Writer, M.D.

by Leah Kaminsky

  This, I suspect, is the reason for the physician’s dodge: the “I just assist” rap; the “We have a new procedure for this that you are perfect for” speech; the “You need a central line” without the “I am still learning how to do this.” Sometimes we do feel obliged to admit when we’re doing something for the first time, but even then we tend to quote the published complication rates of experienced surgeons. Do we ever tell patients that, because we are still new at something, their risks will inevitably be higher, and that they’d likely do better with doctors who are more experienced? Do we ever say that we need them to agree to it anyway? I’ve never seen it. Given the stakes, who in his right mind would agree to be practiced upon?

  Many dispute this presumption. “Look, most people understand what it is to be a doctor,” a health policy expert insisted, when I visited him in his office not long ago. “We have to stop lying to our patients. Can people take on choices for societal benefit?” He paused and then answered his question. “Yes,” he said firmly.

  It would certainly be a graceful and happy solution. We’d ask patients—honestly, openly—and they’d say yes. Hard to imagine, though. I noticed on the expert’s desk a picture of his child, born just a few months before, and a completely unfair question popped into my mind. “So did you let the resident deliver?” I asked.

  There was silence for a moment. “No,” he admitted. “We didn’t even allow residents in the room.”

  One reason I doubt whether we could sustain a system of medical training that depended on people saying “Yes, you can practice on me” is that I myself have said no. When my eldest child, Walker, was eleven days old, he suddenly went into congestive heart failure from what proved to be a severe cardiac defect. His aorta was not transposed, but a long segment of it had failed to grow at all. My wife and I were beside ourselves with fear—his kidneys and liver began failing, too—but he made it to surgery, the repair was a success, and although his recovery was erratic, after two and a half weeks he was ready to come home.

  We were by no means in the clear, however. He was born a healthy six pounds plus but now, a month old, he weighed only five, and would need strict monitoring to ensure that he gained weight. He was on two cardiac medications from which he would have to be weaned. And in the longer term, the doctors warned us, his repair would prove inadequate. As Walker grew, his aorta would require either dilation with a balloon or replacement by surgery. They could not say precisely when and how many such procedures would be necessary over the years. A pediatric cardiologist would have to follow him closely and decide.

  Walker was about to be discharged, and we had not indicated who that cardiologist would be. In the hospital, he had been cared for by a full team of cardiologists, ranging from fellows in specialty training to attendings who had practiced for decades. The day before we took Walker home, one of the young fellows approached me, offering his card and suggesting a time to bring Walker to see him. Of those on the team, he had put in the most time caring for Walker. He saw Walker when we brought him in inexplicably short of breath, made the diagnosis, got Walker the drugs that stabilized him, coordinated with the surgeons, and came to see us twice a day to answer our questions. Moreover, I knew, this was how fellows always got their patients. Most families don’t know the subtle gradations among players, and after a team has saved their child’s life they take whatever appointment they’re handed.

  But I knew the differences. “I’m afraid we’re thinking of seeing Dr. Newburger,” I said. She was the hospital’s associate cardiologist-in-chief, and a published expert on conditions like Walker’s. The young physician looked crestfallen. It was nothing against him, I said. She just had more experience, that was all.

  “You know, there is always an attending backing me up,” he said. I shook my head.

  I know this was not fair. My son had an unusual problem. The fellow needed the experience. As a resident, I of all people should have understood this. But I was not torn about the decision. This was my child. Given a choice, I will always choose the best care I can for him. How can anybody be expected to do otherwise? Certainly, the future of medicine should not rely on it.

  In a sense, then, the physician’s dodge is inevitable. Learning must be stolen, taken as a kind of bodily eminent domain. And it was, during Walker’s stay—on many occasions, now that I think back on it. A resident intubated him. A surgical trainee scrubbed in for his operation. The cardiology fellow put in one of his central lines. If I had the option to have someone more experienced, I would have taken it. But this was simply how the system worked—no such choices were offered—and so I went along.

  The advantage of this coldhearted machinery is not merely that it gets the learning done. If learning is necessary but causes harm, then above all it ought to apply to everyone alike. Given a choice, people wriggle out, and such choices are not offered equally. They belong to the connected and the knowledgeable, to insiders over outsiders, to the doctor’s child but not the truck driver’s. If everyone cannot have a choice, maybe it is better if no one can.

  It is 2:00 p.m. I am in the intensive-care unit. A nurse tells me Mr. G.’s central line has clotted off. Mr. G. has been in the hospital for more than a month now. He is in his late sixties, from South Boston, emaciated, exhausted, holding on by a thread—or a line, to be precise. He has several holes in his small bowel, and the bilious contents leak out onto his skin through two small reddened openings in the concavity of his abdomen. His only chance is to be fed by vein and wait for these fistulae to heal. He needs a new central line.

  I could do it, I suppose. I am the experienced one now. But experience brings a new role: I am expected to teach the procedure instead. “See one, do one, teach one,” the saying goes, and it is only half in jest.

