"Walking the Fine Line: A Medical School Memoir" was written almost 38 years ago. I intend to start publishing it on Substack in weekly installments, and add a chapter at the end, which incorporates my reflections on the past 38 years. Should there be sufficient interest, I plan to continue and hope readers will understand if I respectfully ask them to become paid subscribers to support my work. This request is made with great humility and gratitude. My weekly newsletter will remain free of charge. For those who wish to continue reading the book without becoming a paid subscriber, that is completely acceptable—just please let me know.
As I reflect on why to publish it now, perhaps it is some mixture of self-deluded self-importance but maybe some hope that I still have a story to tell. I suppose that what started out as a somewhat cathartic memoir, perhaps even a regurgitation of 4 years in an effort to reboot or at least re-digest my experiences from medical school. Of course, there are elements that are purely me, reflecting my own identity struggles at the time, and maybe even some personal trauma, as I tried to reinvent how I saw myself. There are historical artifacts of the early 1980s, a somewhat pre-“cross-cultural”, pre-AIDS, pre-gentrification, pre-9/11 era which depict social and cultural polarities that may no longer exist in the same way. However, there is a search for universal truths, and if anything, there may be more polarity today in the world at large, as well as in medicine. It’s no surprise that my own path following medical school led me to an academic career in Child and Adolescent Psychiatry at Columbia, where I directed a clinical service and taught medical students, residents, and fellows at all levels of training for the past 31 years. Listening to these students convinces me more that though much has changed in medicine, the psychological process of becoming a physician remains quite similar, and along with it the attempt to reconcile one’s experiences with one’s education and values.
Many similarities remain, which were brought to bear as I read an assigned reading for the first year medical course when I was a seminar leader, which is Francis Peabody’s 1927 paper, “The Care of the Patient”, which bemoans the trend toward the loss of humanism in medicine, which was as shockingly relevant then as it is today in 2014; Peabody notes that “young graduates have been taught a great deal about the mechanism of disease, but very little about the practice of medicine--or to put it more bluntly, they are too ‘scientific’ and do not know how to take care of patients (p. 877).”
Is it any surprise that my struggles from the early 1980s are not more anachronistic? Does this mean that medical education has continued to fail in its quest to create more empathic physicians who treat patients as people and who are oriented towards the caring side of medicine? I don’t think so, as I see differences in my world of medical education as compared with the world of the students today, where narrative texts, reflective writing exercises, and classes and readings on humanism and ethics permeate at least the first two years of the curriculum.
"Walking the Fine Line" may be somewhat of a precursor to the P&S Portfolio, a reflective, personal online document created by Columbia students to chronicle their experiences in medical school. Maybe more accurately, the field of Narrative Medicine, developed by Dr. Rita Charon, embodies what I was trying to do before I understood it. Her intuition, creativity and narrative focus filled the gap in education that I unfortunately could not benefit from at the time. Hopefully, endeavors like this translate into more humanistic physicians, particularly after the students leave the safe confines of the classroom and enter the MCY, or major clinical year; there, they are exposed to the sobering experiences of death, suffering, and humble helplessness which characterizes even the most well-informed and best-intentioned medical efforts—that is really the question.
At a very basic level, being a doctor is about responding to and easing the suffering of others, perhaps a Beatlesque version of “take a sad song and make it better.” To do this, one must first learn to listen, and that in order to “heal the other, one has to empty oneself of thought, distraction, and goals” and establish the “empty cup of attention” noted by Henry James and written about by Dr. Charon, ready to be filled with the patient’s story.
How much of my own struggles were personal, reflective of any young, somewhat “privileged” man growing up in the northeast in the 1980s, and how much reflects generalities of medical education either specific to that time or generalizable to now—I’ll leave that up to the reader, which hopefully will include medical students. Suffice it to say, the quests for self-definition, loss of the idealism of youth as it is tempered with the realities of life, are not specific to medicine, nor perhaps is the struggle to maintain one’s humanity in the process. Medicine does, however, provide a unique window into this battle, one in which the casualties are those we care for, in addition to ourselves. My words reflect the evolution of the young physician from student to doctor in ways that I believe remain the same, such as the diametric of “inside vs. outside” so eloquently portrayed by Abraham Verghese. His writing is assigned as reading to the first-year Columbia students as part of the Foundations of Clinical Medicine Class that I was so fortunate to lead as part of a small seminar group of 13 students.
We travel this road together, all students of this trip that always finds curiosities along the way as we reflect on our journey and ourselves. The world then—and now—remains one of contrasts, with lines perhaps even more distinctly drawn, between those who have and those who do not. Aspects of the memoir are certainly anachronistic. There have been some very positive specific changes in medical school curriculum, particularly in the Foundations of Clinical Medicine Course, which provides seminars of small groups of students and a forum to read, write, and reflect, both in a group, privately, and with a faculty member, about the process of becoming a doctor.
My own experiences depict the somewhat classic struggle of how to hold onto one’s humanity when the forces at large seem hell-bent on ripping it away the way a linebacker tries to violently wrest the ball from the running back’s desperate grip. Medicine has certainly changed substantially in all these years, but if anything, with the pressure of productivity, electronic documentation, new regulations governing the delivery of care, and explosion of technology that must be learned and incorporated into practice, it is even easier for the patient to be lost, as he seems to be growing smaller and smaller. At the end of my own education, I clearly wondered what the hell had happened to me. So many years later, I have more of an idea. So, for now, let’s rewind to 1981.
