A Life in Medicine

by Robert Coles

  “But you were always a good man of business, Jacob [Marley],” faltered Scrooge, who now began to apply this to himself.

  “Business!” cried the ghost, wringing its hands again. “Mankind was my business. The common welfare was my business; charity, mercy, forbearance, and benevolence were, all, my business. The dealings of my trade were but a drop of water in the comprehensive ocean of my business!”3

  I reaffirm that relationships are the bedrock of medical practice. We are not risk managers or information brokers, entrepreneurs or bureaucrats. We are nobody’s agent except the sickly who entrust us with their care. Our actions are not unerring, never easy. Thus the well-intentioned physician needs a moral compass, a sense of solid footing, and the stamina to carry on. These are the fruits of living in community.

  A decade ago, Pellegrino challenged the New York Medical Society with his vision of medicine as a moral community.4 Sadly, who can agree? No centripetal force draws us together as one body. Real communities are centered on service to others, not pecuniary zeal. They do not fence their membership or boundaries but promote a sense of common cause. Time is needed, unbillable time, time enough for conversation or coming to an understanding. More time than is required for a procedure and its recovery, a clinical clerkship, or a granting cycle. What endures is loyalty and trust, such as you find in lasting friendships.

  The purpose of community (because, in an affluent age, we no longer need it for physical survival) is to remind us who we are. This message is refreshed every Saturday morning at public market, along the Fourth of July parade route, at yard sales, benefit suppers, community plays, and YMCA runs. Today’s archenemy is tomorrow’s teammate, our auto mechanic, my daughter’s dentist, or the crucial vote in an upcoming election. However difficult it might be to shed the role of “doctor” when I leave the office, my work is blessed by the roles I bring back: husband, father, runner, gardener, singer, churchgoer. They nourish and enlarge me: they ensure access to honest advice, gentle reproves, words that can mend and mold me.

  It is a shame, really, that doctors spend so little time in the communities where they practice. If we did, we might come to see our patients from a different angle, as real people on equal terms, capable of returning more than they receive. With greater depth of field, we might more easily grasp their worries and woes, and recognize our failure to help them. We might be fed by their gratitude, motivated by friendship instead of their demands or our sense of sacred duty or the lure of the almighty dollar. Perhaps our panel of patients, and those who assist us in their care, are the communities we seek.

  Fourteen years have passed. I cope more easily now with the small but niggling regrets of the daily grind, surrendering these and their moral burden to my Thursday morning meeting of partners. Here, for an hour each week, we air our dirty laundry, search our foibles, sift through soured interactions and missed opportunities that would otherwise fall through the cracks. Following Dr. Williams’s suggestion, we exchange “heart-to-heart stories,” knowing that “the more open we are about what gets our moods going and how those moods affect our work, the more likely we are to catch hold of ourselves—in the nick of time.”5

  Within a few short years, I have learned to walk on two empiric legs. First is the knowledge that doctors rise to their best by serving the least of their patients—the least insured, the least curable, the least attractive, responsible, or grateful. The least like us. Second is my belief that personal and clinical contributions to the patient’s well-being are an indivisible act—fused in their timing, their import, and the totality of patients’ expectations.

  Virtue is about the everyday responsibility of living in community. It is not the province of heroes and saints, whom we idolize and elevate and leave holding the bag. We must overcome fear and false modesty in order to reclaim virtue and in the process a fuller sense of ourselves.

  If there are any heroes or saints left in the world, they are each of us at our best, responding to the worst that the world imposes. Like a photo mosaic, our lives create the ethereal outline of virtue. But it is in the individual faces, or parts thereof, that virtue becomes most worthy of emulation.

  Mr. M. and I did not undo the past. We stumble forward as best we can, two lives mingled by fate and pulled on providential leash. Happily, I didn’t botch my second chance. I realize now that its very possibility depended on living in a community where the doctor’s fallibility and faithfulness are a matter of record. Yes, occasionally I’m a hero in the small town. But more importantly, I am moored to my patients’ predicament, their fleshed-in lives, and the unflinching fact that we are interchangeable. Commoners all. Located by the real things we live by.

