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For my last installment in this series on Tolstoy’s short novel exploring the process of death and dying, I have selected a passage that occurs halfway through the story. In this passage, the protagonist identifies what has exacerbated his crisis beyond physical suffering as he compares the approach of his family, friends, and doctors to that of a young, honest servant named Gerasim:

Ivan Ilyich suffered most of all from the lie, the lie which, for some reason, everyone accepted: that he was not dying but was simply ill, and that if he stayed calm and underwent treatment he could expect good results. Yet he knew that regardless of what was done, all he could expect was more agonizing suffering and death. And he was tortured by this lie, tortured by the fact that they refused to acknowledge what he and everyone else knew, that they wanted to lie about his horrible condition and to force him to become party to that lie. This lie, a lie perpetrated on the eve of his death, a lie that was bound to degrade the awesome, solemn act of his dying to the level of their social calls, their draperies, and the sturgeon they ate for dinner, was an excruciating torture for Ivan Ilyich. And, oddly enough, many times when they were going through their acts with him he came within a hairbreadth of shouting: “Stop your lying! You and I know that I’m dying, so at least stop lying!” But he never had the courage to do it. He saw that the awesome, terrifying act of his dying had been degraded by those around him to the level of a chance unpleasantness, a bit of unseemly behavior (they reacted to him as they would to a man who had emitted a foul odor on entering a drawing room); that it had been degraded by that very “propriety” to which he had devoted his entire life. He saw that no one pitied him because no one even cared to understand his situation. Gerasim was the only one who understood and pitied him. And for that reason Ivan Ilyich felt comfortable only with Gerasim. It was a comfort to him when Gerasim sat with him sometimes the whole night through, holding his legs, refusing to go to bed, saying “Don’t worry, Ivan Ilyich, I’ll get a good sleep later on”; or when he suddenly addressed him in the familiar form and said: “It would be a different thing if you weren’t sick, but as it is, why shouldn’t I do a little extra work?” Gerasim was the only one who did not lie; everything he did showed that he alone understood what was happening, saw no need to conceal it, and simply pitied his feeble, wasted master. Once, as Ivan Ilyich was sending him away, he came right out and said: “We all have to die someday, so why shouldn’t I help you?” By this he meant that he did not find his work a burden because he was doing it for a dying man, and he hoped that someone would do the same for him when his time came.

The need to convey information is great, and within this task lies the greater challenge of finding the right balance between honesty and compassion. This exchange belongs to the art of medicine, not the science, which many students of medicine lack at the beginning of their training. During our education, it is though that we will learn from our clinical instructors and physician mentors: in emulating them, we may adopt their attitudes, behaviors, prejudices and passions. On this account, I am concerned about a great many doctors in the generation of physicians in their late thirties and forties, embittered by their experiences with managed care, malpractice litigation, and increasing demands for credentialing and record keeping without a concomitant rise in respect or salaries. I am worried about what lessons and models might be learned from physicians who are tired, beaten, rushed, and unhappy with their careers.

I have often learned best in defiance of odds or models to which I refuse to conform. Although probably not a bad physician, one doctor propelled me onto the road to becoming a physician when she failed me as the young child of a dying cancer patient. Brimming with hope from my mom’s slightest sign of recovery from a unconscious state, I approached the rounding physician wearing my feelings on my shoulder. However, in response to my hopeful comments, the physician gave no words in response: only a look, more brutal and crushing than any combination of words that can convey a bad prognosis. There was no hand on the shoulder, no compassionate smile and probing of my understanding. And furthermore, I never saw the physician again. She did not lie, but she also did not tell the truth or offer any understanding: she completely disengaged from any potential interaction, whether for lack of ability, energy, or feeling of responsibility. In her, I found a model of what not to be and what not to do: if I can do better, if I can teach others to do better by engaging the emotions and confusion, I will have done something worthwhile. Soon enough, I will be on the wards, and the situations in which I find myself will put my own art and ability to the test. Will I be able to detect and speak to the unspoken fears and suffering? Will I be able to speak truthfully and still offer hope, guidance, and companionship?

Sickness can be a very isolating experience, not just for the uniqueness and strangeness of the experience but also because of the ways it affects our relationships with others. This passage about a card game from Tolstoy’s short novel illustrates this:

What more could he have wished for? He ought to have felt cheered, invigorated–they would make a grand slam. But suddenly Ivan Ilyich became aware of the gnawing pain in his side, the taste in his mouth, and under the circumstances it seemed preposterous to him to rejoice in a grand slam.

