully fertile ground of the humanities, where our souls reside.

July/August 2008 San Francisco Medicine

On Illness Virginia Woolf How common illness is, how tremendous the spiritual change that it brings, how astonishing when the lights of health go down the undiscovered countries that are then disclosed, what wastes and deserts of the soul a slight attack of influenza brings to view, what precipices and lawns sprinkled with bright flowers a little rise of temperature reveals, what ancient and obdurate oaks are uprooted in us by the act of sickness, how we go down into the pit of death and feel the waters of annihilation close above our heads and wake thinking to find ourselves in the presence of angels.

Editorial Mike Denney, MD, PhD

Stories, Paradox, and Medicine

I

n Cervantes’ famous novel, Don Quixote of La Mancha expounds about knight-errantry, stating that it is a science that includes all other sciences and that demands many skills, including that of physician. He says that a knight “must be chaste in thought, a man of his word, generous in action, valiant in deed, patient in adversity, charitable to the needy, and finally, a maintainer of the truth.” At one point, Don Quixote opines, “I say that he must be able to swim as well as they say Fish Nicolao did.” In this statement, Cervantes was referring to the legend of Nicolao the Fishman, who was said to repeatedly swim back and forth between Sicily and mainland Italy, and for whom celebrations were held annually at Messina and Naples. According to the story, Nicolao also possessed the secrets of health, youthfulness, and longevity.

In this issue of San Francisco Medicine, with its theme of Literature and Medicine, Cervantes’ novel might offer a lesson for modern doctors, a parable to the effect that in order to offer health, youthfulness, and longevity to patients, doctors must be versatile, virtuous, diligent, persistent, and skilled. In a larger sense, however, the narrative might also show that the relationship between literature and medicine is far more complex and paradoxical than simple allegory.

Rita Charon, MD, PhD, director of the Narrative Medicine Program at Columbia University, says, “The effective practice of medicine requires narrative competence, that is, the ability to acknowledge, absorb, interpret, and act on the stories and plights of others.” Such narrative competence fosters empathy as learned through the travails, triumphs, and tragedies of characters in stories—empathy that can then be applied by doctors to the living stories of sick people, colleagues, and society. This empathy can also become paradoxically self-referential—doctors can reflect upon their own drama in the story of illness, the implications of what they do, the spiritual dimensions of healing, their personal ethics, and their own well-being.

In regard to developing narrative competence through literature, this paradox of self-reference can be found in Don Quixote, in which the invention of the novel is accomplished by including in the novel the author’s act of writing the novel. In the prologue, for example, Cervantes speaks directly to the reader.

Writing in this prologue about the difficulties of trying to write a www.sfms.org

prologue, he confesses that he had decided not to write a prologue but that a friend told him what a prologue should be. Then, in a self-referential paradox, he states that he now agrees with his friend, and thus presents this story about writing the prologue of his book as the prologue to the book he is writing.

In reflection upon this self-referential paradox in the theme of literature and medicine, it might be helpful to reveal a story of many years ago about a troubled fifteen-year-old, who, having grown up in very difficult circumstances and without guidance or awareness of self, had flunked out of high school because of truancy and misbehavior and was being sent to a correctional facility for juvenile delinquents.

One day, the young man read a novel, Magnificent Obsession,

by Lloyd C. Douglas, a story about a fictional young man who fails in college but, with the help of a benevolent physician, finds his true self, returns to college, completes medical school, and becomes a neurosurgeon. In the climax of the story, the neurosurgeon saves the life of a woman with a severe head injury. It was a woman with whom he had been infatuated before he had failed in college. Thus the two are reunited. They soon fall in love and join together as husband and wife.

After reading that story in the novel Magnificent Obsession, the troubled fifteen-year-old became imbued with his own magnificent obsession. Despite his failure and the seemingly insurmountable obstacles before him, he felt that the author was speaking directly to him with a message about empathy for others. He immediately reformed his behavior and pleaded for one more chance. He went on to earn a scholarship to college, was accepted into medical school, and later completed his surgical residency.

After many years of practicing, teaching, and writing, this same man became the Editor of San Francisco Medicine, the Journal of the San Francisco Medical Society. Then, in a self-referential paradox, like Cervantes writing a prologue, he wrote this editorial about narrative competence and how stories can engender in doctors not only empathy for patients but also self-realization.

July/August 2008 San Francisco Medicine

Literature and Medicine

The Permanent Patient The Life of Marcel Proust Thomasine Kushner, PhD

I

llness as catalyst for artistic creativity is not a new theme, and surely Marcel Proust should count as one of its most celebrated examples. In Proust’s case, his life as an invalid and his fame as perhaps the greatest writer of his time are so inextricably linked that some awareness of the role illness played in his life and art may deepen our understanding of his work.

Proust, a sickly child, grew up in a medical environment, as the son of a distinguished physician and later the brother of another. In 1871, the year he was born, Paris was in turmoil. The city had been invaded by the Germans and his father’s narrow escape from death by a stray bullet had severely shocked his pregnant mother.

Fear and hunger were rampant throughout the population, and the infant Proust was believed to be too weak to survive. Throughout his life he attributed his precarious health to those circumstances surrounding his birth.

When he was nine years old, he suffered his first attack of asthma on returning from a family outing in the Bois de Boulogne. The attack was so violent that his frightened family thought he was suffocating and even his physician father felt powerless to aid his stricken son. From then on he was never free from the threat of a recurrent attack, and it became the shadow that dominated his life and directed his actions. Because of it Proust thought he was allergic to flowers and once remarked that the pansy was the only flower he could smell without provoking an attack. He was also convinced that he was sensitive to perfumes, and later in his life a distinguished visitor calling on Proust at home was turned away by his loyal housekeeper, Celeste, with the remark, “Monsieur is very much afraid of the scent

of princesses.”

Much has been written about Proust’s asthma, often by literary critics under the influence of the limited medical knowledge of the day. The result has been an overem-

“In Proust’s case, his life as an invalid and his fame as perhaps the greatest writer of his time are so inextricably linked that some awareness of the role illness played in his life and art may deepen our understanding of his work.” phasis on the emotional components of his illness, specifically the intense bond between Madame Proust and her son. Proust’s dependency on his mother, his appeals for her affection and support, and his despair when he felt them denied were immortalized in the famous scene in Swann’s Way depicting an event that occurred when Proust was seven years old. The narrator recounts a time when the child, Marcel, has gone to bed while his parents are entertaining a friend downstairs. He cannot fall asleep without the nightly ritual of his mother’s kiss. Weeping and begging, he calls for her, but despite his pleas she does not want to leave her company.

Fully expecting to be severely punished for his transgression and weakness, he is incredulous when his father intervenes and directs his mother to attend to him. His father even goes so far as to suggest that she stay the night in his room in order to

10 San Francisco Medicine July/August 2008

quiet him. She complies with a mixture of tender concern and reluctance. Many years later, Proust said, “ . . . this evening opened a new era that must remain a black date in the calendar.” The realization that by showing weakness and dependence he could influence a desired result was to establish a pattern, according to Proust’s own account, that would endure for the rest of his life.

As an adult, Proust used his fragile health for secondary gain. As a reserve officer in the French army, there were occasions when he was summoned for more periods of training. Appealing on grounds of ill health, he successfully managed to avoid these calls.

He wrote to his mother, probably in 1896, “If any questions are asked, I’m supposed to be suffering from a slight attack of asthma this morning.” Thus asthma provided an increasingly familiar escape and excuse to avoid distasteful demands.

Proust was a prolific and talented correspondent, and his letters constitute a formidable medical history. In letters to his family and friends, references to health and sickness—both his own and others’—abound. His voluminous letters to his mother are replete with details concerning his congestion, fumigations, medications, digestion, and exhaustion.

Since his early childhood, she had expressed worried concern for his well-being, and when she felt Proust did not furnish sufficient details she would chide him on his omissions and prompt him to provide more information.

His correspondence with his large and caring circle of friends is similarly filled with talk of health and illness. Some found it difficult to reconcile his seemingly healthy appearance with his descriptions of grave illnesses and impending death. Eventually, www.sfms.org

it became apparent that Proust’s maladies made it possible for him to avoid people and reserve time for himself to devote to his writing.

Proust used a wide variety of therapies to manage his ailments. Unwisely, he often used them in combination and to excess. He was undoubtedly dependent on sedatives; for his asthma he relied on the popular “fumigation” remedies of the day, such as smoking stramonium cigarettes or Espic antiasthma cigarettes, or burning Legras or Escouflaire powders. Medicating himself was an important part of his daily routine, and toward the end of his life he was consuming little nourishment and living chiefly on cold beer and strong coffee.

Despite his medically oriented family, Proust harbored mixed emotions when it came to doctors and the medical establishment. Once, following a visit to one of his numerous doctors, he said, “I’m going to write a book about doctors.” Although he never did, doctors play roles as important characters in his work—not always portrayed flatteringly. Doctors are derided when they make mistakes. One example occurs in his early novel, Jean Santeuil, when a boy with a serious physical condition is dismissed as being emotionally disturbed by his doctor. Also, in his monumental work A la Recherche du Temps Perdu (most accurately translated as In Search of Lost Time), a pompous doctor declares there is nothing wrong with the grandmother, who promptly succumbs to a stroke. Proust as author is clearly getting his revenge as a patient who resents that his complaints are not being taken seriously enough and that he may be regarded by the physician as unreasonable or perhaps psychogenic.

After his mother’s death in 1905, he moved into an apartment once owned by her uncle at 102 boulevard Haussman, where he constructed the now famous corklined bedroom to keep out the dust and daylight from the busy street below. Here he began his routine of sleeping during the day and working at night, and he essentially became bedridden for much of the remainder of his life. His inherited wealth allowed him to use his time as he wished, and most of In Search of Lost Time was written here.

(The building is now a bank, and visits can www.sfms.org

be arranged to view the apartment.)

Over time, like his characters, Proust underwent a gradual but striking change.

From the gregarious dandy, accused of frittering away his time in fashionable salons, he became the driven recluse, capable of Herculean effort, with only one thought— to complete his novel. Once regarded as a snob and social dilettante, he became one of society’s keenest observers and severest critics, as his novel attests.

There is little question that Proust’s asthma served him well in his steadfast devotion to the monumental task of finishing his novel, which continued to expand in size, eventually encompassing more than 200 characters.

A constant worry was, “I had to ask myself not only: ‘Is there still time?’ but also ‘Am I well enough?’” During the remaining two decades of his life he was driven with an obsession to finish his book, and always, with the fear that time was short, he used his illness as an excuse to avoid social obligations and other difficulties. His sickroom became his unassailable refuge from the world.

In the spring of 1922, he suffered a serious accident when he administered an injection of undiluted adrenalin, which left him “completely shattered.” Still suffering the aftereffects, he announced to his housekeeper and companion, Celeste, that he had written the word fin and “Now I can die.” In September he suffered several bouts of unusually severe asthma attacks. In early October he went to a party and caught a cold that developed into bronchitis and pneumonia. Although ill for some weeks, he rejected food and medical treatment in an effort not to be diverted from making last-minute corrections and additions to his novel. Fearing interference, he even refused to see his personal physician or his brother, by now a noted surgeon, until almost the very end. On the 18th of November, an abscess in his lung burst and he died at age fifty-two. His fame was already spreading, and Proust was buried with great pomp at Père Lachaise cemetery.

On a recent visit to the site, on the anniversary his birth, I saw that a small bunch of flowers had been placed on his tomb—pansies, the only flowers he said he

could enjoy without fear of asthma attack.

For a more detailed account of this topic, see The Maladies of Marcel Proust by Bernard Straus, Holmes & Meier Publishers, 1980.

Thomasine Kushner is coeditor of the Cambridge Quarterly of Healthcare Ethics.

2008-2009 SFMS Member Directory Available Now! Directories are now available!

All SFMS members receive one copy of this valuable resource as part of their memberships. Please watch for your copy in the mail.

If you are interested in ordering additional copies please contact Carol Nolan at (415) 561-0850 extension 0 or cnolan@sfms.org for information.

July/August 2008 San Francisco Medicine 11

Literature and Medicine

Sniffing the Same Air Using Lear and Loman to Teach Future Doctors about the Human Condition Larry Zaroff, MD, PhD

G

reat works of art—novels, paintings, dance, music, plays—though centuries old and seemingly widely separated from our daily lives, persist because they interrogate the human condition and deal with universal problems: relationships, pain and suffering, death and dying. These products of the imaginations and experiences of great artists describe the origin, in families and other close connections, of how we form relationships and how we develop our basic values, including love, hate, jealousy, generosity. Over the centuries, these sensations remain the same—good or bad—forming our basic identities, how we feel about ourselves and others.