  NOTES

  1 Smith H., Churchill L. Professional Ethics and Primary Care Medicine. Durham, NC: Duke University Press; 1986: 50.

  2 Berger J., Mohr J. A Fortunate Man. New York, NY: Vintage International Edition; 1997: 105–106.

  3 Dickens C. A Christmas Carol. Boston, Mass: Atlantic Monthly Press.

  4 Pellegrino, ed. The medical profession as a moral community. Bull NY Ac Med. 1990; 66: 221–232.

  5 Coles R. The Call of Stories. Boston, Mass: Houghton Mifflin; 1989: 117–118.

  PERMISSIONS

  We are grateful for permission to reproduce copyrighted material:

  “Outpatient” by Rosalind Warren, from Vital Lines, edited by Jon Mukand. © 1990. Used by permission of St. Martin’s Press.

  Excerpt from “First Sermon on Reverence for Life,” from A Place for Revelation, by Albert Schweitzer, translated by David Larrimore Holland. Copyright © 1989 by Macmillan Publishing Company. Used by permission of Simon & Schuster, Inc.

  “Like a Prayer,” from The Poetry of Healing: A Doctor’s Education in Empathy, Identity, and Desire, by Raphael Campo. Copyright © 1997 by Raphael Campo. Used by permission of W. W. Norton & Company, Inc., and Georges Borchardt, Inc., for the author.

  “The Body Flute,” by Cortney Davis, from Between the Heartbeats: Poetry and Prose by Nurses, edited by Cortney Davis and Judy Schaefer. Copyright © 1995. Used by permission of the University of Iowa Press.

  Excerpt from “Can You Teach Compassion?” from The Midnight Meal and Other Essays about Doctors, Patients, and Medicine, by Jerome Lowenstein, M.D. Copyright © 1997. Used by permission of Yale University Press.

  “1852: J. Marion Simms Perfects a Repair for Vesicovaginal Fistula,” from How Do You Feel? By Kirsten Emmott (Victoria BC: Sono Nis Press). © 1992. Used by permission of Kirsten Emmott.

  Excerpt from The Nazi Doctors, by Robert Jay Lifton. Copyright © 1986 by Robert Jay Lifton. Reprinted by permission of Basic Books, a member of Perseus Books, L.L.C.

  “The Lie,” by Lawrence D. Grouse, M.D., from A Piece of My Mind: A Collection of Essays from the Journal of the American Medical Association, edited by Bruce B. Dan. Copyright © 1988 by the American Medical Association. Used by permission of Alfred A. Knopf, a division of Random House, Inc.

  “The Wound Dresser,” from Leaves of Grass, by Walt Whitman.

  “The Good Doctor” by Susan Onthank Mates. Copyright © 1994 by Susan Onthank Mates. Used by permission of the University of Iowa Press.

  “Episode of Hands,” from Complete Poems of Hart Crane, edited by Marc Simon. Copyright © 1933, 1958, 1966, by Liveright Publishing Corporation. Copyright © 1986 by Marc Simon. Used by permission of Liveright Publishing Corporation.

  Excerpt from Deep River, by Shusaku Endo, translated by Van C. Gessel. Copyright © 1994 by Shusaku Endo. Translation copyright © 1994 by Van C. Gessel. Used by permission of New Directions Publishing Corp. and Peter Owen Publishers.

  “The Cadaver,” from The Knot, by Alice Jones. Copyright © 1992 by Alice Jones. Used by permission of Alice James Books.

  “Anyuta,” from The Lady with the Dog and Other Stories, by Anton Chekov, translated by Constance Garnett (New York: Macmillan, 1917).

  “The Man with Stars Inside Him,” from The Knitted Glove, by Jack Coulehan, M.D. (Tro
y ME: Nightshade Press). Used by permission of Jack Coulehan.

  “From the Heart,” from My Grandfather’s Blessings, by Rachel Naomi Remen, M.D. Copyright © 2000 by Rachel Naomi Remen, M.D. Used by permission of Riverhead Books, a division of Penguin Putnam, Inc.

  “The Seductive Beauty of Physiology,” by Jeffrey R. Botkin, from The Journal of Clinical Ethics, vol. 3, no. 4 (Winter 1992), pp. 274-277.

  “People Like That Are the Only People Here,” from Birds of America by Lorrie Moore. Copyright © 1998 by Lorrie Moore. Used by permission of Alfred A. Knopf, a division of Random House, Inc. and Faber Ltd.

