Introduction

Medical training, which includes four years of medical school, one year of internship, plus three or more years of residency, stands apart from ordinary human experience in much the same way that war lies outside the normal realm. Medical training, like combat, involves extraordinary encounters and practices.

Three factors in particular help explain why medical training differs so much from ordinary life. First, the intensity of emotion, work load, responsibility, and knowledge required is beyond the average. Very few people have to remember as many facts, work as many hours, read and absorb as many pages, interact with as many emotionally distraught people, and take care of as many persons as do doctors-in-training. Second, the stakes involved in medicine are extraordinarily high. Life itself is the currency of medicine, much as it is in war. Mistakes by physicians are costly in terms of suffering and death. Finally, very few other human activities involve such immersion in death . One need only see a first-year anatomy class dissecting cadavers to appreciate how early the death immersion process begins.

Unfortunately, because of the enormous pressure of work to be done, the material to be absorbed, and the sophisticated scientific method required to master modern medicine, few students of medicine become students of the emotional, human, and humane aspects of medicine. Most doctors instead are trained to

subvert, deflect, or bury their true feelings and reactions and to intellectualize their patients' sufferings and deaths. This intellectualizing is a necessary process toward the rational and scientific treatment of disease, but there is more to medicine than the merely rational and scientific. We believe that doctors can become better healers when they recognize their own human reactions to death and suffering during their training—and afterwards.

Certainly, we are not the only ones to believe this. In recent years, numerous medical educators have recognized and even championed the importance of the human in medicine. Their recognition is evident in the relatively new and expanding field of medicine and literature or, in a broader sense, medicine and the humanities. Many medical schools now offer formal elective courses in medicine and literature or courses that relate medicine to other aspects of the humanities, including philosophy and ethics. There are several explanations for this.

There is, at present, a growing dissatisfaction with medical school curricula. The four years of medical school and the years of internship, residency, and, often, two or more years of a specialty fellowship that follow emphasize the sophisticated, technical aspects of medicine to the virtual exclusion of the humane elements. Whereas medical students are carefully trained in such areas as biochemistry, pathology, laboratory medicine, anatomy, and physical diagnosis, as well as in the latest innovations of life-monitoring and life-supporting gadgetry, they are seldom exposed—if they are exposed at all—to the thought processes necessary for evaluating, understanding, and appreciating what it means to be a patient who is sick, in pain, terrified, or dying. This emphasis on the technological has contributed to the dehumanization of modern medicine. The new doctor is well trained to take care of a body but not of a person. We wish to stress that it is not the emphasis on the scientific, technological, and quantifiable that is to blame for the dehumanization of modern medicine: it is the emphasis on these at the expense of the human that is so unfortunate. And when medical care is dehumanized, both the patient and the physician are losers.

The dehumanizing process of medical education actually begins early in college, where future medical students often adhere to the premedical track with its heavy emphasis on courses in the

sciences. Of course, these science requirements are set by the medical schools, and it is obvious that a grounding in science is necessary for a modern medical education. But while medical school admissions committees generally demand that their applicants present outstanding achievements in science, they generally deemphasize equally outstanding backgrounds—suggesting different but equally outstanding abilities—in humanities and arts. The result is that our medical schools are full of superbly trained, sophisticated technicians in the medical sciences who often have an excessively narrow humanistic background on which to draw to broaden and deepen their thought processes.

A related outcome of this selection process is that many people trained as bright, innovative thinkers, including writers, musicians, artists, philosophers, language experts, historians, and students of literature, have been systematically excluded from medicine. Some of those with expertise in the humanities and the arts could easily adjust to a rigorous science program once in medical school. Education in the sciences teaches a person to think in one way; education in the humanities and the arts teaches one to think and to approach problems in other ways. Medicine, which intimately involves both science and the human being, could profit from diverse ways of thinking and solving problems.

Another shortcoming of medical education is that medical students and physicians have little exposure to language at its best, that is, the language of great literature. Premedical students, medical students, and practicing physicians read countless scientific articles detailing the latest research in the basic sciences and medicine. But all these scientific articles are written in the worst style imaginable: the dehumanized, passive, so-called objective style mandated by modern scientific journals. This language—rather, this misuse, mutilation, and murdering of language—purports to be nonpersonal and therefore scientific. In fact, it is dehumanized, dead, and deadening. It dulls the senses and the mind. The jargon of contemporary scientific journals is not an acceptable model for effective communication. Yet this is the language model on which doctors are nurtured, trained, and sustained.

Medicine, however, is not lifeless: it treats the stuff of life. Physicians could profit from intense exposure to the colorful, rich, feeling, expressive, and probing language of literature. The fine

use, tuning, and understanding of language are crucial to meaningful human communication. And is not one of the most meaning-charged communications the interchange, precisely, that occurs between a patient and the physician tending him? Perhaps if physicians could learn to express themselves better, to listen to their patients better, to understand what their patients are implying by their words, tones, and gestures, they might be able to communicate more effectively with them. In his introduction to Medicine and Literature , Edmund D. Pellegrino, M.D., one of the pioneers in the field of medicine and the humanities, stresses the importance of language—and therefore of literature—to the physician, since one of the physician's primary jobs is to listen and communicate.