  There is a junior resident on the service. She has done only one or two lines before. I tell her about Mr. G. I ask her if she is free to do a new line. She misinterprets this as a question. She says she still has patients to see and a case coming up later. Could I do the line? I tell her no. She is unable to hide a grimace. She is burdened, as I was burdened, and perhaps frightened, as I was frightened.

  She begins to focus when I make her talk through the steps—a kind of dry run, I figure. She hits nearly all the steps, but forgets about checking the labs and about Mr. G.’s nasty allergy to heparin, which is in the flush for the line. I make sure she registers this, then tell her to get set up and page me.

  I am still adjusting to this role. It is painful enough taking responsibility for one’s own failures. Being handmaiden to another’s is something else entirely. It occurs to me that I could have broken open a kit and had her do an actual dry run. Then again maybe I can’t. The kits must cost a couple of hundred dollars each. I’ll have to find out for next time.

  Half an hour later, I get the page. The patient is draped. The resident is in her gown and gloves. She tells me that she has saline to flush the line with and that his labs are fine.

  “Have you got the towel roll?” I ask.

  She forgot the towel roll. I roll up a towel and slip it beneath Mr. G.’s back. I ask him if he’s all right. He nods. After all he’s been through, there is only resignation in his eyes.

  The junior resident picks out a spot for the stick. The patient is hauntingly thin. I see every rib and fear that the resident will puncture his lung. She injects the numbing medication. Then she puts the big needle in, and the angle looks all wrong. I motion for her to reposition. This only makes her more uncertain. She pushes in deeper and I know she does not have it. She draws back on the syringe: no blood. She takes out the needle and tries again. And again the angle looks wrong. This time, Mr. G. feels the jab and jerks up in pain. I hold his arm. She gives him more numbing medication. It is all I can do not to take over. But she cannot learn without doing, I tell myself. I decide to let her have one more try.

  The Infernal Chorus

  ROBERT JAY LIFTON

  On March 30, 1979, after having lived in Muni
ch for almost seven months, I hosted a small party to say goodbye to a few of my friends. At the gathering I told one of them that I was “tired of interviewing Nazis,” and that I was not surprised but nonetheless troubled that not one of them had made a genuine moral confrontation of past behavior.

  That night I had a dream in which I was part of a male singing group, a version of a barbershop quartet, and we were about to sing something. But I knew that it was no ordinary group, that it was an “infernal chorus,” and was vaguely aware, even in the dream, that infernal meant the underworld, hell, death. I woke up with the phrase “infernal chorus” reverberating in my head, and quickly associated it with the voices of Nazi doctors. My interviews with them had made me part of the chorus, and I was expressing my discomfort at “singing” with such a group. I was feeling a strong need to sing my own song, detach myself from the infernal chorus, and have my say about it.

  In one sense I was simply following my general pattern of returning from work in the field to the solitude of my American study to give structure and meaning to that work. What was different this time was my convoluted relationship with the country from which I was returning. I never forgot that, during their twelve-year Nazi binge, German leaders and large numbers of German people wanted to murder me along with all other Jews. At the same time I was aware of how much I valued the bonds I formed with individual Germans, many of whom were remarkable in their intelligence, sensibility, and dedication. Our shared confrontation of grotesque historical details infused our colleagueship with special intensity and our friendships with special affection.

  I think of many warm dinners with Iring and Elisabeth Fetscher in Frankfurt. Iring, a political philosopher and leading German intellectual voice, contributed to my work at every level. He even appeared on a panel with me on Nazi doctors and, himself an authority on Marxism, defended my research against a Marxist critic who faulted me for a psychological rather than an economic emphasis. Elisabeth took loving care of me when I developed a gastrointestinal condition while staying at their home. Their son Sebastian, a physician who spent time in America, visited us at Wellfleet and became one of the German translators of my book. And their other son Justus, a literary scholar, hosted us in Berlin and taught me much about German generational struggles in connection with the Nazi era. My wife, BJ, and I had a memorable experience with the Fetschers as a family (two of their three adult children were present) in viewing together in early 1979 an episode of the German version of the American television series Holocaust. The original film was in many ways flawed, and had a mixed reception in the United States, but for many Germans it was an important historical event, evoking in a number of viewers confessional memories and expressions of guilt in connection with behavior at the time. The Fetschers had insisted that we rush through dinner to be able to see the film. We all watched it in silence, though Elisabeth sobbed during a portion depicting the killing of Jews, and no one had much to say afterward. But we knew we had experienced a moment of communion in confronting together what Germans had done to Jews.

  Nazi Doctors on My Desk

  Yet even when leaving Nazi doctors behind in Germany, I was far from rid of them. Facing my records of them, my thousands of pages of interviews and notes, was just as difficult as talking to them. I remember a revealing moment soon after my return when I walked into my Wellfleet study, perhaps my favorite room in the world, to find myself completely devoid of the pleasure I usually experienced when entering it. Great piles of folders on my large desk made me feel completely alone with Nazi doctors. Until then I had been somewhat protected from taking in fully what they had been part of and what they had done by the very activity required for arranging and carrying out the interviews. Now I had no such protection, and knew that I had no choice but to permit Nazi doctors to dominate my imagination so that I could interpret their behavior and compose what I had to say about them. Only by writing that book could I get them out of my study.