  “Admission, Children’s Unit,” by Theodore Deppe, from The Wanderer King (Farmington ME: Alice James Books). © Theodore Deppe. Used by his permission.

  “The Village Watchman,” from An Unspoken Hunger: Stories from the Field, by Terry Tempest Williams. Originally appeared in The Past of Friends, Houghton Mifflin, 1994. Copyright © 1994 by Terry Tempest Williams. Used by the permission of Pantheon Books, a division of Random House, Inc., and Brandt & Hochman Literary Agents, Inc.

  “Antistrophes” and “Tenth Elegy,” from The Selected Poetry of Ranier Maria Rilke, translated by Stephen Mitchell. Copyright © 1982 by Stephen Mitchell. Used by permission of Random House, Inc.

  Scene III from The Elephant Man by Bernard Pomerance. Copyright © 1979 by Bernard Pomerance. Used by permission of Grove/Atlantic, Inc. and Faber and Faber Ltd.

  “Leech, Leech, Et Cetera,” from The Youngest Science: Notes of a Medicine Watcher, by Lewis Thomas. Copyright © 1983 by Lewis Thomas. Used by permission of Viking Penguin, a division of Penguin Putnam, Inc.

  “Baptism by Rotation,” from A Country Doctor’s Notebook, by Mikhail Bulgakov, published by the Harvill Press. English translation © Michael Glenny, 1975. Used by permission of the Harvill Press.

  “Who Owns the Libretto?” by Judy Schaefer, from Between the Heartbeats: Poetry and Prose by Nurses, edited by Cortney Davis and Judy Schaefer. Copyright © 1995. Used by permission of the University of Iowa Press.

  “The Tallis Case,” by David T. Nash, M.D., from Journal of the American Medical Association, vol. 249, no. 7 (2/18/83), p. 879f. © 1983. Used by permission of the American Medical Association.

  Excerpt from My Own Country, by Abraham Verghese. Copyright © 1994 by Abraham Verghese. Used by permission of Simon & Schuster and The Orion Publishing Group.

  “What the Doctor Said,” from A New Path to the Waterfall, by Raymond Carver. Copyright © 1989 by the Estate of Raymond Carver. Used by permission of Grove/ Atlantic, Inc.

  “This Red Oozing,” from Breathless, by Jeanne Bryner, RN, GA, CEN (Kent State University Press). Used by permission of Jeanne Bryner.

  Excerpt from In the Country of Hearts: Journeys in the Art of Medicine (Delacorte), by John Stone. Copyright © 1990 by John Stone. Used by his permission.

  “Large Woman, Half,” by Alyson Porter, from Journal of the American Medical Association, vol. 262, no. 9 (9/1/99), p. 823. © Alyson Porter. Used by her permission.

  “The Knee,” by Constance J. Meyd, from A Piece of My Mind: A Collection of Essays from the Journal of the American Medical Association, edited by Bruce B. Dan. Copyright © 1988 by the American Medical Association. Used by permission of Alfred A. Knopf, a division of Random House, Inc.

  “Voice Offstage,” from The Diving Bell and the Butterfly, by Jean-Dominique Bauby, translated by Jeremy Leggat. Copyright © 1997 by Alfred A. Knopf, a division of Random House, Inc. Used by permission of Alfred A. Knopf, a division of Random House, Inc., and Fourth Estate, a division of HarperCollins Publishers (UK).

  “Letter from the Rehabilitation Institute,” from Intensive Care, by Lucia Cordell Getsi. Copyright © 1992. Used by permission of New Rivers Press.

  “Breast Cancer: Power vs. Prosthesis,” from The Cancer Journals, by Audre Lorde (San Francisco: Aunt Lute Books). Copyright © 1980 by Audre Lorde. Used by permission of The Charlotte Sheedy Literary Agency.

  “A Small Good Thing,” from Cathedral, by Raymond Carver. Copyright © 1983 by Raymond Carver. Used by permission of Alfred A. Knopf, a division of Random House, Inc., and International Creative Management, Inc.

  “Pies,” by Timothy J. Fisher, M.D. © Timothy J. Fisher. Used by his permission.

