“Nothing will sustain you more potently in your humdrum routine… than the power to recognize the true poetry of life—the poetry of the commonplace, of the ordinary man, of the plain, toil-worn woman, with their loves and their joys, their sorrows and their griefs.”

— William Osler (1)

“The practice of medicine is simply poetry in motion.  The art of medicine is the validation of everything that makes the human experience. I learned more about myself than I ever imagined…”

–4th year medical student journal, 2011

In his late sonnet, “Transplant,” cardiologist-poet John Stone evokes the scene of a medical miracle.  As a recipient lies waiting in an operating room, a donor heart arrives by helicopter from Wisconsin.  Surgeons remove the recipient’s diseased heart (“Within the green purpose of the room / there were ten beating hearts, but now are nine”) and insert the silent, motionless replacement. The sonnet concludes with the miraculous moment when the patient’s new heart comes alive:  “And then the shock, the charmed expectant start, /        the last astonished harvest of the heart.” (2)

When I teach this poem, students readily appreciate the amazing technological feat of heart transplantation. They can also appreciate how moving it must be for a physician to see his patient reborn in such a fashion. However, students who have had experience with patients respond to this poem with additional insight. They often relate stories of more mundane events, episodes when a patient said this or did that, small encounters that had nothing to do with technology, but which caused them to experience moments of fulfillment or astonishment. These moments, I suggest to the students, are the astonished harvest of medical practice.

As a junior faculty member in Pittsburgh, I worked at a community health center in Terrace Village, the city’s largest public housing project. With its institutional buildings and drab, cracked streets, the place looked nothing like a village and the only place resembling a terrace was a huge slab of broken concrete in front of the housing office. The clinic was one of the few safe places to socialize.  I remember one woman who had lived in the “projects” since the day President Roosevelt cut the ribbon at their opening in 1943.  This lonely widow had multiple medical problems and lived in constant fear of the hoodlums in her building.  I hated to see her name appear on my office schedule because her symptoms never improved, her medications always caused side effects and, according to her, I was too young to know anything. Yet she never missed an appointment, if only to tell me that she had been carried to the emergency room, where they did special tests and gave her new prescriptions.

One day just before Easter, Celia Houston appeared in my office wearing a child-like white lace dress and carrying a small potted plant that she brought for my office. “An act of Christian love,” she said, “not a sign of being personal.” I was stunned by the unexpected gesture of gratitude from this chronically dissatisfied woman and afterwards wrote a poem called “The Act of Love” that ended like this:

As for me, I’m stunned

out of the ordinary anger

at failing to help her

 

by the waxy-leaves of her gesture

and I receive this wafer of the season,

heartbroken for no reason.

 

It was a moment of astonishment.

I began to use poetry in teaching medical students and residents because poems can capture in a fairly direct way the joys, uncertainties, and emotional distress of medical practice.  Rafael Campo hit the nail on the head when he wrote, “Many of us find ourselves looking instinctively to the humanities as a source of renewal, reconnection, and meaning.” In my mind these three words—renewal, reconnection, and meaning—summarize the yearnings of many clinicians who daily face the existential demands of medicine, while often moving too fast, or becoming too detached, to experience its existential rewards. I love poetry and literature and history and the visual arts for many reasons, but in teaching future practitioners of the art of healing, I value these disciplines as catalysts for reflection and self-discovery.  Although making poems is a major part my own process of renewal. reconnection, and meaning, I’m always quick to reassure students that many pathways are available for them to move toward reflective practice.

Encounters with patients have always engaged my emotions. From the beginning I resisted the idea that doctors should foster detachment in order to achieve objectivity. For me “detached concern” is an oxymoron. What can empathy be, if not a form of human connection? How can a person be caring or compassionate in the context of emotional distance?  At the same time, I often found myself frustrated, dejected, and angry, sometimes even wanting to run away from it all.

While “Transplant” may open the door to astonishment, reflective practice must lead us to these darker doors as well.  This was the case when I took care of Ronald Colman some years after I had left the neighborhood health center and was practicing in a university setting. Mr. Colman was a proud and aggressive man from a distinguished local family. I always felt a little defensive in his presence. At times he would exude a hearty camaraderie, but I sensed arrogance and entitlement beneath it. It seemed at each office visit he would find a reason to mention a restaurant in Cannes, the happy state of the market, or his uncle’s recent retirement to Barbados.  On one occasion I ordered an MRI to investigate Mr. Colman’s “it’s probably nothing” abdominal pain. It turned out to be something: carcinoma of the head of the pancreas. The day he returned for follow-up, Mr. Colman was full of himself as usual, remarking that he had already made an appointment at a well-know clinic, but he needed a script for Vicodin until he could get there. Later, I tried to capture my conflicted feelings in a poem called “The Words,” which begins

For the third time this month

his bronzed face

sits with its swaggering list

 

of what he needs me for…

 

and ends

 

I want to escape from the room,

 

to leave him with his power

and run from mine, the words that cut

to his core: Behold the pancreas!

 

He looks at me with faint unease

rising in the creases of his eyes–

My words will make him mortal, he will die.

 

I don’t think my strong aversion to sharing the bad news with him (“I want to escape from the room”) resulted only from my usual desire to avoid causing distress. Rather, it was also fed by a subversive fear that I might actually enjoy giving him pain, I might somehow compensate for my feelings of inferiority by knocking this “Olympian father of the gods” down to size. Poetry provided me with a way of coming to understand and “work through” (in today’s jargon) these feelings.