*"Am I someone or anyone?
Am I a robot or a human?
Am I dead or alive?
What am I doing here?"
*Words of a schizophrenic patient
Preface
My belief is that the purpose of any piece of writing is to, at the very least, inform the reader, ideally provoke thought, and, in the best case, contribute to a change in behavior. Influential figures like Dr. Robert Coles have impacted me in this way. I hoped that by exploring the changes I experienced during my medical education, I could better understand the evolving doctor-patient relationship in our society. My reactions to the forces encountered during my education may not mirror those of my colleagues, but the underlying elements of change are similar. Understanding these elements may help in deciphering the broad spectrum of physicians' approaches to patient care. For those who have completed their education, it might enable a revisiting of the core conflicts and emotions that have been layered over time, like rings on a tree. For students, I hope to contribute to the growing forces in our society that aim to alter medical education to emphasize more humanistic aspects of becoming and being a physician.
I have attempted to present a view of medicine that focuses more on feelings—on both sides of the examining table—since there is an overrepresentation of technology and textbook learning in medical education today. I firmly believe that for a physician, maintaining a strong connection with the patient's perspective is not only the most respectable but also the most beneficial approach to a patient's health and comfort, both emotionally and physically. As physician and author Robin Cook, the commencement speaker at my medical school graduation, pointed out, one of the best things that could happen in the education of a physician today would be for them to spend a month or two as an inpatient in a hospital.
The significance of the therapeutic alliance between physician and patient cannot be overstated. It is often key to managing physiological abnormalities and diseases due to the importance of compliance and the undeniable connection between mental and physical health. The absence of this alliance and trust also contributes to the growing number of legal actions against physicians today; as Dr. Cook noted, people don't sue their friends.
I have chronicled my experiences during the four years of medical school at Columbia as dots of color on a Pointillist canvas, collectively shaping my attitudes as a young physician. Often, it seems that the essence of experiences is obscured by "rational analysis" and a focus on "safe" irrelevancies. Yet, feeling one's own intense emotions, whether love or pain, is the only way to stay in tune with those of others. If there is an equally important message for anyone contemplating a career in medicine, it is to tailor the career to fit one's life and lifestyle, not vice versa. Don't spend your life striving to be great—spend it striving to be happy.
As Oscar Wilde once said, "In this world there are only two tragedies. One is not getting what one wants, and the other is getting it.”
When I graduated from medical school, my comrade and former roommate, Ben Rosenberg, sent me a copy of "Blue Highways" by William Least Heat Moon, a story of a man's travels along America's back roads. Inside the front cover, Ben inscribed this message:
"It's the end of one highway—who knows where the next one leads? 'There is a road, no simple highway, between the dawn and the dark of night.'* Keep walking the fine line, man, because you do it so well."
*Lyrics by Robert Hunter
"Words are flowing out like endless rain into a paper cup…they slither while they pass, they slip away across the universe." - John Lennon
Foreword
By Robert Sigal, MD
In my bed, I lie the night after Mr. O'Toole's death and think of his entrance to the hospital, and my life. A large man, John Wayne-like in healthier days from his bearing, he now bore a gut swollen by disease; enough of him remained on his frame for me to read his past clearly—a man of responsibility, well-liked and respected, with dry humor. His manner was that of his old self—inappropriate in his new, unimproved body. He had no future, I believed that. So did he. Each morning when I came to him on my rounds, we would chat about the misery of his previous night—a night far removed from the morning—a night belonging to some other large man near death. Daylight wiped away his lonely insomnia and brought him back to a world full of cheery, bright-eyed young people who could still pull their pants up over flat stomachs. His nights belonged to a different world. Sounds of illness—cries, moans, monitors—played a solemn fugue to a man unaccustomed.
As he grew progressively sicker from his fatal illness, I grew to wonder at his naiveté. How long would it take him to relate his night-time world to himself? He was dying—he could not walk anymore (he was too weak), he could not eat anymore (he had no appetite), and none of his clothing fit him (he was too swollen). I knew he was dying—it was obvious to me that his night-time world was real. Didn't he realize? Couldn't he feel it?
The fear came upon him one morning during our chat. He'd had trouble breathing that night for the first time, losing his breath as he struggled from his bed to the bathroom. As he related the incident, I saw the fear shake up from his swollen belly and fill his eyes with a mixture of horrified recognition and pitiful hope in my ability to cure him. He must have been stunned when I replied compassionately and then asked about the particulars of the products of his trip. He had unified his night-world with himself, and that unification brought a fear to his eyes that chilled me. A man confronted his fate.
Mr. O'Toole died when I wasn't there. He had grown steadily worse until he was unable to recognize his devoted wife—or me. I came to see him the last time on Saturday morning. He was a large man, but he was so fragile—an almost dead tree waiting to topple down. I looked at his wife, and her eyes were those of a woman—strong, loving, realistic. I turned from him and her, wrote my note, and left. And that night when he died, I took off my glasses and, nearly blind, drifted off to sleep.
Thank you so much, I can’t tell you how much it means to me that you shared your thoughts in that way.
I am so impressed! Never knew that you had written book--so anxious to read it and learn more about my beloved son! Mom