William Shakespeare in King Lear and Arthur Miller in Death of a Salesman were as much products of different cultures as were their protagonists. Yet these two great tragedies are similar. Their creations, the two old men King Lear and Willy Loman, one a king and the other a salesman, could nevertheless be clones, alike in their desires and their failed solutions. Each seeks love and loyalty, but each gives away what he seeks through poor judgment and cognitive failure. They rarely examine themselves until, near the end, they are stripped to bone by tragedy. Then, suffering and in pain, they must struggle to find out who they are and to discover their comfort zone in identity.

Self-value for Loman had rested on what others thought of him; he had to be “well liked.” However, he had little inside but dryness, dust, and who would value that? For Lear, his worth was based more the trappings of a king than in being a king; he was covered, but naked inside. When Loman and Lear lose their exoskeletons, their protective shells, they become different, helpless, and finally hopeless. When Lear

abandons his throne, how can he remain a king without a castle or knights? When Loman loses clients, can’t sell, can he still be a salesman? When Lear gives away his crown, when Willy Loman gets fired, they

“Great works of art persist because they interrogate the human condition and deal with universal problems: relationships, pain and suffering, death and dying.” try to find the valuables and the values that have evaded them. Hitting bottom, they scuttle to locate their real identities.

Both fail in the beginning of the plays and, inevitably, fail at the conclusion.

They are trapped, held underwater by their mistakes. They have the same fatal flaws: They could not accept reality nor could they tolerate being ordinary. They had no insight into family dynamics. The results: hot, poor judgments; throwing away their most important assets. Lear accepts the words of his two spoiled daughters and gives away his kingdom while excluding his youngest daughter, Cordelia, who truly loves him. Willy gives his sons false words that describe a false world, telling them that it is easy—without effort and study—to become a king by looking kingly. Lear and Loman fail in their most important role, that of being fathers who wisely bring up their children. Their children learn from them, and they too make mistakes in relationships.

What is the underlying cause of their awful misjudgments? Is it organic, cortical,

12 San Francisco Medicine July/August 2008

dementia, or something similar? Synaptic failure, intellectual or emotional misfiring, depression? Or has their behavior also been transmitted from their parents? Lear was reared from childhood to understood only kingship; Loman, missing a father, was humiliated by a brother.

They each have brief insights into their respective collapses. Lear sees the mindbody connection: “We are not ourselves when nature, being oppressed, commands the mind to suffer with the body,” and he realizes his plainness when he says, “They told me I was everything. ’Tis a lie. I am not ague-proof.” Loman, a traveling salesman all his life, drives off the road onto the shoulder, not recalling he was driving, and muses, “I don’t remember the last five minutes.”

They have aged and weakened, undraping what was once covered by ermine robes and sales success.

Lear and Loman breathe the same air.

Not oxygen, not inhaling the real. They must believe in a false atmosphere to survive. Lear dislodges a kingdom, England, and severs himself from a daughter. No longer a king, he has no identity. Loman flees from New England, his territory as a salesman. Who is he if not a salesman? He offers a false kingdom to his sons and loses them in the offering.

In the end each wishes for, believes in, redemption by suicide. Lear and Loman each make a conscious decision to die: Willy Loman through an auto crash, Lear of a heart unable to pump through the wall of grief as he lies beside Cordelia, his dead daughter. Today we might call a code, bring him back to reface his tragedy—but Kent, his close friend, stops the action: “Vex not his ghost. O, let him pass! He hates him that

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Literature and Medicine

Seized by the Muse Dostoevsky’s Convulsive Poetics in The Idiot Dennis Patrick Slattery, PhD

T

o speak of the medical affliction of the great Russian author Dostoevsky in relation to his writing of The Idiot might require a somewhat unconventional way of speaking about epilepsy, its location in mind and body, and its relation to the creative process. We might treat Dostoevsky’s convulsive disorder not only in terms of how it is projected onto characters or in terms of the writer’s medical and psychological history but also in terms of what we might learn about the multifaceted character of the illness as a biological phenomenon, a cultural construction, and a mythic structure that provided the writer with an epistemological paradigm about the mysterious relationship between psyche and soma.

Dostoevsky constantly scrutinized his own disease and was alternately fascinated and repulsed by it. He was attracted to it for its “ecstatic aura,” that instant just before the convulsions and the unconsciousness that attend the seizure. Writing The Idiot may have enacted a ritual of healing for Dostoevsky. As one of the most profound psychological novelists, he believed that there is a close relationship between psyche and disease and that the pollution of illness finds its way into the psyche’s images, often in the form of wounds, dreams, and fantasies, and certainly in the active disease.

Let us begin, then, by considering what we might see differently if, rather than saying Dostoevsky “had” temporal lobe epilepsy, we were to say that epilepsy “had” Dostoevsky. Let us grant the disease some autonomy as a creative force that may at times even take on a character of its own. Part of the trouble in speaking about disease in conventional ways is that we get caught in too narrow a focus on symptoms.

Yet few would dispute that diseases, though www.sfms.org

grounded in physiology, are also culturally shaped and adapted to the mythos prevailing at a particular place and time. As mythic constructions, they may serve to articulate particular ideas, values, and notions. In this

“As one of the most profound psychological novelists, he believed that there is a close relationship between psyche and disease and that the pollution of illness finds its way into the psyche’s images, often in the form of wounds, dreams, and fantasies, and certainly in the active disease.” novel, epilepsy is manifested in character, climate, culture, cadence, and plot structure, and it develops a certain habit of being that produces its own language and images. The fiction lies in the disease, rather than the disease in the fiction, and thus provides the motive or intention that gives shape to fictive time and space. The disease sets the beat of the narrative pulse and takes on a voice of its own in the story that is told. Epilepsy has its own story to tell.

The novel reveals a world that is petty, obsessed with economics and social success, full of self-interest, and with an absence of authentic love and a disregard for the ancient myth of Mother Russia herself; a world demythologized and in need of an act of remembering to return it to its sacred roots.

In The Idiot the disease enters in the figures of Prince Lyov Nikolayevich Myshkin and Paryfyon Rogozhin. Having left Russia four years earlier to recuperate in a Swiss village because of his epilepsy, Myshkin returns to Petersburg feeling that he is now cured and life is going to be ideal.

Rogozhin also enters Russia again after an absence of several months, having suffered from delirium, diagnosed as brain fever.

After his father’s recent death, he returns to Peters­burg ready to inherit millions. Thus, epilepsy appears in the novel as a tension of extreme opposites. On the one hand is Myshkin’s dreamy innocence, his vision of a golden age of timelessness, a retrieval of paradise before the fall. It is countered by the rapacious, instinctual, erotic, and excessive acquisitiveness of Rogozhin, who projects the animal lust of human nature into the novel. These two forces in our mortal nature have become split from one another.

The two men meet on the WarsawPetersburg train and strike up a conversation, which soon turns to a woman, Nastasya Filippovna, whom Rogozhin loves and plans to marry. A young busi­nessman, Ganya Ivolgin, is also desirous of courting Nastasya and hopes to win her hand, along with large sums of money. He is supported in his suit

by General Yepanchin, because the old man also sees a possibility for taking Nastasya as his own mistress. For years she was the kept woman of a wealthy landowner, Totsky, whom she now rebukes publicly.

Thus epilepsy acquires a complex, rich poetic voice in its split nature. Dostoevsky reveals in Myshkin and Rogozhin the defining actions of the disease: the breakdown, the fragmentation of conscious­ ness, the falling sickness in the seizure,

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July/August 2008 San Francisco Medicine 13

Seized by the Muse Continued from the Previous Page... the disintegration of a sense of self, and the moment of complete harmony that categorizes the so-called ecstatic aura—an ecstasy and timelessness that precede uncon­ sciousness and depression, a fall into the underworld and despair.

It is impossible to separate Myshkin and Rogozhin in their respective illnesses from the disease of the society into which they tumble headlong on the Warsaw-Petersburg train. Dostoevsky felt that Petersburg was also split, with Russian intellectuals living too much within their ideas and the heart of the Russian folk being ignored.

Accordingly, epilepsy, as Dostoevsky presents it in The Idiot, is a disease of verticality, of extremes of high and low, conjuring images of lofty Swiss mountains and plunging waterfalls and of depressingly deep falls into underworld darkness. That it is called the falling sickness tells us its direction, the movement of the body as it pulls the individual having the seizure to the ground in a violent and uncontrollable release of energy. The falling sickness becomes in the novel an extended metaphor for the first fall, for the fall from innocence out of the garden, as Myshkin falls into Petersburg and for Nastasya Filippovna, to whom he is attracted from the time he sees her photograph—and who, in turn, will feel from the first time she meets Myshkin that she has known him in a dream as one who would come to rescue her from the greedy men who wish to possess her.

Myshkin is impotent owing to his disease but believes himself capable of loving the young beauty, whom other men both lust after and fear. Between Myshkin’s unrelenting compassion and Rogozhin’s ferocious passion for her, Nastasya is driven to the brink of madness, and she is finally murdered by the latter. As an image of the violated and abused and as a figure of Aphrodite’s presence in the novel, she embodies the erotic and the aesthetic impulses of the soul. The split between Myshkin’s innocence and Rogozhin’s rapacious rage eventuates in the destruction of both beauty and erotic passion. The culture loses the grace of Aphrodite as the knife that “cuts

both ways” slices into Nastasya’s delicate yet essential presence.

Throughout the various shifting drafts of the novel, Dostoevsky seems to stay with this one unrelenting idea, described in his fourth plan: absolute innocence coupled with a murderous desire. Of Myshkin, Dostoevsky writes in the eighth revision, “His way of looking at the world: he forgives everything, sees reasons for everything, does not recognize that any sin is unforgivable, and excuses everything.” It is the absoluteness of this epileptic or distorted ideal that all is forgiven, even when forgiveness is not sought or desired by those who offend, that makes Myshkin a figure of Dostoevsky’s affliction.

The Idiot also represents the physical characteristics of the disease. Early on Dostoevsky depicts two important sensations associated with epilepsy: the “large, blue, and intent” eyes of Myshkin that, in their gentle, heavy appearance, allow those who study his face to see in them the affliction of the falling sickness as contrasted with “the fiery eyes” and “deathly pallor” of Rogozhin.

Dostoevsky certainly experienced something like this when, in writing The Idiot and revising it eight times, his own illness manifested itself in recurrent seizures, becoming a forceful factor in the creative process. In addi­tion, the story borders uneasily on incoherence as it imitates in lan­guage, symbol, and action the epileptic seizure brought on by the light of the cupola and the feeling that eternity is possible in time.

It is a manifesto of a Romantic fantasy that understands the human being as pure and unfettered if one can only avoid the ambiguous and passionate nature of life.

In the disease is the discovery of what is needed and what is to be purged.

Epilepsy has judged Peters­burg and found it wanting. Epilepsy’s presence promises the possibility of reestablishing some values that Dostoevsky felt had been lost in the Russian soul: the people’s collective myth that offers them coherence, a relationship to the earth and to their sacred tradition; less obsession with capitalism and a world motivated by self-interest; a muting of a rage for individualism with no regard for the larger collective good; less idolizing of Western intellectualism that divides the

14 San Francisco Medicine July/August 2008

head from the heart, intellect from the social and religious body of Russia rooted deeply in the black soil of the Motherland; and the retrieval of a grounded vision that allows one to view and judge the present through the authority of a larger tradition that includes an incarnated, imaginal way of knowing.

Perhaps Dostoevsky did in fact wish to create a perfectly good man, but disease speaks through and within this goodness in a different voice. Perhaps while having the intention of creating “perfect” goodness, Dostoevsky was smitten by the sobering voice of his own disease. Perhaps epilepsy in Prince Myshkin not only reveals shifting cultural relations but also espouses the people’s relation to their origins and to the personal myth that gives them coherence and a formed identity.

Dennis Slattery, PhD, is a poet and a professor of psychology and mythology at Pacifica Graduate Institute. His published books of poetry include, Just Below the Water Line and Casting the Shadows.

Send Your Message to 2,500 Health Care Professionals The San Francisco Medical Society offers multiple advertising opportunities ranging from fullpage, 4-color display ads to classified ads with discounted rates for members. Please contact Ashley Skabar for more information, (415) 561-0850 extension 240 or askabar@sfms.org.

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Literature and Medicine

Shakespeare’s Doctors A Medical Lesson from Literature Mike Denney, MD, PhD

I

n Shakespeare’s sixteenth-century England, medical care was in a state of upheaval. The sweeping reforms of the church by Henry VIII had decimated much of the Catholic-based medical institutions and facilities. Some medical practitioners followed the folk medicine, alchemy, and mind-body theories of Paracelsus, and others such as William Harvey were beginning to move toward a more scientific approach.