We often attribute detachment and burnout in today’s physicians to the rapid pace and dehumanizing features of our health care system. Yet, long before medicine became a roiling pressure cooker, teachers like John Gregory, Thomas Percival, William Osler, and Francis Peabody warned their students that a life in medicine can foster emotional distress, hardness, and insensitivity. Although these physicians wrote in a language of virtue and moral sentiment that seems archaic to us, in many ways their expressions capture our existential concerns more vividly than does today’s aseptic language of medicine.  For example, students often complain that they are being dehumanized by their training, or they find themselves morally conflicted about the way one of their patients was treated, or they feel abused, but powerless to do anything about it. In these situations, they can more easily relate to metaphors like “hardness of heart,” and concepts like balancing steadiness and tenderness, than to ethical principles like autonomy and beneficence.

 

I began using poetry in clinical teaching some years before it entered my pre-clinical repertoire. I occasionally brought a poem, usually chosen as a reflection relevant to a patient we had discussed the previous day, to read toward the end of rounds. I distributed copies, and we sat and discussed the poem for a few minutes. My objectives were originally focused on behavior, e.g.  helping them become better observers or more careful listeners. I’d say the majority of team members responded to the poetry with genuine interest. Topics, like grief or the psychology of chronic illness, that would fall flat when discussed as “issues” were enlivened when they appeared in Denise Levertov’s “Talking to Grief” and James Dickey’s “Diabetes.” The words of poetry appeared to provide these trainees with a more humane way of understanding and responding to their work. I smuggled poetry into pre-clinical teaching later, when I became responsible for an extensive medical ethics and humanities track that ran through the first two years of the medical school curriculum.  Not surprisingly, many students would begin with comments like, “I don’t understand poetry” and “I don’t see how poetry is relevant.” I think for most this attitude changed when they realized our focus was on sharing experience and self-discovery, rather than literary analysis.

It took me a while to realize that the real value of poetry in medical education is just that: self-discovery. Attentiveness, careful observation, empathic responding, i.e. the clinical skills, are desirable but secondary phenomena. The primary process involves mindfulness, self-awareness and the moral imagination, a process in which reflective reading and writing, especially poetry, may play a significant role.

In “Metaphor and Memory,” Cynthia Ozick claimed that doctors cultivate detachment from their patients because they are afraid of finding themselves “too frail … to enter into psychological twinship with the even frailer souls of the sick.”  (3) All of us, not just physicians and other health care professionals, fear this vulnerability. Acknowledging frailness is a step toward resilience, just as discovering tenderness is a step toward steadiness. In 1990 I visited the Oglala Sioux Reservation at Pine Ridge, South Dakota, as part of a study of coronary artery disease among Native Americans.  While there, I was invited to observe a Sun Dance near the site of the 1890 Massacre at Wounded Knee, when the 7th US cavalry shot and killed about 200  defenseless Sioux men, women, and children. In the Sun Dance, young men and women seek to restore harmony in their lives by discovering and communing with their totemic spirits. At one point during the several day ceremony, participants invite spectators to pick up a stone and bring it to a great circle. I did so. The dancers and medicine men moved around the circle, stopping to bless each supplicant with sage branches and a medicine pipe. I was moved to tears by this ceremony. Back at home, I put my little stone in a buckskin pouch that I still carry in my briefcase. Later, I tried to evoke the healing power of that experience in a poem:

 

This stone I picked at a medicine dance

on a cold June day near Wounded Knee.

 

In my bare feet, I carried this stone

into the circle of those with need.

 

A sun dancer danced in front of me,

touched my shoulder with a sprig of sage.

 

A sun dancer chanted in front of me

and blessed me with his medicine pipe.

 

Here in the city, the sky is brilliant.

I carry this stone in a buckskin pouch.

 

Here in the city, we suffer in private.

Each of us stands at the circle alone.

 

This stone is an aspect of soul that lasts.

This stone is a remnant of no account.

 

Here in the hospital, coyote is dead.

This small stone is of no account.

 

Wolves, spiders, moles, snakes, ants are dead.

This spherical stone is of no account.

 

Eagles, hummingbirds, ravens, bats are dead.

This stone is a remnant of no account.

 

Only the voices of suffering live,

the skin, and what happens beneath the skin.

 

Still, I carry this buckskin pouch

and a small stone wrapped in a wad of sage.

 

This stone is an aspect of soul that lasts.

I call it my friend, my black stone friend.18

 

Poetry speaks for the art in healing, for the “aspect of soul that lasts,” for meaning and value in medical practice. As Gregory, Percival, Osler, and Peabody knew, the risk of losing heart, or of hardening one’s heart, and concluding “this small stone is of no account” is always present in medicine.  In pursuing objectivity it is tempting to neglect the more difficult project of nourishing tenderness in our relationships with patients and with ourselves. However, taking this path prevents us from reaping John Stone’s “astonished harvest of the heart.” Poetry bids us to consider taking a different path  in our professional lives.

 

References

  1. Osler W (2001). The student life. In Osler’s ‘A Way of Life” & Other Addresses With Commentary & Annotations, S Hinohara and H Niki, Durham, Duke University Press, p. 314
  2. Stone J (2004). Transplant. In Music from Apartment 8. New and Selected Poems by Jon Stone, Baton Rouge: Louisiana State University Press, p. 1573
  3. Ozick C (1989). Metaphor and memory. In Metaphor and Memory: Essays. New York, New York, Knopf, pp. 265-283

 

Biographical Note

Jack Coulehan is a poet, physician, and medical educator whose latest collection of poems is  Bursting With Danger and Music (2012).  He recently received the Nicholas Davies Award of the American College of Physicians for “outstanding lifetime contributions to the humanities in medicine.”

 

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