IN MIDWINTER JULIA shuffled into my office and slowly lowered herself into the chair beside my desk. It was a cold, wet Melbourne morning and patients were starting to pile into the clinic, sheltering from the wind. The clock on the wall showed fifteen past nine and I knew I was in for a busy day.
In the waiting room people had peeled off their coats and scarves. Dripping umbrellas huddled in the corner stand. Everyone sat flipping through old magazines or chatting quietly on mobile phones. A small child at the play table was building a tower of blocks, his construction demolished every so often by an angry coughing fit.
Julia placed a paper coffee cup on my desk. She wore an orange floral shirt, crimson pants and a pink crocheted poncho: not the standard outfit for a ninety-year-old great-grandmother. I glanced up at the screen, scanning her long list of illnesses and operations. They read like a litany of woes: osteoarthritis, osteoporosis, hypertension, hypercholesterolaemia, abdominal aortic aneurysm, ischaemic heart disease, appendicectomy, hysterectomy, bunionectomy. Not bad. Then I checked her medications: Lasix, Lipitor, Norvasc, Fosamax, Aspirin, Metamucil, Ostelin, Stilnox, Zoloft. Perhaps I should think about cutting some of these back, but not this visit. There was no time. I started printing out the scripts she had probably come in for and prepared myself to guide her gently out of the room; I needed to get a move on and see the coughing child in the waiting room before he infected everyone else.
Julia reached into a string bag and pulled out an envelope, her knobbly fingers trembling as she opened it. She fumbled with a letter inside, eventually managed to pull it out and cleared her throat, demanding that I turn away from her medical record and listen. 'We are delighted to accept your application to participate in this year's Senior Olympics in the over-75s 50-metre Breaststroke,' she read. 'Please ask your doctor to fill out the attached medical documents and return to us as soon as possible.' She handed me the forms and sat waiting, hands folded in her lap.
I had to stop myself from snorting. I wondered if I should run a dementia screen, send her off for blood and urine tests, arrange a brain scan. Composing myself, I asked: 'Are you sure about this, Julia?'
'Yes, doc,' she answered confidently. 'Besides, I'm guaranteed to win the race.'
I pulled up the Mini-Mental State Exam on the screen and started interrogating her: What is the time, day, date? Where are we right now? Count backwards from 100 by sevens. To my amazement, Julia scored full marks. I picked up my stethoscope and carefully checked her blood pressure, listened to her heart for murmurs, her lungs for fluid, measured her blood sugar, made her point back and forth rapidly from the tip of her nose to my finger, asked her to walk heel-to-toe in a straight line. She passed with flying colours.
Nonetheless, I was very reluctant to sign off on her fitness to participate. Julia was ninety, after all. What if she had a heart attack or a stroke in the water? She might slip on the edge of the pool and break her hip, or suffer severe pain and muscle cramps during the race.
Still, I initialled the papers, stood up and signalled that the consultation had ended. I was running way behind schedule, so I opened the door and held my hand out, gesturing towards the waiting room. Julia hauled herself up, shoved the forms in her bag and left my office, a huge smile on her face.
'Good luck!' I said, rolling my eyes behind her back.
I AM ASHAMED to admit that on that wintry Monday morning in my office with Julia, under the pressure of the brimming waiting room, I had a relapse of a condition I call 'tunnel vision of the soul'. I started developing this affliction when I first became a medical student, many years ago. It is a crippling ailment in which you see only things that are straight in front of you. You focus on the sickness and cannot see the person. Your peripheral vision is blurred, so you don't notice your surroundings unless you deliberately turn your head to look. The onset can be insidious, the symptoms barely perceptible. It is contagious in my profession; in fact, I think it has reached epidemic proportions.
During the consultation that day with Julia my tunnel vision returned with a vengeance. I was looking at her through the narrow lens of scepticism and so-called professionalism, and I saw a fragile old woman on the verge of death. I failed to listen to what she had been trying to tell me.
Up until that morning I thought I had been cured years ago when, during my training as a hospital intern, I began to read the poetry of Dr William Carlos Williams and the short stories of Dr Anton Chekhov while on night duty. Their lens on the world coaxed me to return to writing – something I hadn't done since high school. With a trembling pen, I began to heal my own wounds and to try to make some sense of what I had experienced as a young doctor. Since then, my medicine has always fed and informed my writing, and I feel that, more importantly, writing and reading has somehow made me a better doctor, opening my eyes so that I am better able to see my patients as human beings, each one with their own unique narrative.