Clinically, the diagnostic tools available to doctors were little more than gross examination of urine, taking of the pulse, and looking at the patient’s face. There were textbooks of medicine and also popular books, some of which began to speak of resuscitating victims of life-threatening emergencies and bringing the dead back to life. Doctors might have belonged to the recently formed College of Physicians or Guild of Barbers and Surgeons, or they might be self-taught noblemen and herbal apothecaries.

Shakespeare shows a keen awareness of the state of the art of medicine in his many hundreds of references to sickness and healing. He seems also cognizant of the various personalities, peculiarities, and relative competencies of the doctors and other healers of his day. In his plays there are nine medical practitioners, ranging from the highly competent to the less effectual to buffoons and shams. If literature can offer time-tested wisdom for the living world, are there lessons modern doctors can learn from the theories, practices, and personalities of those in Shakespeare’s plays?

In the play King Lear, for example, one of Shakespeare’s doctors treats a psychiatric emergency confidently and skillfully. After being banished from his castle by Goneril and Regan, his traitorous daughters to whom he had abdicated the throne of England, www.sfms.org

King Lear is found disoriented and wandering near the cliffs of Dover. When restrained by attendants he rants, “Let me have surgeons; I am cut to the brains.” Cordelia, the daughter Lear had disinherited but who

“Shakespeare shows a keen awareness of the state of the art of medicine in his many hundreds of references to sickness and healing. He seems also cognizant of the various personalities, peculiarities, and relative competencies of the doctors and other healers of his day.” later married the King of France, has a plan to bring the French army to defeat her evil sisters and restore her father to the throne.

She finds her father sleeping in a tent under the care of a doctor. By bringing some musicians close to the bed and encouraging Cordelia to communicate with her delirious father, the doctor helps her through a conversation that gradually restores Lear’s sanity as he admits to being not of perfect mind but that, “I think this lady to be my child Cordelia.” The doctor then assures Cordelia that her father is now of sound mind, saying, “Be comforted, madam: the great rage, you see, is kill’d in him.” So they take Lear out for a walk and some fresh air.

What can be learned from Doctor Cornelius, a major figure in the play Cymbeline, who is highly competent and whose medical expertise is instrumental in the politics of

the day and the denouement of the story? In this complicated plot, Imogen, the daughter of King Cymbeline of Britain, mysteriously falls into a coma so deep that she seems to be dead, yet she later awakens. Confused by this and many other interrelated events involving intrigue in the castle and an impending war with Rome, virtually every member of the cast shape-shifts during the bizarre story. Finally Cornelius, the court doctor, steps forward and heroically explains his role in resolving the events. He states that the queen, Imogen’s stepmother, had for some time been asking him for poisonous concoctions, to be used, she had said, to get rid of household vermin. Suspecting her motives, however, he had instead created a medicine that could make a person appear to be dead but then later recover full consciousness, which explains Imogen’s amazing experience. Additionally, the good doctor reports, the queen has died, and on her deathbed admitted to giving the concoction to Imogen in an attempted murder, all in a conspiracy to obtain the throne for her son, Cloten.

With Doctor Cornelius’s dazzling disclosure and remedies, King Cymbeline is able to give thanks to the gods and to declare peace and friendship with Rome, saying, “Never was a war did cease, Ere bloody hands were washed, with such a peace.”

Is there something to be learned from the inept and burned-out doctor in the play Macbeth? After her husband went on a murderous rampage, killing Duncan, the King of Scotland, and Macduff’s wife and son, the traumatized Lady Macbeth goes mad. The Doctor of Dunsinane Castle is summoned. Listening to her ranting about foul whisperings and unnatural deeds, the doctor is frightened and seems confused and

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July/August 2008 San Francisco Medicine 15

Shakespeare’s Doctors Continued from the Previous Page... reluctant to become involved, saying, “My mind she has mated, and amaz’d my sight: I think, but dare not speak.” Later, Macbeth pleads for a cure for his wife, saying, “Canst thou not minister . . . and with some sweet oblivious antidote cleanse the stuff’d bosom of that perilous stuff which weighs upon the heart?” The doctor says only, “Therein the patient must administer to himself.” In a later aside, the doctor confesses that if it weren’t for the money, he would no longer practice medicine.

Are there present-day doctors interested in medical politics who behave like Doctor Butts in the play Henry VIII? Among the many conspiratorial and political power struggles in this play, King Henry is allied with Cramner, the Archbishop of Canterbury. One day, Doctor Butts happens by a group of men who are conspiring against Cramner in order to gain power in the kingdom. Overhearing part of the conversation and sensing trouble, Butts says, “This is a piece of malice. I am glad I came this way so happily: the king shall understand it presently.” He then goes to Henry’s chambers and makes him aware of the knavery, thus protecting Cramner’s favoritism with the king and helping to put down the conspiracy.

What pertinence to modern medical practice might emerge from two of Shakespeare’s medical practitioners who become involved in saving lives? In Pericles, Prince of Tyre, Lord Cerimon, a self-proclaimed doctor, says, “I have . . . made familiar to me and to my aide the blest infusions that dwell in vegetives, in metals, stones; and I can speak of disturbances that nature works, and of her cures.” With this medical armamentarium, Lord Cerimon approaches the casket of Thaisa, wife of Pericles, and, applying a kind of cardiopulmonary resuscitation, brings her back to life. In All’s Well That Ends Well, Helena’s deceased father, Gerard de Narbon, a world-renown doctor, posthumously heals the terminally ill King of France.

Before he died, the doctor had instructed his daughter, Helena, in his most powerful remedy. Later, Helena offers this remedy to cure the terminally ill King of France, if he

will give her hand in marriage to the man of her choice. Her father’s remedy saves the King’s life, and Helena is then allowed to marry Bertram, her true love.

Shakespeare also used doctors as comic figures. In A Comedy of Errors, through curious twists of the plot, two separated sets of twins are reunited. One of these lost twins, Antipholus of Ephesus, gets a hint that something is amiss when people he doesn’t know seem to recognize him. He thereupon goes a little crazy, running around town with his sword drawn, ready to battle imaginary assailants. The citizens, thinking that Antipholus has gone mad, summon Doctor Pinch, who tries to cast the evil out of his patient, saying, “I charge thee, Satan, housed within this man, to yield possession to my holy prayers.” When there is no effect, the people see that Doctor Pinch is really a sorcerer and a sham.

In another comedy, The Merry Wives of Windsor, the mother of Ann Page wants her daughter to marry a doctor and has chosen Doctor Caius, an eccentric who speaks with a bizarre French accent. However, Ann’s father wants his daughter to marry someone else. The merry wives, Ann’s mother and another woman, conspire to secretly arrange Ann and Doctor Caius’s wedding.

The plan involves having partygoers wear masks and dress in fairy costumes so that in the revelry, Ann Page and Doctor Caius can steal away. This escape seems to be carried off smoothly, and the couple, still in disguise, is apparently married. However, when the masks are removed, Doctor Caius discovers that he has made a terrible mistake in identity—he has married a servant boy!

Caius says, “Vere is Mistress Page? By gar, I am cozened: I ha’ married un garçon, a boy; un paysan, by gar, a boy!”

Happily, in modern medicine most doctors are competent, highly skilled, and caring healers, like Lear’s doctor who helps restore the king’s sanity, and Cornelius in Cymbeline who uses his medicine wisely to prevent a tragic death. There are also a few modern doctors who, like the Doctor of Dunsinane Castle, are disillusioned, burned out, and holding on to their profession solely as a means of financial support. There are a number of other doctors who, like Dr. Butts in Henry VIII, enjoy the intrigue and

16 San Francisco Medicine July/August 2008

power struggles of medical politics. These physicians are wont to seek membership on committees and associations and to become active in political causes, even running for government offices. Certainly, there are modern emergency physicians, hospitalists, and intensivists who repeatedly apply their skills to resuscitate the critically ill, sometimes seeming to bring the dead back to life as did Lord Cerimon in the play Pericles. Moreover, like the world-renown Gerard de Narbon instructing his daughter Helena, most physicians effect some healing posthumously through their research or teaching of students, residents, and younger physicians. And, of course, among the many faceted doctors, each with unique personalities, there are those who can appear to be comical, like Doctor Caius, sometimes mistaking the identity of others and even, on occasion, marrying the wrong person.

But there may be more to be gleaned from literature’s comparative images of doctors. There is yet another doctor in Shakespeare, one who may offer profound wisdom for modern healers. He is the second doctor in the play Macbeth. In Act IV, Scene III, an event occurs that bewilders literary scholars because it seems out of place, extraneous to the plot—an unnamed doctor enters the stage, makes one statement, and exits. He tells of the kindly King of England, who has a gift for healing by prayer and benediction.

Speaking of the King and his spiritual healing of the afflicted, the doctor says, “At his touch, such sanctity hath heaven given his hand, they presently amend.”

Perhaps this scene, so puzzling to literary scholars, has meaning for practicing physicians. Maybe one of the most important lessons doctors can learn from literature is that attending to the sick is a sacred task.

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Literature and Medicine

The Starving Artist (An Excerpt) Ashley Skabar

H

ere, it’s the absence, the what-is-not.

Like a stopped heart, a shriveled raisin, it is the lack of the thing itself, the what-is-not, by which the thing is defined.

Like sitting in a hotel room, it is the absence of you that reminds you what you are.

Anorexia has made me into a negative print of someone else. All the dark shadows, the absence of space, exist as reminders of a distant highlight, a woman I’ve never quite grown into. To look at anorexia, to see an anorexic, is to acknowledge first an absence—the absence of food, the absence of flesh—to define the thing by what it is not. Like a chair chipped and weathered by the sun that will never be seen as simply a chair again (if repaired it will forever be a chair re-painted), anorexia, once realized, forever becomes definitive of the anorexic.

In the same way, hunger, or the absence of satiety, becomes a thing in itself to the anorexic. And like hunger, anorexia often occupies a space much larger than the one it eats away.

Upon leaving a hospital stay of several months, I was told by one of my fellow patients (a surgeon, incidentally), that I should be thankful for a life of struggle, that at least I would “have something to write about.” Her seemingly simple, if not sarcastic, words have rooted themselves in my mind in a profound way; they have led me to question what it is that causes one to write, to create, as well as what, in spite of all that it is not, this disorder is. Furthermore, this has caused me to question the way in which we treat disorder in our society, one that says be this, so you are not that.

In Western society, we tend to view artists and writers as persons whose sacrifice is valued by virtue of their creations.

In academia, we teach Virginia Woolf, www.sfms.org

Dorothy Parker, Ernest Hemingway, Sylvia Plath, and others, noting their “destructive” behaviors with a sense of gratitude for their sacrifice, for their art. We idolize the martyr, the idea of sacrifice for the sake of creation, and while we may describe these artists as alcoholic, depressed, or insane, it is as though these are accepted as necessary evils for the sake of the art left behind. Indeed, the role of the “starving artist” is revered, as much for its dependence on creation as its reliance on destruction.

In discussion with fellow students and colleagues, I have dared to postulate that anorexia is, in essence, the sacrifice of one’s self for the sake of creation––that it is an art in itself. It is a way of connecting and a way of putting on a mask. It is a way of looking through a lens, putting a frame around something, and placing a shield between one’s self and reality. It is like tak-

ing a photograph of something real, both looking at something and not looking at the same moment.

In order to better understand this relationship between art and illness, however, we must first explore what it is to create art and what it is to have a disease that is defined by absence.

Art is by nature a contradiction. It is both a connection of the artist to the world, breathing something in to breathe out something new and changed, and an act of representation, of creating abstractions to stand in place of something real. Art is an act of internalization as well as exposure.

Art both connects the artist with reality and gives the artist the ability to alter reality, to hold up a filter in the face of the world. To put it simply, art is a way to make things other things.

Quite similarly, anorexia is, by nature, a contradiction and a confusion of what is and what is not. Anorexia is a disease that does not allow for eating but at the same moment eats one whole. Anorexia says, I do not need to eat, I do not need to drink, I do not need to rest, as it also says, I am hurt, I am hungry, I am thirsty. Anorexia exposes and conceals, makes the anorexic feel weak and powerful at the same time. In order to be a successful anorexic, one must at the same moment fail: To succeed as an anorexic is to die.

Like so many persons I’ve met with this disorder, I have exhibited a level of compulsive perfectionism in many aspects of my life, not only those pertaining to food and body but extending into academic, artistic, and professional endeavors as well. It is this quality that others have recognized and labeled as the “soul of an artist,” or the “heart of a writer.” (I write this in remembrance

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July/August 2008 San Francisco Medicine 17

The Starving Artist Continued from the Previous Page... of a nine-year-old night during which I stayed awake to write a twenty-page story that had a one-page length requirement.)