Literature . . . teaches the physician something of me significance of symbol and language as the media linking human minds and personalities. Language is the instrument of diagnosis and therapy, the vehicle through which the patient's needs are expressed and the doctor's advice conveyed. Understanding the nuances of language, its cultural and ethnic variations and its symbolic content are as essential as any skills the clinician may possess.^[1]

Yet another reason that literature, language, and other humanistic studies are being recognized as relevant to medical studies is that a technological explosion has occurred in medicine which has created new ethical dilemmas: terminally ill patients can now be kept artificially alive on life-support systems well beyond their natural lives; artificial hearts can replace a patient's damaged heart; amniocentesis can detect potential birth defects prior to birth; genetic engineering brings an entirely new horizon of scientific intervention. All of these advances raise questions that cut across medical, religious, ethical, philosophical, and societal boundaries. As the chief engineers and representatives of the medical profession, physicians are forced to participate actively in finding solutions to these new ethical dilemmas. Yet, by training, most physicians have little or no special background to help them deal with such profound problems of a multidisciplinary nature.

A very distressing problem today is an outgrowth of the technological explosion. A large proportion of practicing physicians suffer a kind of technological isolation in their practice of medi-

cine. They tend to divorce their daily handling of life, death, and health issues from the larger context of human experience in general. This technological isolation is detrimental both to the physician and to the patient. To some extent, of course, the physician must be objective and unemotional, distanced from his patient and from his patient's suffering, so that he may make a rational judgment about the best treatment to recommend. Still, the doctor must be able to understand and relate to his patient as a thinking, feeling human being.

Although the physician's technological isolation may be seen as a result of his highly technical, essentially nonhumanistic training, it may also be seen as one of his defenses: a shield that protects him from his patient's suffering and pain. But the doctor's isolation is also his burden; it prevents him from reaching out to his patient, and it inhibits him from broadening and deepening his own emotional world, which is, in fact, not so different from his patient's emotional world. After all, what doctor does not become, at some time, a patient? And what doctor, like his patient, is not plagued, at some time, by haunting fears, worries, doubts, and feelings of sadness?

For all the above reasons, and more, it has been recognized that something is missing in the training and education of the modern physician. The discipline of medicine and literature, or medicine and the humanities, is emerging to try to help fill that vacuum. This work is an attempt to contribute to this humanistic movement in medicine.

Each chapter of our book contains one or more medical case histories from Richard Peschel's experience. Since each case history relates a very personal experience, all are told in the first person, the "I" being, of course, Richard Peschel. Even though all the patients in the case histories have passed away, all names and other identifying details have been changed to protect everyone's privacy. In every chapter, the case histories are accompanied by literary parallels, examples from literature which treat similar or related themes or ideas. The literary parallels were chosen by Enid Peschel. Each chapter concludes with a discussion of how the literary parallels illuminate and amplify the medical case or cases. Because these discussions summarize the reflections of both of us, we have deliberately used the plural "we."

Our literary selections come from a wide variety of epochs and cultures, from the ancient Greeks to modern times. We did this because we did not want to limit ourselves to a single era, country, or culture. Instead, we wanted to sound something of the human experience common to all men which cuts across time, space, language, and land. One of our primary aims is to illustrate, through many varied examples, how great literature can help physicians, other health care professionals, and lay persons understand something about the human dramas and dilemmas of medical life. We also hope that the literary examples we use will encourage our readers, medical and nonmedical alike, to look further to literature for many more insights into medicine, man, and life itself.

Starting from the rich human drama—people in moments of crisis, in pain, filled with fear—that a doctor not only witnesses but in which he also participates (sometimes playing a crucial part), we go on to explore, through examples from literature, what other people have done or thought in similar circumstances. Literature offers a wealth of information about how human beings think, feel, act and react, speak and/or are silent. In his daily work, the physician may see or experience some of these feelings and reactions both in his patients and in himself, but he may not be able to probe or explore them much deeper on his own. The literary parallels we use may permit the reader to stand back and watch those feelings and events, think about them, judge them, and try to understand and come to terms with them.

We recognize that our book emphasizes the doctor's role. This, of course, is but one aspect of the total medical picture, only one type of interaction that occurs between a patient and health care professionals. Nurses, medical technologists, receptionists, nurses' aides, physicians' associates, and orderlies make an enormous contribution to the care of patients, and they all have their own unique relationships with patients. Although their interactions with patients may differ in detail from the doctor's, their experiences are similar to his because all involve intimate, human contact with people who are often in pain, frightened, and feeling terribly alone. And so, although our book gives just the physician's viewpoint, we believe it will appeal to numerous other health care professionals who have had countless similar experiences in med-

icine. Rather than suggesting that the experiences and feelings in our book are unique to physicians, we wish to emphasize that they are common to all of medicine.

We try here to relate one doctor's modest experience and to find for it parallels in human experience portrayed in what Virginia Woolf called "that complete statement which is literature."^[2] The medical case histories related here actually took place. Although some of them may seem bizarre, shocking, or unbelievable, they in fact reflect aspects of the common medical experience. Other doctors and health care professionals could tell similar tales, strange in the same ways or in different ways but all suggesting the strengths and weaknesses, fine points and limitations, victories and defenses of the baffled and baffling creature called man.

We hope this marriage between medicine and literature will give the public a greater understanding of the doctor of modern medicine. We also hope these case histories and literary parallels will give the practicing physician a greater insight into himself. We would be glad if our book inspired others—doctors, other health care professionals, patients, and relatives and friends of patients—to probe, judge, and question some of the human and medical events through which they have lived. We know that these chapters from a young doctor's life, along with the literary parallels and our joint reflections, are but a small sampling of what is, in reality, the vast, vital, intense—and moving—human experience of medicine.