  At the same time I was struggling psychologically with my whole German experience. As I wrote to Iring Fetscher, “BJ and I are still very much in transition spiritually.… I find that all kinds of things are working on me internally.” Some of what was working on me came out in two kinds of dreams I was then having. One category was that of transition dreams involving European locales and activities as well as amorphous journeys. In one such dream I was in London uneasily seeking out two destinations: an open-air sports facility that somehow resembled a Nazi camp, and an obscure “massage parlor.” I noted the next day the dream’s unpleasant juxtaposition of “athletics, sex, and the Nazi death camps.” In these transition dreams I could not seem to settle into, or even locate, a destination. I felt well described by A. R. Ammons in his poem “Return,” where he speaks of coming “a long way/without arriving” and of climbing a peak but finding “no foothold/higher than the ground.”

  The second category I called death dreams, and they were more eerie and disturbing. They involved people who had died but appeared as sometimes vigorous phantoms: my father, my mother, Robert Vas, Les Farber. Those dreams reminded me in turn of two earlier dreams: In one of them a friend notified me that my obituary had appeared in The New York Times and I checked and found it to be there. And in another dream, I observed someone spreading ashes, only to realize that the ashes being spread were my own. My psyche had long been accumulating macabre death imagery, and that process was greatly intensified by my exposure to Nazi doctors. I was surviving my travels among the dead, but not easily. Heinrich Böll’s observation that “the artist carries his death within him like a good priest his breviary” extends, I believe, to the psychological witness of mass killing and dying.

  I also seemed to require life-giving antidotes, some of which were expressed in other dreams I had that I related to healing. At about that time I had an additional dream that I still remember with some pleasure. It consisted solely of two neatly printed words, “Vatican grapes,” surrounded by a vine of actual purple grapes to form an attractive tableau. It was clear to me even during the dream that the grapes were (as I wrote the next day) “associated with healing.” While I have never been a particular fan of the Vatican, I thought of Pope John XXIII, the appealing ecumenical figure who, from 1958 to 1963, sought to heal the Catholic Church in its relationship to the world. I thought also of the healing encounters I had personally experienced with such Catholic figures as the Berrigans, Joe O’Rourke, and Bishop Barker. But the dream also seemed humorous, and when I told BJ about it we bantered about producing a healing elixir called “Vatican Grapes” that would make us rich, speculating on whether we would need permission from the pope for a patent, and on considering a brand of “Jewish Grapes” as well. And in my note I had a little fun with associations to “grapes”—“sour grapes, Grapes of Wrath, food, wine, Dionysus, orgies, languid sexual feeling.” Maybe I was desperate for antidotes.

  In working on the book and on articles and talks along the way, I was concerned—and not without cause, as it turned out—about how such emotionally freighted material would be received. When I spoke at medical schools and hospitals, physicians mostly raised thoughtful questions about potential American transgressions, such as giving lethal injections in carrying out executions, involvement in military violence as in Vietnam, or being socialized by their medical institutions to various forms of callous behavior. Psychiatrists and psychoanalysts tended to be fascinated by the psychological motivations of Nazi doctors and interested in my personal struggles over the course of the work. But there were notable exceptions, for instance doctors who were angered by suggestions of parallels of any kind with what American doctors did, insisting that Nazi behavior be seen as unique and unrelated to that of anyone else.

  There were also more extreme reactions. I still have an image in my mind of the prominent psychoanalyst who stormed up to the podium after my presentation and screamed into the microphone: “I don’t give a damn about what’s in the mind of a Nazi doctor! I don’t want to know what he�
�s thinking or feeling!”—with a vehemence that temporarily disrupted the professional meeting. I responded by insisting on the importance of grasping motivations of Nazi doctors in order to combat the kind of behavior they represented and the kind of system they were part of. I was troubled by the incident because it threatened the rationale of my entire study. Together with a supportive colleague, I wrote a letter to the sponsoring psychoanalytic group, insisting on our profession’s obligation to probe the most disturbing questions, in accordance with the Enlightenment principle “Dare to know!” I still believe strongly in that principle, but must confess a certain retrospective sympathy for the protesting psychoanalyst’s simple outrage. I have frequently felt the same way myself.

  My struggles in writing the book had to do not only with the extremity of the subject matter, but as always with structure, in this case with the kind of structure that could best encompass the full dimensions of what I had observed. Now the mosaic had to include the broad Nazi biomedical vision, leading from sterilization to “euthanasia” to the death camps, as well as detailed exploration of the psychology of Auschwitz as an institution and of individual Nazi doctors who served it. In the last section of the volume, I extended the mosaic to include a systematic grid of what I took to be the overall psychological steps of any genocide. I found getting this book written especially demanding, and the help of an astute editor crucial. The editor, to my good fortune, was my friend Jane Isay, who had edited several of my earlier books, had an unusual grasp of my work in general, and offered her counsel during trips to Wellfleet as well as in New York City. Were it not for her, those Nazi doctors might still be sitting on my desk.