This compulsive aspect of my personality has become the trait by which I am constantly defined and for which I am praised by others, whether in regard to scholastic achievement, professional efficiency, or a general dedication to quality.

This level of compulsion, needless to say, destroys as it creates, not only in the sense that hours of one’s life are consumed by efforts to produce and to learn, but also in the sense that it requires a great amount of energy and sacrifice in order to maintain.

These sacrifices are rarely noted or recognized by others, as long as the outcome is decidedly worthwhile. In the hospital, however, this behavior has a name—several, in fact. And in 2003, at the climax of a decade-long struggle, I was told that this “heart of a writer” was really called anorexia nervosa, obsessive-compulsive disorder, and posttraumatic stress syndrome.

It would seem, then, that we, as a culture, simultaneously cherish and demonize the compulsive spirit.

When I have expressed this view to acquaintances and colleagues, they have argued that, while many writers and artists suffered their addictions and disorders, these were separate from their art––that while alcohol or depression no doubt influenced their writings, it did not enable them to create. I find this argument a little like attempting to sever a person from his or her past, from the colors that we individually recognize as red or blue. We could no more claim that an artist is an artist independent of his or her disorder than we could claim that the disorder exists independently, without the person whom it affects. We cannot sever the disorder from the artist any more than we could slice a person in two. And, we, as writers, as artists, create nothing entirely on our own, in the same way that nothing can be created without an exchange of energy, without some degree of destruction.

The retort often follows that the difference between an anorexic and, say, Virginia

Woolf, is that while the artist destroys (time, hours, papers, self), she does so in order to create, which relies on the assumption that anorexia does not create, but only destroys.

What is it, then, that anorexia creates?

Here, it is the absence. Here, it is the lack.

Here, it is an emptiness of self that defines the space, like sinking into a bathtub, feeling your space because there is so little of you.

Here, I am not me, and so I am someone else.

Strange, how things can become other things sometimes. Seeds into trees, maples.

Girls into women. Nighttimes into daytimes.

And vice versa.

It is strange that I know that yesterday I was me only because now I am someone else.

In a tangible sense, the act of starving is a way of shaping and molding, of whittling and paring away in order to change one’s physical body. It is a breaking down and a changing of form that has its own byproducts of released endorphins and an almost spiritual sense of euphoria––which lends itself to the creation of other art. In my case, I will write for days, for hours upon hours, with no food but with a fierce sense of creativity that has never been achieved under other circumstances. In this sense, the anorexic behavior is a drug under the influence of which the art is made, similar to alcohol or another narcotic.

But what is more, anorexia, like art, like eating, makes things into other things.

Food is no longer food to me. Its preparation, its nutritional value, and the way that it enters into the body, giving of itself for something else, is beautiful. Food has become something other than nourishment, so that I see it and love it, but I have no desire to ingest it and make it a part of me, because it already is.

My body is no longer my body. Its functions, its quirks, grooves, and hollows, they are works of art from years of compulsory actions.

My arms, my legs, my chest—all have been thoughtfully manipulated into something else, so that I do not feel the pain I inflict, do not see that I am thin, that I am dying.

Anorexia is capable of making things into other things, capable of rendering an intelligent woman incapable of responding to natural impulses––rendering her, in a sense, color-blind. But more importantly,

18 San Francisco Medicine July/August 2008

anorexia exists not for the ultimate sake of making art of food and body, but to put a filter between oneself and reality, to both connect and disconnect at the same time.

To make a life, to make memories, into something else. To make what is weak strong, to conceal what is exposed. (Artists do not write, do not paint, for the sake of words or paint on a page, but for a contribution to the world and themselves.)

In treatment, however, the anorexic is told that what she sees as red is blue, that what she feels she cannot trust, and that she must forsake herself in order to survive.

While I believe that treatment had many benefits and that it literally saved my life, buying me time and allowing me the space and quiet to think and reflect, I also have found a kind of extremism in the way that our society views recovery. The conventional methods of treatment suggest, though never directly, a disrespect of disease and an unrealistic view of what it means to recover. (One example that comes to mind is the “fast-food challenge” in which I was required to partake during treatment.

Essentially, a van of emaciated women with tubes in their noses, myself included, were driven to a Taco Bell for lunch.) It is as if the medical world believes that it is possible to recover something one has never known.

I make this claim in reference to the many women I came to know and love in treatment, several of whom have since died, who vacillated between recovery and severe disorder, between one extreme and another, so many times, without finding any life in between.

One such young woman, by the age of twenty-six, had been in treatment fourteen times. She was repeatedly hospitalized by her parents, only to return home and relapse within months. For most of her life, she knew nothing beyond the life of the patient or the life of the anorexic. She was either recovering or relapsing, without any sort of balance, any sort of compromise.

Throughout our treatment together, she did everything ever asked of her: she ate all of her food, she accepted all of her increases in meals, and she followed all of the rules. (I, on the other hand, threw butter at a nurse, was caught doing sit-ups in a closet, and made one of the kitchen servers cry.) www.sfms.org

She died of heart failure in 2004. For me, her death communicated that there is no redemption in extremes, or in living one life only to avoid living another.

To the contrary, if there is one thing that I have learned in my struggle, in this art, it is that one is always two things at every moment. We are breathing and living just as we are dying, from the moment we are born. We are walking and moving, rooted to the ground but reaching upward; we are looking in puddles, seeing both the muck and the reflection of clouds at the same moment.

We are forever part patient and part anorexic.

We are manifestations of the contradiction of art; living and dying, creating and destroying.

In treatment, I learned that I cannot forget the bad things without losing the good as well. In the name of my disorder, I had forsaken those I had loved my entire life.

In forgetting the painful parts of my past, I had also forgotten my happiest moments.

It is strange how things become other things.

It is strange that there are memories I didn’t realize I’d forgotten, a past I’ve turned into something else, something blank. Girls running

Sniffing the Same Air Continued from Page 12... would upon the rack of this tough world stretch him out longer.”

We physicians have our fiefdom, medicine, with its moats and walls. We pass through, but our fatigue, our private language, our identity stops others from entering.

What do we want our future doctors to understand about aging and the human condition? That we all die, kings and salesmen.

That we are not unique, not extraordinary.

That regardless of rank, power, knowledge, and money, we are not so different than Lear and Loman. We make mistakes. We prove our humanity when we err. We easily fall into thinking of our work as royal, and that allows us to present ourselves as www.sfms.org

together through yellow summers, barefoot, over Saturdays and linoleum floors; hanging from trees, swinging from willows. Girls laughing together always, whispering in the dark, etching fingernail circles until falling asleep in hopes of sharing dreams.

It is strange that there have been pieces hiding within me; it is strange how much one can starve and still not be able to see it all, how parts can still hide so deep in one’s skin.

It is strange that I no longer know myself and yet I know myself more than I ever have.

Can we exist, full and empty at the same moment? Can we exist as both girls and women, both hungering and sated? Can we truly be here and not, living and dying?

Have I truly forgotten my sister?

And so it is my belief that we cannot recover and lose the disease, the compulsion, entirely.

Anorexia has made me into the negative print of someone else, has etched me from a sense of lack, of absence, into a skeleton of shadows and dark spaces. Anorexia, as an art, consumes the artist until there is only the art, until the disease is the both the art and the artist. Anorexia makes things into other things. Makes women into girls.

And vice versa.

This art, however, is not sustainable, as

its presence relies on absence.

There is an artful balance, I have found, to living with anorexia, a disease that saves and lives only through dying and sacrifice; it is a shaking of hands with an opponent, a kind of negotiation between extremes. I am not recovered, and I doubt that I ever will be. I am an artist who harbors the compulsion to create, to make what is around me new. I know now, however, that giving my all for any art, living in any sort of extreme, is simply not sustainable; it is a way to place a filter between oneself and the world, a way to lose oneself. It is a way to forget the bad while also forsaking the good.

To live with anorexia is to recognize a presence, to recognize what is, not by what-is-not, but by the thing itself. To accept that there are within us destructive parts, memories we’d like to forget, with which we must live. There is as much god as there is devil in all of us, as many cells dying as being born. There are dead things housed within our very hearts.

As artists, there are things we must destroy in order to create.

doctors rather than other humans. Some problems are insoluble, and to see them as such is wise. We may have missed or misdirected—because of training, tortured clinic hours, emergencies—our children’s admiration, respect, love. At the end, we may have spilled a life of hope, and found little. Can we learn from great literature, learn the lessons of the tragedies of Loman and Lear? In Ian McEwan’s Atonement, the protagonist thinking of a future as a physician argues that … this was the point, surely: he would be a better doctor for having read literature. What deep readings his modified sensibility might make of human suffering, of the self-destructive folly or sheer bad luck that drive men toward ill health! Birth, death, and frailty in between. Rise and fall—this was the doctor’s business, and it

was literature’s too. He was thinking of the nineteenth-century novel.

Broad tolerance and the long view, an inconspicuously warm heart and cool judgment; his kind of doctor would be alive to the monstrous patterns of fate, and to the vain and comic denial of the inevitable; he would press the enfeebled pulse, hear the expiring breath, feel the fevered hand begin to cool and reflect, in the manner that only literature and religion teach, on the puniness and nobility of mankind.

Larry Zaroff, MD, PhD, teaches medical humanities at Stanford and works as a family doctor at the Marin City Health and Wellness Clinic.

July/August 2008 San Francisco Medicine 19

Literature and Medicine

Losing the Ability to Create Amy Tan on Lyme Disease Amy Tan

I

have late-stage neuroborreliosis. I have had this disease since 1999. My case is in many ways typical. Like many, I had little awareness of Lyme disease, for I did not live in what was considered the tick-infested hotbeds on the East Coast. I am a Californian—that’s where I file my taxes—and I live among the hills of San Francisco with its tick-free, concrete sidewalks. For a good long while it did not seem significant that I also have a home in New York, that I weekend in the country, and my main form of exercise is hiking. In addition to trekking in the woodlands of Mendocino, Sonoma, and Santa Cruz Counties in California, I have also sojourned to leafy spots in Connecticut and upstate New York. I once loved to sit in the tall grass next to the river, and lean my back against a shady oak tree.

I passed off my early symptoms—a stiff neck, insomnia, a constant headache, and a bad back followed by a frozen shoulder—as the unpleasant aftermath of too much airplane travel. I was often tired and jittery, but that, I reasoned, was the consequence of an active and exciting life. Who was I to complain? I had a wonderful life, a great husband, lovely homes, a successful career.

I was rarely sick and went to the doctor only for my annual checkups. Even when I came down with the fever, aches, and pains of the “flu” earlier in the summer, I had managed to beat it back without developing any of the respiratory sequelae. What a great immune system I had!

When my feet grew tingly and then numb, I mentioned to my doctor that I had had an unusual rash earlier that year.

It had begun with a tiny black dot that I guessed might have been a pinprick-sized blood blister. It grew more rounded as it filled, and then I either scratched it out or

it fell out on its own, leaving a tiny pit and a growing red rash, which, curiously, did not itch, but lasted a month. Because that rash seemed so unusual, as did my neuropathy, I wondered aloud whether they were related.

My doctor said no.

“By day, my memory was held together with friable threads, my concentration was as easy to disperse as blown dust ... I did not possess any of the skills necessary to write fiction, for I was barely able to traverse the distance of sentence to sentence ...”

Like many chronic Lyme disease patients, as my symptoms mounted and a scattering of tests proved positive for an array of seemingly disparate conditions, I was referred to specialist after specialist, until I eventually had consulted ten and had taken countless lab tests. Because one repeated test revealed my blood sugar inexplicably dipped from time to time into the twenties and thirties without symptoms, I underwent a forty-eight-hour fast. An MRI revealed fifteen lesions in my frontal and parietal lobes, but my doctors felt that was normal for a person my age; I was forty-nine at the time. A CAT scan showed an incidentaloma on my adrenal gland, and that was where I hung my hopes, on a tiny benign tumor, which I could excise laparoscopically in hopes of being rid of my enervating symptoms. Instead, after beginning steroids,

20 San Francisco Medicine July/August 2008

the bizarre symptoms worsened. Hallucinations began, what I now realize were likely simple partial seizures, the result of lesions in my brain. I saw people walking into my room, two girls jumping rope, numbers spinning on an odometer, a fat poodle hanging from the ceiling. I also had strange episodes in which I behaved strangely but had no recollection of what I had done as reported to me by others. I apparently rang people up at midnight and talked in a wispy voice.

I flung laundry around the living room. My husband said I acted at times as if I were in a trance, eyes wide open but unresponsive to his and a friend’s questions. I now had nightly nightmares and acted them out, punching at lamps or my husband, and once landing on my head in a dive toward my dream assailant.