He saw his partner, Mikhail Mikhailovich, rapping the table with a vigorous hand, courteously and indulgently refraining from snatching up the tricks, pushing them over to him, so that he could have the pleasure of picking them up without having to exert himself. “Does he think I’m so weak I can’t stretch my hand out?” Ivan Ilyich thought, and forgetting what he was doing, he overtrumped his partner, missing the grand slam by three tricks. And worst of all, he saw how upset Mikhail Mikhailovich was while he himself did not care. And it was dreadful to think why he did not care.

They could see that he was in pain and said: “We can stop if you’re tired. Rest for a while.” Rest? Why, he wasn’t the least bit tired, they’d finish the rubber. They were all gloomy and silent. Ivan Ilyich knew he was responsible for the gloom that had descended but could do nothing to dispel it. After supper his friends went home, leaving Ivan Ilyich alone with the knowledge that his life had been poisoned and was poisoning the lives of others, and that far from diminishing, the poison was penetrating deeper and deeper into his entire being.

For many people, I think this is one of the main reasons why we do not like to discuss our own pain and suffering: it brings a dark shadow into the lives of our loved ones and friends. It feels harder to hold it in, but it is actually easier to hide one’s suffering rather than let others share in it. When we, as physicians, wonder why it takes some people so long to seek medical help for their health problems, this may often be one of the contributing factors: not having frequent enough contact with someone outside one’s family or circle of friends who can assess and discuss one’s health without fear of bothering or hurting others.

The following passage in Leo Tolstoy’s The Death of Ivan Ilyich highlights a few responses that patients may take to serious illnesses:

After his visit to the doctor, Ivan Ilyich was preoccupied mainly with attempts to carry out the doctor’s orders about hygiene, medicine, observation of the course of his pain, and all his bodily functions. His main interests in life became human ailments and human health. Whenever there was any talk in his presence of people who were sick, or who had died or recuperated, particularly from an illness resembling his own, he would listen intently, trying to conceal his agitation, ask questions, and apply what he learned to his own case.

The pain did not subside, but Ivan Ilyich forced himself to think he was getting better. And he managed to deceive himself as long as nothing upset him. But no sooner did he have a nasty episode with his wife, a setback at work, or a bad hand of cards, than he immediately became acutely aware of his illness. In the past he had been able to cope with such adversities, confident that in no time at all he would set things right, get the upper hand, succeed, have a grand slam. Now every setback knocked the ground out from under him and reduced him to despair. He would say to himself: “There, just as I was beginning to get better and the medicine was taking effect, this accursed misfortune or trouble had to happen.” And he raged against misfortune or against the people who were causing him trouble and killing him, for he felt his rage was killing him but could do nothing to control it. One would have expected him to understand that the anger he vented on people and circumstances only aggravated his illness and that, consequently, the thing to do was to disregard unpleasant occurrences. But his reasoning took just the opposite turn: he said he needed peace, was on the lookout for anything that might disturb it, and at the slightest disturbance became exasperated. What made matters worse was that he read medical books and consulted doctors. His condition deteriorated so gradually that he could easily deceive himself when comparing one day with the next–the difference was that slight. But when he consulted doctors, he felt he was not only deteriorating but at a very rapid rate. And in spite of this he kept on consulting them.

The patient’s perception of his illness is a subject that does not seem to be commonly explored in the day-to-day operation of a medical practice or hospital. It is often a subtle matter that may not be easily elicited with open-ended questions as the words to describe one’s feelings and beliefs may be difficult to find (in contrast with Tolstoy’s simple and elegant, third-person description of a patient’s experience). Nonetheless, I think good physicians are able to perceive differences in belief and troubled thoughts from behavior or answers to questions inconsistent with expected responses.

Some medical schools discuss this topic in the context of cultural competency with respect to particular ethnic groups or religions that may have beliefs that influence medical decisions, sometimes in disagreement with the expectations that the physician may have for a patient in his or her position. However, understanding a patient’s perception and attitude toward illness should not be limited to these groups. I noticed on the first installment of my licensing exams that there were many questions regarding the appropriate response a physician should make to a patient making an unconventional choice, and the recommended approach usually involves “exploring” the patient’s understanding of the situation. However, how does one do this? I have been told by others that I am a good listener and have a keen perception for subtle differences in behavior and thought in others, and yet I wonder how challenging this process of “exploring” will be, especially with limits on time spent with each patient and the incredibly alienating nature of disease. I hope that as a physician I will be able to fulfill the same role in illness that priests hold in spiritual crises: the role of the listener, mentor, and guide, someone to whom a person may reveal her most frightening and troubling thoughts and in whom she may find a path out of the darkness. I wonder, with managed care, time constraints, and malpractice litigation, how much of this aspect of the patient-doctor relationship has been needlessly sacrificed.

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