Jerome Groopman, a professor of medicine at Harvard Medical School and the author of How Doctors Think (Scribe, 2007), writes: 'The wise doctor probes not only the organs of his patient but also his feelings and emotions, his fears and his hopes, his regrets and his goals. And to accomplish that most important task of applying wisdom, the physician also needs to take his own emotional temperature, to realise how his own beliefs and biases may be brought to bear in his efforts to secure a better future for his patient.'
Writing can be a means of distilling the experience of being a doctor.
Abraham Verghese, a professor of medicine at Stanford University and an alumnus of the fabled Iowa Writers' Workshop, believes that although the humanities and medicine may seem disparate worlds, for him they are one. 'Doctors and writers are both collectors of stories,' he says. Both careers have 'the same joy and the same prerequisite: "infinite curiosity about other people".'
There is a long tradition of physician-writers. Apollo managed to combine a dual career as the Greek god of both poetry and medicine. Copernicus, Maimonides, Bulgakov and Chekhov were all physicians who purloined their patients' narratives. Many contemporary doctor-writers, such as Oliver Sacks, Norman Doidge and the Australians Peter Goldsworthy, Nick Earls, Karen Hitchcock and Jacinta Halloran afford us a glimpse of the world through the eyes of a person who deals daily with existential matters and traumatic situations.
UNTIL RECENTLY, THE physician was embedded in the patient's narrative. The ultimate role of the village doctor, present at every rite of passage in a person's life, would be to sit vigil at their deathbed, often simply holding a hand as a way of saying I am here – I will stay with you till the end. Nowadays, with all the bells and whistles of medical technology, the last thing many patients hear before they die is the muffled farewell beep of the ECG monitor in the intensive care unit. 'As for last words, they hardly seem to exist anymore,' Atul Gawande wrote recently in his New Yorker article on palliative care, 'Letting Go'.
To combat this dehumanisation of medicine, many medical schools have introduced courses in Narrative Medicine and Medical Humanities. Dr Felice Aull, editor of the Literature, Arts, and Medicine database at New York University School of Medicine, observes in the mission statement of the NYU Medical Humanities website: 'The humanities and arts provide insight into the human condition, suffering, personhood, our responsibility to each other, and offer a historical perspective on
medical practice. Attention to literature and the arts helps to develop and nurture skills of observation, analysis, empathy, and self-reflection – skills that are essential for humane medical care. The social sciences help us to understand how bioscience and medicine take place within cultural and social contexts and how culture interacts with the individual experience of illness and the way medicine is practiced.'
In this vein, Danielle Ofri, an associate professor at New York University School of Medicine and editor-in-chief of the Bellevue Literary Review, says: 'On rounds each day, I always carry ten copies of a poem or essay to distribute to the team. But when the moment comes – as we are finishing the case presentation – I'm always overcome with hesitation. It feels supremely awkward...I'll read the poem aloud. My fantasy is that [the students] will jump for joy at the end, bursting with insight and inspiration. Most often, however, there is just silence; awkward, painful silence. I'll never really know, but I'll just have to hope that it plants some seed or thought in a few of them.'
I wish I'd had a consultant like Professor Ofri when I was a medical student.
Every patient has a story to tell. It's just that as a doctor you need to look beyond the massive MRI and CT scanners to see that.
SEVERAL WEEKS AFTER our fraught consultation about her swimming race, Julia returned to see me. The apple tree outside the window was in full blossom and the sun shone into the room.
'How did it go?' I asked her, wondering if she'd even made it into the pool.
Julia fumbled in her pocket, then pulled out a gold medal and placed it between us on the desk. She beamed. 'I won!'
I sat there in disbelief.
She placed her hand on mine, as if to reassure me. 'I never had any doubt I would come first, my dearest,' she said. 'The way I see it, I had it in the bag before I even started. All I needed to do was simply finish the race.'
'How's that?' I asked, puzzled, preparing to repeat the dementia test.
'Well, doc,' she answered with a little shrug, 'I was the only entrant.'