By day, my memory was held together with friable threads, my concentration was as easy to disperse as blown dust, and when I tried to read, I often found by the second page that I had no idea what the book was about. When I wrote by hand, I reversed letters. When I spoke, I substituted words with like-sounding beginnings. I did not possess any of the skills necessary to write fiction, for I was barely able to traverse the distance of sentence to sentence, let alone keep in mind a narrative that had to span four hundred pages and keep taut multiple intricacies of plot, characters, and thematic imagery. Thus, my novel-in-progress lay abandoned between feeble attempts to resuscitate it. At times, when asked what I was writing, to my horror, I could not remember, and I would struggle over the next hour trying to recall the faintest details.

I no longer dared get behind the wheel of a car, because I could not process fast enough when to depress the accelerator and when www.sfms.org

the brake. When I did venture out on foot, I would sometimes find myself lost in what I knew was a familiar place, my neighborhood of thirty years. Why didn’t that building on the corner look familiar? Why did everything seem as though it were the first time I had been there? I easily became lost in stores, hospitals, hotels, and I would panic, certain I was losing my mind and developing dementia related to early Alzheimer’s. My anxiety was a hundredfold of what was warranted, even in a post-9/11 era. Eventually, I could no longer leave my house alone. In any case, it hurt to walk too far. My muscles were stiff, my knees and hips ached. And I was almost too tired to care anymore.

Let me add here that my doctors were affiliated with major urban hospitals, were tops in their department, well known, well respected. I liked them. I still do. Not once did they raise the idea that I was a hypochondriac. But they also did not raise the possibility of Lyme disease. Actually, one doctor had considered the possibility that I was infected with a spirochetal bacteria, and he gave me an ELISA test, which was negative—not for Lyme but for syphilis.

I turned to the Internet, which is where doctors believe patients catch terminal illnesses, that is, whatever disease they see described before them on the terminal. And there I saw that an ELISA was also used to screen for Lyme disease. Further reading led me to see that all my symptoms could easily fall under the multisystemic umbrella of borreliosis. Further sleuthing gave me the name of a Lyme specialist, someone my other physicians acknowledged was “a good doctor.”

My Lyme specialist considered the history of my rash, the summertime flu, the migrating aches and neuropathy, the insomnia and fatigue. He thought fifteen lesions in my brain were significant in light of my neurological symptoms. He saw on previous tests that I had some interesting changes in my immune system. He ordered a complete battery of tests from IGeneX, a lab specializing in tick-borne illnesses, to check for not only Lyme disease but its common coinfections. Two weeks later, I learned I was positive for Lyme on the Western Blot. My doctor told me that the test only confirmed what he already knew. www.sfms.org

Let me hasten to add that not all chronic Lyme patients test positive on the Western Blot, at least not at the levels set by doctors who follow CDC surveillance criteria as diagnostic. There is much more to be done before the tests can be considered reliable in every lab across the country. I know this firsthand because after I started antibiotic treatment, I took part in a study in which my blood was sent out to five different labs for the ELISA and Western Blot.

The results were all over the place—with Lyme-specific bands lighting up in one lab and not the other. There was almost not a single consistency. In addition, I had a negative ELISA test but a positive PCR, that is, I had DNA evidence of borrelia in my blood. And this was nine months after I had started antibiotic treatment.

Like many late-stage neurological Lyme patients, it took a while for symptoms to begin to lift. A day after starting antibiotic treatment, I became feverish and ill with the classic Jarisch-Herxheimer reaction. A month later, the joint and muscle pain eased up somewhat. Two months, and some of the fog finally lifted, and I frantically wrote for long days, fearful that the curtain would come down again. After six months, I had no muscle stiffness or joint pain remaining.

Today, I can once again write fiction, speak at conferences, and walk in my neighborhood alone and without anxiety and panic.

I’ve been under treatment now for over a year. I consider myself 85 percent improved from where I was a year ago. I still have what I call memory “black holes” when I am tired, and I have neuropathy in my feet, which at times becomes too painful for me to walk more than a block. I know that my late diagnosis means I am in this for years, perhaps even for life. But at least I have my mind back.

As a patient, I have joined a club of people with a stigmatized disease that many doctors do not want to treat. While I have been lucky enough to find a doctor who is willing to provide open-ended treatment—and I have the means to pay for it—many of my fellow Lyme patients have gone without appropriate care. As a consequence, they have lost their health, their jobs, their homes, their marriages, and even their lives.

I now know the greatest harm borrelia has caused. It is ignorance. Lyme disease is more prevalent than most people think. It is more difficult to diagnose than most doctors think. It requires more research before we know how it can be adequately treated and, one day, cured.

In the meantime, my advice to friends and family is to be aware and be informed.

Realize that Lyme disease has been reported in every state except Montana. The CDC estimates the actual numbers of those infected each year is at least tenfold of what is documented. Some Lyme specialists believe the numbers are even much higher than that.

And if you are bitten by a tick and suspect you have been infected, go see a Lyme-literate physician. Get treated early and adequately.

Don’t wait, as I did, and let a treatable disease turn into a chronic one.

For more information on Lyme disease, a Lyme-literate physician, or LymeAid4Kids, see www.LymeDiseaseAssociation.org.

For information on research on Lyme disease, see www.ilads.org.

“The Opposite of Fate”, from THE OPPOSITE OF FATE by Amy Tan, copyright © 2003 by Amy Tan. Used by permission of G.P. Putnam’s Sons, a division of Penguin Group (USA) Inc.

For Magazine Archives, Health Care News, and Local Events of Interest Please Visit Our Website, www.sfms.org.

July/August 2008 San Francisco Medicine 21

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The Cooperative of American Physicians, Inc. is the only physician owned and directed company whose core product, Mutual Protection Trust, is Rated A+ (Superior) by A.M. Best Company. If you want more from your medical professional liability provider, call 800-252-7706 or visit www.superiorphysicians.com.

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Literature and Medicine

Medicine as Muse Writing My Way through Medical School Craig Chen

A

s I begin my third year of medical school, I am bombarded by the wealth of stories on the wards. I journal my own struggle of adjusting to medicine outside the classroom, listen to patients recount captivating narratives, and weave a tale out of each history of present illness. This transition into active participation in the hospital rather than passive lecture learning has jump-started my imagination and motivation for creative writing.

As medical students, we have developed a keen intuition about when to jot down an attending’s clinical pearls of wisdom. The writers among us have simply transferred that instinct to identifying images, metaphors, emotions, and phrases that may trigger a story or poem. At the end of each day, I clean out the overfilled pockets of my white coat, and among the debris of the tuning fork and pocket pharmacopoeia, I find a note card jotted with ideas. Just yesterday, I had scribbled “organ donor asked how long for liver to regenerate; didn’t Promethius’s [sic] liver regen overnight?” With Greek mythology in mind, I realized that this campus sits on Parnassus, home to the muses, and the informatics system at UCSF is named after the Greek physician Galen. This juxtaposition of classical and contemporary medicine begged for a poem.

The ideas are replete, but finding time is the constant struggle. My interest in creative writing blossomed when I took workshops with Stanford University Stegner Fellows as an undergraduate. One of my writing mentors told me that it is easy to be a student who writes, but it is much harder to be a writer who’s also a student. To practice this art of the pen, I commit a block of time each day to writing. Whether it is reflection on topics from Grand Rounds on my daily blog or a www.sfms.org

sketch of a poem about going to a reservation with the Indian Health Service or a revision of a completely fictional short story, I force myself to craft something every day.

The greatest inspiration and motivation, however, come from my peers and physi-

“I’ve often had the skeptic ask me, ‘How can you possibly find time as a medical student starting on the wards to do any writing?’ I make time to write because it’s fun.

It’s therapeutic.” cian-writers in the Bay Area community.

Through remarkable vision and leadership, my classmate Mel Hayes organized a group of students who find writing the ideal vehicle for expression. Our hodgepodge collection of playwrights, creative nonfiction writers, poets, essayists, and storytellers has grown over the last two years; while it began as a handful of students gathering at cafes and apartments, it soon piqued the interest of many, from incoming first years to fourth years completing an area of concentration in the medical humanities.

Amazingly, faculty members were eager to support our budding writer’s group. Dr. David Watts, author of Bedside Manners, invited us to his office on Monday evenings to workshop our stories, prompt our imaginations, and discuss the nuances of narrative.

Dr. Louise Aronson, whose short fiction has won national literary awards, organized an elective to formally recognize our time and work in narrative medicine. Even community writers such as Bill Hayes (The Anatomist; Five

Quarts; Sleep Demons) join us in exploring both fiction and nonfiction as mediums for play and communication.

I’ve often had the skeptic ask me, “How can you possibly find time as a medical student starting on the wards to do any writing?”

I make time to write because it’s fun. It’s therapeutic. Journaling is a way to debrief and reflect on that poor patient interaction, that frustrated staff member, that terrifying moment in the emergency department. Short stories allow me to experience situations from other perspectives, to think about how a patient interprets my actions, to listen to a family member interpreting. Poems help me capture a feeling, follow a curious train of thought, ask questions without expecting answers. Writing has value to me as well as those audiences who stumble upon my work.

This combination of writing and medicine is not new. All of us recognize that perennial symbol of medicine, the Rod of Asclepius, and most of us know the eponym refers to the Greek god of medicine. But few, I suspect, know that Asclepius is the son of Apollo, the patron god of music and poetry and the leader of the muses. The original classical Hippocratic Oath begins by invoking both Asclepius and Apollo. From afar, poetry and medicine seem to be discordant disciplines, representing the fuzzy humanities and the objective sciences. But as I enter this phase of my medical training, learning more the art than the science of medicine, I realize the Greeks might have gotten it right after all; that writing, like medicine, seeks to characterize and palliate the human experience.

Craig Chen is a third-year medical student at University of California, San Francisco.

Please see the poetry section on page 30 to read one of his poems.

July/August 2008 San Francisco Medicine 23

Literature and Medicine

Learning from Literature Literature, Medicine, and the Good Doctor Lawrence J. Schneiderman, MD

“M

edical professionalism in the United States is facing a crisis, just as serious as the crisis facing the health care system,” laments Dr. Arnold Relman, the former editor of the New England Journal of Medicine. He defines medical professionalism as “the commitment of physicians to put the needs of patients ahead of personal gain, to deal with patients honestly, competently, and compassionately, and to avoid conflicts of interest that could undermine public trust in the altruism of medicine.” (Relman 2007) Relman warns that even while the scientific and technical authority grows stronger and medical science and technology are flourishing, the moral foundations of the medical profession have lost their influence on the behavior of physicians.

Jordan Cohen, MD, president emeritus of the Association of American Medical Colleges, states, “Professionalism denotes a way of behaving in accordance with certain normative values, whereas humanism denotes an intrinsic set of deep-seated convictions about one’s obligations toward others.” He adds, “Humanism provides the passion that animates authentic professionalism.” (Cohen 2007) As someone who entered medical school more than fifty years ago after majoring in literature, I cannot resist the notion that it could well be that because the hard sciences and technology are flourishing in medical education that the “softer” aspects of medical professionalism, such as ethics and the humanities, have been squeezed out.

I have my own dark image of medical education, based on the term neurologists use to describe a brain tumor growing within the confines of the skull. They call it “an expanding space-occupying lesion.” Gradu-

ally and inexorably, the hard tumor enlarges and crushes the soft tissue of the brain. By analogy, medical student education, since the beginning of the twentieth century, has taken place within the rigid confines of

“As someone who entered medical school more than fifty years ago after majoring in literature, I cannot resist the notion that it could well be that because the hard sciences and technology are flourishing in medical education that the ‘softer’ aspects of medical professionalism, such as ethics and the humanities, have been squeezed out.” a four-year curriculum. Consider all the discoveries in hard science that have occurred since then—in physics, physiology, molecular biology, genetics, biochemistry, pharmacology, pathology, immunology. Once upon a time subjects like history and fine literature were considered essential to the education of the complete physician. But not anymore.

The barons of the “core curriculum” simply cannot find any room. And so, not surprisingly, these “soft” subjects—and the human values traditionally expressed and nurtured in the humanities—have been crushed into extinction. This is particularly distressing

24 San Francisco Medicine July/August 2008

since the professional purpose of medicine is to serve human values above all.