  “Communion,” by Sarah Lentz, from Academic Medicine, vol. 73, no. 2. © Sarah Lentz. Used by her permission.

  “The Nature of Suffering and the Goals of Medicine,” by Eric J. Cassell, M.D., from The New England Journal of Medicine, vol. 306, no. 11. Copyright © 1982 Massachusetts Medical Society. All rights reserved.

  “Repose,” by Matt Dugan. © Matt Dugan. Used by his permission.

  “The Girl with the Pimply Face,” from The Collected Stories of William Carlos Williams. Copyright © 1938 by William Carlos Williams. Used by permission of New Directions Publishing Corp. and Carcanet Press Limited.

  “Healers: The Physician and the Mori,” by Michael Weingarten, from Patients and Doctors, edited by Jeffrey M. Borkan. © 1999. Used by permission of The University of Wisconsin Press.

  “Poverty Medicine,” from Not All of Us Are Saints, by David Hilfiker. Copyright © 1994 by David Hilfiker. Used by permission of Hill and Wang, a division of Farrar, Staus and Giroux, LLC.

  “In Terror of Hospital Bills,” from Shall We Gather at the River, by James Wright. Copyright © 1968 by James Wright. Used by permission of Wesleyan University Press.

  “Another Case of Chronic Pelvic Pain,” from Rehab at the Florida Avenue Grill, by Veneta Masson. Copyright © 1999 by Veneta Masson. Used by permission of Sage Femme Press, Washington DC.

  “Rez Dogs and Crow Dreams,” from The Scalpel and the Silver Bear, by Lori Arviso Alvord M.D., and Elizabeth Cohen Van Pelt. Copyright © 1999 by Lori Arviso Alvord and Elizabeth Cohen Van Pelt. Used by permission of Bantam Books, a division of Random House, Inc.

  “Unwed,” from How Do You Feel? By Kirsten Emmott (Victoria BC: Sono Nis Press, 1992). Used by permission of Kirsten Emmott.

  Excerpts from A Wise Birth, by Penny Armstrong and Sheryl Feldman. © 1990 by Penny Armstrong and Sheryl Feldman. Used by permission of HarperCollins Publishers, Inc., and The Martell Agency.

  “The Eight Questions,” from The Spirit Catches You and You Fall Down, by Anne Fadiman. Copyright © 1997 by Anne Fadiman. Reprinted by permission of Farrar, Straus and Giroux, LLC.

  Excerpt from Another Turn of the Crank, by Wendell Berry. Copyright © 1995 by Wendell Berry. Used by Permission of Counterpoint Press, a member of Perseus Books, L.L.C.

  Excerpt from An Unquiet Mind, by Kay Redfield Jamison. Copyright © 1995 by Kay Redfield Jamison. Used by permission of Alfred A. Knopf, a division of Random House, Inc.

  “A Young Psychiatrist Looks at His Profession,” from The Mind’s Fate: Ways of Seeing Psychiatry and Psychoanalysis, by Robert Coles. Copyright © 1975, 1995 by Robert Coles. Used by permission of Little, Brown and Company, Inc.

  Excerpt from The Tennis Partner, by Abraham Verghese. Copyright © 1998 by Abraham Verghese. Used by permission of HarperCollins Publishers Inc. and Mary Evans Inc.

  “Facing Our Mortality: The Virtue of a Common Life,” by David Loxtercamp, M.D., from Journal of the American Medical Association, vol. 282, no. 10 (9/8/1999), p. 923f. © 1999. Used by permission of the American Medical Association.

  a “Report 1: Learning Objectives for Medicine Student Education—Guidelines for Medical Schools.” Association of American Medical Colleges: Washington, D.C., 1998.

  b Hans Hefelmann, chief of the responsible Chancellery office, remembered that the child lacked three limbs and that its grandmother made the request. Brandt made the father the petitioner.

  c Manon is the poet’s daughter.

  d Gallup Indian Medical Center.

  Compilation © 2002 by Robert Coles and Randy Testa

  Introduction © 2002 by Robert Coles

  All rights reserved.

  No part of this book may be reproduced, in any form,

  without w
ritten permission from the publisher.

  Published in the United States by The New Press, New York, 2002

  Distributed by W. W. Norton & Company, Inc., New York

  Pages 325-329 constitute an extension of this copyright page.