One serious consequence of today’s narrowly focused course of education appears to be callousness in patient care. In a study exploring the experiences of third- and fourth-year medical students, researchers reported that “although the students generally regarded callousness as undesirable, they reported seeing callousness modeled by their mentors 20 percent of the time.” Furthermore, some students were inclined to think that “being callous toward patients and colleagues can serve them well in some situations.” (Rentmeester, Brack, and Kavan 2007) Another problem that lurks for today’s young physicians trained without the benefit of the humanities perspective is the aging of the U.S. population. They will face increasing numbers of elderly patients. Educators emphasize that “an important step in educating future physicians to care for older patients is to diminish the influence of negative stereotypes they often hold about older people.” (Shue and Arnold 2005) How to diminish this influence? I suggest that young physicians familiar with the writings of Chekhov, Tolstoy, and other great writers would not be so easily misled by such negative stereotypes.

In pursuit of this notion I posted a notice on the medical students’ bulletin board in the spring of 1985 at UCSD School of Medicine announcing a new elective course, The Good Doctor: The Literature and Medicine of Anton Chekhov. (Schneiderman 2001) It was a presumptuous announcement. Although I had majored in literature, I had never taught a literature course, had never even participated in a book discussion group. Naturally, I looked about for experienced colleagues to help www.sfms.org

me out.

My first contact was not encouraging.

A professor with expertise in Chekhov bluntly refused to have anything to do with me. “I don’t want a doctor who knows Chekhov, I want a doctor who knows how to take out my appendix.” Fortunately, I was able to locate more agreeable colleagues from literature and theater.

Over the years since then, we have read many of this writer’s short stories and his play, Cherry Orchard, and observed a rehearsal by graduate theater students. For background, we also read some of Chekhov’s letters, and, to gain insights into the methods actors use to understand their characters—namely, how skilled professionals achieve empathy—we read selections from Konstantin Stanislavski’s My Life in Art and An Actor Prepares, and Uta Hagen’s Respect for Acting.

Thanks to Chekhov, I found many occasions to relate our readings to experiences I had as a physician. I also pointed out how, by selecting a few of many possible details, Chekhov makes vivid his descriptions and reveals his characters. This, I said, is what we all must do as physicians: select details among the many we observe, find the pattern in those that reveal the diagnosis, that make vivid the patient’s illness and the routes to treatment.

At first, all I hoped was that the seminars would be interesting. It was not long, however, before I realized that what the students were going through was not only interesting but important. By the end of the course that first year, I was convinced it was not only important but essential. Nowhere else in the medical curriculum did they confront and discuss the wide array of human concerns raised by Chekhov (and by our patients)—the deep and painful thoughts and feelings aroused by illness and death, the capriciousness of fate, the unexpected dignity in suffering, the power of simple acts of kindness, the haunting desires and ambitions we discover in ourselves, sometimes at the worst of times.

Several changes developed over the years. Practicing physicians joined us, adding their thoughts and experiences, along with medical trainees who found it an effective strategy for generating mindful practice www.sfms.org

amidst the pressure cooker of clinical life.

(Charon 2006; Kuczewski 2007) Also, I decided to expand beyond Chekhov. This, in part, I suppose, was because I was getting my fill of the same author, but also because I was aware of so many other fascinating works of fiction as well as poetry, including the works of Eudora Welty, William Carlos Williams, Sylvia Plath, and Ann Sexton. In particular I like to compare the tempestuous richness of Anne Sexton’s “Unknown Girl in the Maternity Ward” with the terse jottings of Williams’s “Spring and All”—the kind of reduction that takes place between the patient’s story and the medical record.

If you’re really a good physician, I tell the students, you will, in your abbreviated version, like Williams, somehow keep the story alive. I also like to show how great writers provide a descriptive accuracy beyond mere numbers. (For example, who needs a thermometer when Shakespeare’s Hamlet says, “The air bites, shrewdly; it is very cold,” and Horatio replies, “It is a nipping and an eager air.”)

I now have hopes to bring these experiences to physicians in the San Francisco area. As a Visiting Scholar in the Program for Medicine and Human Values at the California Pacific Medical Center, I have been in discussions with residents and faculty who have expressed enthusiasm for finding a place for literature and medicine seminars in the training program. Will these kinds of admittedly vicarious experiences make the participants better doctors?

I confess I have no empirical evidence to support my belief that they will. But (to shamelessly plagiarize) I continue to hope audaciously.

Lawrence J. Schneiderman, MD, is a professor emeritus in the Department of Family and Preventive Medicine and an adjunct professor in the Department of Medicine at the University of California, San Diego. He is founding co-chair of the UCSD Medical Center Ethics Committee and is a recipient of the Pellegrino Medal in medical ethics. He is presently a visiting scholar in the Program in Medicine and Human Values at the California Pacific Medical Center.

Schneiderman has written more than 170 medical and scientific publications, including Embracing Our Mortality: Making Difficult Medical Decisions in the Age of “Miracles”

(Oxford), which will come out in the Spring of 2008.

Schneiderman is a fellow in the American College of Physicians and serves on the editorial board of the Cambridge Quarterly of Healthcare Ethics.

For a full list of references, see www.sfms. org/archives.

Welcome New Members!

The San Francisco Medical Society would like to welcome the following new members:

Stacy L Drasen, MD UCSF/SFGH

Todd LeVine, MD The Permanente Medical Group

Referred by Charles Wibbelsman, MD

John Pakula, MD The Permanente Medical Group

Referred by Charles Wibbelsman, MD

Lynne Portnoy, MD, MPH Referred by Mei-Ling Fong, MD

July/August 2008 San Francisco Medicine 25

Literature and Medicine

Reflective Writing Providing a Useful Tool to Medical Students Gail Ellison, PhD

M

edical education is a strenuous rite of passage, likened by one student to climbing Mt. Everest: “You can sometimes catch a glimpse of the peak, but most of the time the pinnacle seems very far away as you trudge on.”

The process of educating future physicians is also daunting for those in charge of medical education, who are mandated to teach not only burgeoning scientific and technological information, but also professionalism—how to be a humane, culturally competent, caring, ethical, compassionate practitioner.

In the words of the Accreditation Council for Graduate Medical Education (ACGME), competencies should include “interpersonal and communication skills that result in effective exchange of information and collaboration with patients, their families, and other health professionals.

Gregory Makoul, PhD, notes that these skills “have become key criteria for the accreditation of medical schools and residency programs, as well as the certification of practicing physicians.” The Association of American Medical Colleges (AAMC) has also addressed the need for students to develop skills in verbal and non-verbal communication, demonstrate cultural sensitivity, “demonstrate proficiency in dealing with difficult situations”, and so on.

The University of Florida College of Medicine (UF COM) addresses those needs in several courses, including one that surprises many physicians when they first hear about it: an elective called Reflective Writing/Reflective Practice, offered for first-, second-, and fourth-year medical students. The course, initiated in 2003, has expanded to five sections per year.

One hour a week, students enrolled

in the Reflective Writing elective pause to write poetry and journal entries about their soulful, inspirational, raw, amusing, and/or overwhelming experiences: the observation of birth, the shock of cutting into a cadaver,

“Through writing and reading aloud, the students find meaning and, often, humor in grueling study sessions and back-to-back exams.” the pathos of a withered hand extended by a dying patient, the embarrassing moments experienced by any novice, the growing awareness of distance from family and friends, the struggles with self-doubt, the profession’s struggle between materialism and compassionate service to the world’s needy, and so on.

Every class opens with a five- to tenminute guided meditation, led by the instructor, who draws on her training in yoga and mindfulness. The goal is to bring busy students who are preoccupied with lecture notes and test scores into their bodies—to offer a pause in which “inner weather” can be observed and reflected upon.

The class then writes in silence (eating lunch with the nondominant hand) for about fifteen to twenty minutes before being invited to read aloud. Sharing is optional, but inevitably all come to trust the confidentiality of the circle enough to read.

All students must prepare work for posting at the end of the course, but even that can be anonymous.

Nearly every shared poem or essay leads

26 San Francisco Medicine July/August 2008

to group discussion of psychological and philosophical principles. When a student wrote about hearing a fellow anatomy student call his cadaver “a slut,” the discussion moved to the multitude of human ways to cope with experience that is hard to assimilate. When a grandmother was dying, the group paused to remember and offer as support their own memories of death of family and friends. Whatever the emotion, there is always someone to say, as one student did in response to a journal entry on intolerance, “It’s not just you feeling like that.”

The students run into their own biases and false assumptions, as they show up in the writing. “It’s funny,” one observed at the end of her essay, “when you think that attractive people can’t possibly be sick.”

They come face to face with the limitations of medicine, as when they see infants suffering: “People say there’s a reason for everything, but I couldn’t find a reason for this.” Her struggle led to a discussion of the challenge of choosing life as a pediatrician—an attraction for some and an “impossible” specialty for others.

Sometimes the writing moves the lens in to observe fine emotional detail; at other times pulling it back to get perspective on medicine as a field of study. Assignments encourage students to note the body language of patients in the hospital waiting areas or to think about metaphors for the practice of medicine in the twenty-first century.

Always there is attention—heightened through poetry, journal articles, and book chapters distributed in class—to literary themes that run through medicine: being on a journey, meeting the unexpected, or facing mortality.

This is the time when students sort out their firsthand observations. One student www.sfms.org

wrote about the balance between the great honor in her calling and the responsibility, burden, and sacrifice that are part of being a physician. Another, after hearing a resident say, “Let me in here; I can fix this,” even though the patient was quite clearly dying, wrote about the arrogance and omnipotence of the God complex that is sometimes so evident to young people new to the field.

When war and natural disasters are in the news, the writing and conversation shifts to important questions. As one student put it, “If the world ended tomorrow, would you guys be upset that you didn’t become a doctor? Is the important thing the end point or the process?” Another put it a different way: “If you had a terminal illness, would you continue in medical school?”

Not surprisingly, the process of medical education affects much of the writing.

“I mean, what’s the half-life of medical knowledge anyway?” one student mused.

“It feels like they put a hose in your mouth and turn on the spigot—and it’s sometimes nasty tasting! Learning has become a huge swallow and one big burp.”

Through writing and reading aloud, the students find meaning and, often, humor in grueling study sessions and back-to-back exams. The overwhelming amount to be learned in pathology becomes, in one student’s writing, the challenge of carrying a load of laundry that is all socks, with one falling to the floor each time she bends over to pick up another. The student confused by anatomy becomes, metaphorically, an explorer hacking her way through the jungle with a machete, with a vague map but no firsthand experience of the terrain.

There is inestimable value in journaling during the student years. As Dr. Hilfiker, a physician/writer, observes, “I wrote a lot in college, but then we just didn’t do any expressive writing in medical school. Now I write more—I went back to it to restore my perspective after burnout—but there’s no way I can revisit the freshness of the emotions I went through as a medical student.”

This is the time to become conscious of and capable of articulating an inner life—a skill that can never be lost. The course reveals the essence of narrative medicine: The students see what they’re going through as a www.sfms.org

story. Whatever emotion is at the fore one day will morph into another sooner or later.

In recording their own stories and becoming active listeners to the stories of others in the class, they become more likely to view patient stories as having a vector that gives illness (and life) meaning. “I am standing at the bottom of a pole,” one student wrote, “carving out faces. And my own will be at the top, but I won’t know until I get there what it will look like.”

The stress-reducing and communitybuilding aspects of Reflective Writing receive high rankings in student evaluations of the course. The busy students maintain remarkable attendance—typically voting to continue to meet during finals, even though grades have been submitted—not only to write and discuss fears and challenges, death and dying, reservations and commitment, and other topics that determine their future professionalism, but also to drop their shoulders and laugh and cry, together.

During class hours, the container is closed, with an agreement to maintain confidentiality. The course would not work as well if there were a perception, even if inaccurate, that it might determine residency recommendations. At the end of the semester, however, each student chooses work to share with other students and faculty. Students often congratulate each other on how much their writing has improved during the semester.

The students develop a writing practice

that has a rich future. In the words of one first-year student, “It will be so fun to read these journals when we’re, like, doctors for twenty years.” If the results of a course evaluation funded by the Arnold P. Gold Foundation are an indicator, future patients are also likely to enjoy the benefits of reflective writing in medical education. Beneath or inside the life we lead every day is another life. This unseen life runs like a river beneath the city, beneath work, family, ambition, beneath our pleasures and griefs. “There is another world,” says Paul Eluard, “and it is inside this one.”

It is through writing that we can know, most fundamentally, what might be the case with a patient and our relationship with the patient. If we can understand clearly the passages that link the confrontation with a suffering person with the representation of that experience and the subsequent reflection on the meaning of it, we can conceptualize roads toward the eventual goals of narrative medicine—extending empathy and effective care toward the patients we serve and building community with colleagues with whom we do our work.

—Rita Charon, MD, PhD

July/August 2008 San Francisco Medicine 27

Literature and Medicine

South Wing A Medical Mystery Written by the Editorial Board of San Francisco Medicine Editor’s Note: The following story was written collectively by the San Francisco Medicine Editorial Board. In celebration of the theme, literature and medicine, the editorial board created this fictional mystery by each contributing 100 words and then passing the story on. What follows is the result of this exercise.

O

n that early morning on the second floor, South Wing, at California Polyclinica Medical Center, the busy activities of nurses, administrative clerks, physical and respiratory therapists, technicians, phlebotomists, transport personnel, social workers, pastoral counselors, and doctors all seemed blandly routine.

Except for one thing. The door to Room 211 was tightly closed, and a crisscross of plain yellow plastic tape seemed to signal “Do not enter.” It was the room in which the elderly, somewhat cantankerous, yet jovially friendly Ms. Marlyn Hilliard had stayed for more than three months following a simple umbilical hernia repair, refusing to leave the hospital even as the medical staff and administrators pleaded with her to go into a long-term care unit. Now, with her sudden absence, a silent, impenetrable mystery seemed to shroud, like a San Francisco morning fog, all that would unfold on that fateful day.

Doctor Ann Donegan, a dedicated hospitalist, was on her way to spend a minute or two with Ms. Hilliard, whom she had attended and befriended some weeks earlier.

She stopped abruptly when she saw the blocking tape and called over to Mary, the South Wing nursing supervisor, “Hey, what’s happening here?”

“Sorry, Doc,” Mary said, “you need to talk with someone in a pay grade much higher than mine to get this information.”

Donegan was having none of it. “Ms.

Hilliard is my patient. I don’t need permission from some suit to do my job.” She peeled the tape away and pushed the door open. She and the hospital personnel who had gathered behind her gasped audibly as they looked around the room. As they hesitantly entered, an eerie silence permeated that once very occupied hospital room. No bed, no chairs, no TV, no nightstand. A door on the right had swung wide open, revealing that the bathroom was stripped bare as well.

Donegan started toward the bathroom but was stopped in her tracks by an authoritative voice. “Dr. Donegan, you are not authorized to enter this area.” She turned to face her accuser, a tall, middle-aged man with a full head of salt-and-pepper hair, who held out an impressive badge. “I am Inspector Conrad, San Francisco Police.”

Donegan paused and sized up the situation. Just then, Ted Hapner entered the door to Room 211 with his golden retreiver, Sniffer, a companion dog who regularly visited patients. Donegan knew Hapner and the dog because they had spent many hours with Mrs. Hilliard, sometimes even running errands outside the hospital for her. As Sniffer froze, his tail on alert, he emitted a deep-throated growl. In a hunting stance, he pointed at the bathroom closet.

Donegan rushed to the closet and flung the door open.

At that very moment, down at the Investigative Division of the San Francisco Department on Bryant Street, Chief Deputy Danny Bowen talked with Judy, his administrative assistant, about the happenings on South Wing. “I sent Conrad to the hospital to investigate because Ms. Hilliard, my dear maiden aunt who took care of me as a child after my mother died, is missing. She is a wonderful woman, I’ll tell you, with a heart

28 San Francisco Medicine July/August 2008

of gold—the most dynamic and caring person in the world.”

Judy looked up from her computer screen. “You don’t seem too concerned about a missing seventy-five-year-old woman.”

Bowen smiled. “Well, Judy, you don’t know my dear aunt. She’s the most resourceful human being I’ve ever known.”

Meanwhile, back in Room 211, Donegan looked into the closet and saw Ms. Hilliard’s old black purse hanging from a hook. She carefully opened the purse and saw Ms. Hilliard’s wallet, several credit cards, keys, and photos of her grandnieces and nephews.

Donegan looked back anxiously at Inspector Conrad, but he was gone. Standing in his place was the night-shift supervising nurse, Alicia Smith.

Smith, the first African American nurse to be promoted to supervisor at California Polyclinica Medical Center, and still on the job at age sixty-five, was accustomed to taking charge of unusual situations. She looked Donegan in the eye and gently touched her shoulder.

“I know you’re concerned,” she said.

“But, really, things look worse than they are.

It’s true that Ms. Hilliard is gone, but there is no evidence of any harm to her. And in the middle of the night, when we found she was gone, we removed everything from the room so that we could thoroughly clean and disinfect it after having someone in there for three months.”

Donegan put Ms. Hilliard’s purse into Smith’s outstretched hand. Why did the compassionate supervisor seemed so relaxed about this situation? “Well, I’m worried about her,” Donegan insisted.

“Don’t be. The police are on the job, and I’ll keep you informed.”

On the street below, Inspector Conrad www.sfms.org

was on his cell phone with Chief Bowen.

“There’s no evidence of a crime here,” he said. “I’ll have to just file a missing-persons report.”

“Good,” said Bowen. “I’ve put out a general alert and informed the family members to do whatever they can to locate my Aunt Marlyn.”

Conrad paused. “There’s just one thing, Chief,” he said. “She left her purse behind. It seems to me that she wouldn’t do that unless she was under duress.”

“Don’t worry,” said Bowen. “You don’t know my aunt. She spent her whole life leaving her purse behind. All the family members spent countless hours finding her lost purses, or helping her cancel credit cards.”

“OK, Chief,” Conrad murmured.

“And another thing,” Bowen went on, “we’re going to have most of our officers on the job, because it’s going to be congested around the Civic Center and City Hall this afternoon. There are going to be some impromptu demonstrations and a makeshift parade. Some activists want to promote Mayor Gavin Newsom’s plan for universal health care for the City of San Francisco.

They were going to demonstrate anyway, so we gave them a permit.”

“Got it,” said Conrad. “Hey, Chief!”

“Yeah?”

“I’m looking across the street, and there goes that Ted Hapner guy with his companion dog, Sniffer.”

“So?” “So, he and that dog spent a lot of time with Mrs. Hilliard over the past few months.

There’s something suspicious about that guy.

I’m going to tail him for awhile.”

“You’re probably wasting your time, but I won’t stop you,” answered Bowen, and hung up.

Conrad followed Hapner on a strange odyssey through Union Square, then through Chinatown. Conrad was beginning to feel that he was on a wild-goose chase, until Hapner and Sniffer caught the California Street trolley, heading for Van Ness. Following in a taxi, Conrad watched them disembark and saw Hapner grab a taxicab for himself, heading south. Feeling like he was in a movie, Conrad told his taxi drive, “Follow that cab.”

Hapner’s vehicle made its way to an www.sfms.org

old Victorian on a quiet street in Potrero Hill. Hapner and Sniffer entered through a side gate and walked to the rear of the home. There was no lock on the gate, so Conrad quietly followed. He heard voices and peered around the corner into a sundrenched garden.

Hapner said, “Traffic was crazy, as usual.

Are you ready? The universal health care demonstration is starting now. We’ve got to hurry.”

The reply came in the unmistakable voice of Marlyn Hilliard: “Oh, thank you!

Did you find my purse?”

“I couldn’t even look!” Hapner answered. “Your room was crawling with people. But I’m quite sure that Nursing Supervisor Alicia Smith has it safely tucked away. OK, get ready. I’ll call a cab.”

Meanwhile, Doctor Ann Donegan had gone shopping at Nordstrom’s and then, without a clear direction but seemingly pulled by fate, she walked up to Market Street and Van Ness, following the crowd surging toward City Hall. From the other direction, Nursing Supervisor Alicia Smith, who had been too excited to rest when she got home that morning, telephoned the nurses and orderlies who had been on duty on the South Wing during the night to insist that they come with her to City Hall to show their support for the mayor’s health care initiative.

Back on the Victorian’s patio, Inspector Conrad had confronted Hapner and Mrs. Hilliard. “Just give us this one chance,” they pleaded, assuring Conrad that no crime had been committed. Using her indomitable persuasive powers, Ms. Hilliard finally convinced the inspector to join them at the demonstrations. With Sniffer in tow at the elderly woman’s insistence, the group squeezed into one cab and headed back downtown.

A band was playing. A podium with a microphone had been placed at the entrance to City Hall. The throng had gathered, cheering loudly as speaker after speaker, some of them city officials and others just brave volunteers from the crowd, shouted their support for the mayor’s universal health plan. Just to the left of the podium, Donegan had encountered Smith, and soon they were joined by the night nurse, orderlies, the ward clerk, nurses, and other staff who worked together on California Polyclinica’s South

Wing. They turned in surprise when Inspector Conrad and Ted Hapner rushed out of the crowd to greet them.

Smith shouted over the noise of the crowd, “Inspector Conrad, what are you doing here?”

“Don’t worry,” he said. “I’m not arresting anyone. I’m part of the team now. And wait till you see what’s going to happen next!”

Just then, they heard the sirens blaring as two motorcycle police escorted a colorful double-decker San Francisco tour bus, adorned with balloons and ribbons, through the parting crowd and up to the steps of City Hall. The crowd cheered wildly when they saw Ms. Marlyn Hilliard riding on the top deck of the tour bus, with both her nephew, Chief Inspector Bowen, and Sniffer beside her. Ms. Hilliard was waving to the crowd, grinning from ear to ear. When the bus stopped, Bowen jumped down to the sidewalk, helped Ms. Hillard from the bus, and escorted her up to the podium, Sniffer following. The crowd immediately silenced.

Ms. Hilliard spoke for only five minutes, even with the pauses for frenzied applause and cheers from the crowd. She told of how she had staged her own secret protest at California Polyclinica’s South Wing, refusing to leave the hospital for three months, demonstrating for the rights of the uninsured who were often left without access to proper medical follow-up care. During this entire period, Hapner had been informing her of the progress at City Hall in formulating a universal health plan for San Francisco.

When she knew the parade was a strong likelihood, she stole away from the hospital in the night, with Hapner helping and Smith conveniently turning a blind eye, so she could appear in the demonstration in person.

“And,” she concluded, “in this world, healing can only be true to itself if it includes a human concern for everyone—not just for ourselves or our own families, but kindness and a caring relationship with all.”

The applause and cheers, the honking horns and blaring sirens, left everyone there assured that the mayor’s universal health plan would indeed become a reality.

July/August 2008 San Francisco Medicine 29

Literature and Medicine

The Poetry Corner A Selection of Poems by Local Physicians

Breast Imaging

Open Heart

They Don’t See

James A. Clever, MD

Craig Chen

Arthur Deikman, MD

“The human breast is a modified sweat gland whose purpose is the production of milk” —Fred Margolin, MD, Chief of Breast Imaging, CPMC (2007)

We are not unlike pigs, if only they stood proudly on two legs, wrote limericks, ran races by day, businesses by night.

Etta,

He spoke as if he meant it. No one laughed. I smirked.

Holding my breath, I stare into the steel reflection of the scalpel, stainlessly negotiating the bloody terrain of this man’s wish-broken car-trampled heart.

While the surgeon works deftly carving this new home for a porcine graft, I wonder how my hands would be: apologetic, curt. For what would you say if, coming home, you saw a pile of straw, a starving wolf, a huff, a puff, a piggy dream cut out?

On a tropical beach, sweat modified by palm tree shade, book in hand and beer close by, I pretend to read while I view bikini-clad women on the sand.

I know that they know I that I watch.

And why.

Last year a close friend had a breast mass. After sweating surgery, chemotherapy and radiation, it now returns in her bones to modify her plans. She knows that I know that she will die.

But why?

Another woman views her breasts too small. her plastic surgeon says no sweat to modify this wretched self-image.

We know that she knows it serves her well. And why.

Craig Chen is a third-year medical student at the University of California, San Francisco.

Clinicians speak as if we meant it. We don’t laugh or smirk.

James A. Clever, MD, practiced internal medicine in San Francisco from 19702005.

30 San Francisco Medicine July/August 2008

They don’t see When they see Your paintings That they see you Freed of your Freed of your body’s shape Become color, line and form, Forming something energized With you.

When I see you, I see Etta Inside her body’s shape, I see your spirit reach beyond space, On its journey To the source and destination.

What do you see, Etta?

Can you see Your own soul Radiant in canvas forms?

I think not.

So with words I paint My own picture Of you To show you You, Painting.

Arthur Deikman, MD, is a Clinical Professor of Psychiatry at the University of California, San Francisco, and divides his time between research, teaching, and the practice of psychotherapy.

www.sfms.org

Literature and Medicine

Book Review Aging, Time, and Love in the Time of Cholera Ashley Skabar

P

erhaps one of the greatest books written on the enduring quality of love, Love in the Time of Cholera by Garbriel García Márquez, as the title suggests, is also a novel ensconced in a discussion of time and aging. Following the story of the fifty-year ardor of Florentino Ariza to Fermina Daza, the novel stretches the patience of the reader as the chapters detail Florentino’s devotion lasting half a century, extending from the virility of youth to the frailties of old age. Beginning with two deaths and ending with a sense of rebirth on the ship New Fidelity, Márquez plays with the linear quality of life and time throughout the novel, portraying love’s ability both to end life and make one reborn.

The novel begins with the notion that death and love are inextricably united, describing the suicide of Jeremiah de SaintAmour, whose very name suggests a connection between the afterlife and love. Opening with the words, “It was inevitable: the scent of bitter almonds always reminded him of the fate of unrequited love,” we are momentarily lead to believe that the suicide is the result of a love affair gone bitter, when in reality, it is “gerontophobia,” or a fear of aging, that drives Jeremiah de Saint-Amour to take his own life. Described as a man who “loved life with a senseless passion,” it is the sense of waning life that Jeremiah de Saint-Amour cannot bear. (3,37) In this way, the book opens with a sense of inevitability not of death, but of the end of life, exposing life to be a love that, by its nature, can only be unrequited. While Jeremiah de Saint-Amour had a lover who was utterly devoted to him, who was committed to helping him “endure the suffering as lovingly as she had helped him to discover happiness,” it was this life that was his passion, and the “cruel suffering” of www.sfms.org

aging was too much for him to endure.

Márquez at no point in the novel attempts to glamorize old age or soften the harsh realities of enduring years of life; like the pains that Florentino experiences as a result of his passion for Fermina, which resemble the symptoms of cholera, so the characters in the novel endure the physical deterioration of aging, which is described early in the novel as an inescapable, fatal disease with its own set of symptoms: With no scientific basis except his own experience, Dr. Juvenal Urbino knew that most fatal diseases had their own specific odor, but that none was as specific as old age. He detected it in the cadavers slit open from head to toe on the dissecting table, he even recognized it in patients who hid their age with the greatest success, he smelled it in the perspiration on his own clothing and in the unguarded breathing of his sleeping wife. (40)

The novel also suggests, however, that aging does not move in a purely linear fashion, that we are, in a sense, reborn as we enter into old age. Although Dr. Juvenal Urbino, respected physician, husband, and citizen, does all he can to resist the end of life, he finds himself returning to “the childhood his children had taken away from him,” and it is his wife, Fermina, who bathes, dresses, and cares for him. (31) In the last years of his life, the doctor that has taken care of his family and community for so many years must allow others to attend to his basic needs.

While the introductory portion of the novel provides us with a very literal and physical sense of what it is to age, of what it is to return to a youthful state by virtue of mental and physical decline, the remaining chapters of the book, moving effortlessly between past and present, communicate love’s regenerative abilities in detailing Florentino’s “eternal fidelity and everlasting love” for Fermina, even after she has rejected him at the insistence of her father and married Dr. Urbino. (50) After her husband’s death, it is Florentino’s undying love and his letters that help her “to recover her peace of mind,” and give her the courage to set out on the New Fidelity with Florentino on her first river voyage. (302) After fifty years, the couple finally consummates the love of their youth, and the novel leaves us with, not a sense of inevitable bitterness, but of hope, as the captain addresses Florentino: “And how long do you think we can keep up this … coming and going?” he asked.

Florentino Ariza had kept his answer ready for fifty-three years, seven months, and eleven days and nights.

“Forever,” he said. (348)

July/August 2008 San Francisco Medicine 31

hospital news Saint Francis

Wade Aubry, MD

I have just been introduced to a very imaginative program that will soon be launched here at Saint Francis Memorial Hospital: the Patient Navigator Outreach Program. The program is being developed with the help of South of Market Health Center, St. Anthony Foundation/Free Medical Clinic, Glide Memorial Health Services, Curry Senior Center, and the San Francis Community Clinic Consortium. Approved by the U.S. Department of Health and Human Services, the role of the navigator is to improve health care for individuals with cancer and chronic diseases, with a specific emphasis on health disparity populations.

The navigator will be located within the Saint Francis Emergency Room. Upon discharge of E.D. patients or referrals from case managers, he or she will work with these patients to arrange follow-up visits with clinicians at participating community clinics. For patients who have no “medical home” with services close to where they live, such assistance has been shown to clear many of the hurdles they face in accessing primary care medicine.

Besides identifying and coordinating a “medical home,” navigators will assist with transportation issues and with enrollment in Healthy San Francisco.

The concept of a “medical home” is being actively pursued by the American College of Physicians, among other professional societies, to improve primary care and remove barriers to efficient, quality health care at all levels. The Patient Navigator Outreach Program targets a vulnerable, underserved population in our community. Saint Francis’ Bothin Burn Center was recently chosen by Advance for Nurses magazine as the subject of the cover story “Easing the Pain at the Bothin Burn Center.” We are pleased and honored to be recognized as a leader in burn care. The credit goes to the fine physicians, nurses, and ancillary staff who have dedicated their professional lives to caring for burn survivors for these past forty-plus years. Congratulations to Bothin Burn Center Medical Director Clyde Ikeda, MD; Clinical Director Angela Gates, RN; and the entire Bothin team.

St. Luke’s

Jerome Franz, MD

Doctors’ Day was March 31, but because of the nurses’ strike we at St. Luke’s celebrated on May 8 instead, using the spacious atrium of the Monteagle Building. CPMC provided an evening cocktail reception with music by Dr. Jazz. The mood was ebullient as we waited for the deliberations of the Blue Ribbon Panel on the future of the hospital.

There were fun awards designated by hospital staff. For example, medical records cited Barbara Bishop for best handwriting and Sam Ho for signing, dating, and timing all his orders within forty-eight hours. The nurses agreed that Dan Kahler responded more promptly to calls than anyone else, Pedro Guevara was the most courteous at all times, and John Cranshaw was the easiest doctor to call in the middle of the night.

The medical staff gave a special award to Marc Snyder (drummer with Dr. Jazz) for his twenty-five-plus years of service to St. Luke’s and its underserved population. There was also an award given to Dave Atkin for his seventeen years of commitment to the community and to Operation Rainbow.

Gift certificates to the Institute for Health and Healing accompanied all the awards.

32 San Francisco Medicine July/August 2008

St. Mary’s

Richard Podolin, MD

I think few literary works are as pertinent to modern medicine as Frankenstein, by Mary Shelley. Frankenstein was not the monster of movieposter fame, but rather the natural scientist who brought life to a being constructed of cadaveric parts. Quite the opposite of a “mad scientist,” Shelley tells us of Frankenstein’s happy and fortunate childhood; his doting, intelligent parents; and his loving siblings and friends. Frankenstein’s youth in an idyllic country home in Switzerland imbued him with a deep love of the natural world, and a curiosity about its workings.

It was this passion for science that led Frankenstein to unlock the secret of life and create the monster—a monster that did not start out demonic. The monster wished to be useful and accepted, to have only the companionship it saw afforded to every other being. It was Frankenstein’s failure of empathy, and the abuse of the monster at the hands of the citizenry, that transformed the monster into a destructive power.

Frankenstein is a story about the consequences of knowledge that surpasses wisdom.

Though Frankenstein is sometimes invoked in discussions about cloning and genetic engineering, the fact is that every day, in ordinary practice, physicians encounter situations that challenge their wisdom more than their medical prowess. When do interventions, though medically indicated, fail to serve the real needs and desires of our patients? How do we steward limited medical resources to the best advantage for our patients and our communities? At St. Mary’s Medical Center, we are guided by our mission to provide compassionate, high-quality, affordable health care to our community, and to serve our sisters and brothers who are poor and disenfranchised.

www.sfms.org

hospital news UCSF

Ronald Miller, MD

An annual dramatic reading of letters between adult patients with life-threatening illnesses and teenage pen pals took place last month as part of UCSF’s Firefly Project. Begun under Art for Recovery, a program of the UCSF Helen Diller Family Comprehensive Cancer Center, the project supports correspondence between the two groups throughout the school year. Students learn what it feels like to cope with critical illness and how to ask serious questions.

Cynthia Perlis, founder and director of AFR and creator of the Firefly Project, said, “Teenagers and patients are both dealing with similar situations.

Many feel a sense of isolation and loneliness, that people don’t really understand what they are going through.”

To promote potentially life-saving early detection of skin cancer to the general community, UCSF dermatologists offered free skin cancer screenings in May on a drop-in basis at San Francisco’s Castro-Mission Health Center.

UCSF staff conducted more than 240 free screenings at the event. Timothy Berger, MD, professor of clinical dermatology at UCSF School of Medicine, said, “We really want San Franciscans to get the message that prevention and early detection can dramatically improve survival rates.”

The Cardiovascular Research Institute at UCSF celebrated fifty years of research and medical innovation in May with a groundbreaking ceremony for a new state-of-the art building scheduled for completion in 2011. It will house research labs and outpatient clinics. CVRI was one of the first scientific institutes designed to foster medical research across fields of study.

Director Shaun Coughlin, MD, PhD, said that CVRI’s scientific partnerships across disciplines have led to major advances in understanding of cardiovascular disease and medical care, aiding everyone from infants with respiratory problems to adults with thrombosis.

www.sfms.org

In Memoriam Nancy Thomson, MD

Veterans

Diana Nicoll, MD, PhD, MPA

Stephen J. Mathes, MD

The San Francisco V.A. Medical Center recently partnered with the Palo Alto V.A. Medical Center to host “Welcome Home 2008,” a unique outreach and education event for returning combat veterans who served in the Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Global War on Terror (GWOT) theaters of combat.

More than 600 veterans and their families came to Moffett Field for the daylong event, which was designed to provide information to help veterans transition back into civilian life, as well as to thank them for their military service. Veterans had the opportunity to learn about the broad range of V.A. health care services, other V.A. benefits, and available community resources.

The eighty booths were staffed by V.A. outreach staff, college admissions officers, and representatives from many other community programs and services. San Jose Mayor Chuck Reed, U.S. Representative Anna Eshoo of Palo Alto, State Senator Leland Yee of San Francisco, California National Guard Adjutant General Major William Wade, and Dr. S. Pete Worden, NASA Ames research director, participated in the opening ceremony.

The celebration included music, a barbecue lunch, and family entertainment including face painting, arts and crafts, and a disc jockey from a local radio station.

Since the war on terror began, more than 1,800 returning veterans from Iraq and Afghanistan have received care from the San Francisco V.A. Medical Center and its outpatient clinics in Eureka, Ukiah, Santa Rosa, San Bruno, and downtown San Francisco. State-of-the-art health care in a variety of areas specifically related to combat experience, including posttraumatic stress disorder, is provided. The OEF/OIF Integrated Health Care Clinic is designed to meet both the physical and psychological needs of returning veterans and colocates medical, mental health, and social work services.

Stephen J. Mathes, MD, died November 20, 2007, aged 64, after a long battle with amyotrophic lateral sclerosis, better known as Lou Gehrig’s disease. He was born in New Orleans on August 17, 1943. He attended Louisiana State University in Baton Rouge and received his medical degree from Louisiana State University School of Medicine in New Orleans. From 1970 to 1972, he served as a major in the U.S. Army Medical Corps and was assistant chief of surgery at Fort Polk Army Hospital in Louisiana, where he treated soldiers wounded in Vietnam. He then completed a residency in plastic surgery at Emory University in Atlanta. He came to San Francisco, joining the San Francisco Medical Society in 1980, and became a professor of surgery at UCSF in 1984. He was visiting professor in more than two dozen countries and lectured worldwide. More than forty-two research fellows from the United States, Asia, and Europe trained in his UCSF laboratory or in related clinical training.

Dr. Mathes made his surgical mark in developing transplant procedures using a patient’s healthy tissue to cover wounds and deformities. His first textbook, Clinical Atlas of Muscle and Musculocutaneous Flaps, was published in 1977. During his career, more than 200 of his peer-reviewed papers and book chapters were published and, in 2007, his eight-volume textbook on plastic surgery came out. He was a member of thirty-two professional societies, once chaired the Plastic Surgery Research Council, served as president of the Plastic Surgery Educational Foundation, and won numerous awards for his work. According to his friend and colleague Dr. William Hoffman, chief of plastic and reconstructive surgery at UCSF, Dr. Mathis personally treated thousands of patients, but the surgical protocol he helped develop benefited countless others. The use of muscle flaps can save patients the pain and trauma (and expense) of multiple reconstructive surgeries. Unfortunately, his illness forced his early retirement in 2006.

He is survived by his wife, Mary McGrath, MD, a UCSF plastic surgeon; his sons David Mathes of Seattle, Brian Mathes of Boston, and Edward Mathes of San Francisco; mother Norma Mathes of Cookson, Oklahoma; two brothers, Paul Mathes of New Orleans and Peter Mathes of Cookson; and two grandchildren.

July/August 2008 San Francisco Medicine 33

Northern California Physician Opportunities

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