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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.

The next passage from Leo Tolstoy’s The Death of Ivan Ilyich more directly addresses the patient’s experience with the medical examination and the dissatisfaction that may come from the patient-doctor interaction:

… The whole procedure was just what he expected, just what one always encounters. There was the waiting, the doctor’s exaggerated air of importance (so familiar to him since it was the very air he assumed in court), the tapping, the listening, the questions requiring answers that were clearly superfluous since they were foregone conclusions, and the significant look that implied: “Just put yourself in our hands and we’ll take care of everything; we know exactly what has to be done–we always use one and the same method for every patient, no matter who.” Everything was just as it was in court. The celebrated doctor dealt with him in precisely the same manner he dealt with men on trial.

The doctor said: such and such indicates that you have such and such, but if an analysis of such and such does not confirm this, then we have to assume you have such and such. On the other hand, if we assume such and such is the case, then… and so on. To Ivan Ilyich only one question mattered: was his condition serious or not? But the doctor ignored this inappropriate question. From his point of view it was an idle question and not worth considering. One simply had to weigh the alternatives: a floating kidney, chronic catarrh, or a disease of the caecum. It was not a matter of Ivan Ilyich’s life but a conflict between a floating kidney and a disease of the caecum. And in Ivan Ilyich’s presence the doctor resolved that conflict brilliantly in favor of the caecum, with the reservation that if an analysis of the urine yielded new evidence, the case would be considered… From the doctor’s summary Ivan Ilyich concluded that things were bad, but that to the doctor and perhaps everyone else, it was of no consequence, even though for him it was bad. And this conclusion, which came as a painful shock to Ivan Ilyich, aroused in him a feeling of great self-pity and equally great resentment toward the doctor for being so indifferent to a matter of such importance.

This characterization may require a closer inspection of Tolstoy’s perspective. First, Tolstoy wrote this short novel in the mid-nineteenth century, before the advent of Germ Theory, the rise of hospitals and academic medical centers, and the development of a more rigid link between scientific discovery and medical practice. Secondly, although it is unclear whether or not Tolstoy himself had similar interactions with contemporary doctors, he did have a long and agonizing obsession with the subject of death and the process of dying.

With that in mind, what does this characterization mean to a physician-in-training in this day and age? I’m concerned that as much as I would like to think of physicians as a relatively tight knit professional group in comparison with other fields, there is still a degree of heterogeneity that is recognizable not only to members of the field but also to patients. I think this heterogeneity has less to do with diagnostic and technical skill and more to do with being personable and approachable. When we talk about “good doctors” and “bad doctors,” we are usually referring to their manner rather than their ability (since patients are not necessarily good judges of diagnostic or technical ability, especially since a “bad outcome” may be the result of an excellent physician working with an intractable case). Reflecting this notion, Tolstoy’s protagonist finds his only question unanswered and his only need unfulfilled by the physician’s approach. In this case, the physician failed to address the patient’s concerns. It is a failure of empathy rather than communication: Ivan Ilyich’s question of the seriousness of his condition was not difficult to convey, but the doctor did not take any measures to properly address the patient as a person (rather, he focused on addressing the body and its mysterious disease) and affirm that his concerns are important.

I think this is a relatively simple lesson for physicians-in-training: always take a moment to walk in the shoes of your patient. I think this is not difficult for many physicians, but many others do fail at this task for a variety of reasons: through a failure to be open to questions, a failure to address the patient’s understanding of his or her condition, or a failure to consider the person as well as the diseased body.

It has been a long time since I’ve experienced a true vacation from medicine. One of my first cathartic actions after completing the USMLE Step 1 exam was to pack all of my printed course packs from my first two years of medical school into four large paper bags and fling them into the nearest paper recycling bin. Next, after arriving in Boston where I am visiting my fiancée, I had the pleasure of walking around at a leisurely pace without feeling that there was anywhere I needed to go or anything I needed to do. I then spent several hours in a Borders, scouring the shelves for the perfect read (which arrived in the form of Understanding China by John Bryan Starr, a rather stimulating and provocative look at the political and socioeconomic structures of modern China that complements my prior coursework in ancient Chinese history and my film history course on modern Chinese film).

I have three and a half weeks of vacation time until I begin my Neurology clerkship in July as a third year medical student. In addition to playing my guitar, reading books, catching up with friends, and playing computer games, I have allowed myself one medically-oriented diversion: reading the short novel The Death of Ivan Ilyich by Leo Tolstoy, a recommendation and loan from my fiancée. Although concise and quick to read, the novel is not exactly a light read: after completing it on the T, I spent half an hour sitting by the Cambridgeside Galleria fountain, reflexively absorbing the liveliness of the summer day while processing Tolstoy’s dark exploration of the subject of death and dying. I strongly recommend Tolstoy’s short novel to any physician-in-training or physician who may tend to the care of terminally ill or dying patients (e.g. with cancer; failure of the heart, liver, lungs, or kidneys; or any illness leading to a slow decline). This is a book I will reread again several years from now to remind myself of lessons learned and of examples to which I would like to compare and question myself.

In the meantime, I will post a few passages from the short novel with some of my reflections and thoughts on the interactions between physicians and patients and the roles of physicians in the process of dying.

Excerpt from The Death of Ivan Ilyich

This passage discusses the professional life of the protagonist Ivan Ilyich as a judge and his approach to interpersonal interactions with others:

… But on the whole Ivan Ilyich’s life moved along as he believed life should: easily, pleasantly, and properly. He got up at nine, had his coffee, read the newspapers, then put on his uniform and went to court. There the harness in which he worked had already been worn into shape and he slipped right into it: petitioners, inquiries sent to the office, the office itself, the court sessions–preliminary and public. In all this one had to know how to exclude whatever was fresh and vital, which always disrupted the course of official business: one could have only official relations with people, and only on official grounds, and the relations themselves had to be kept purely official. For instance, a man could come and request some information. As an official who was charged with other duties, Ivan Ilyich could not have any dealings with such a man; but if the man approached him about a matter that related to his function as a court member, then within the limits of this relationship Ivan Ilyich would do everything, absolutely everything he could for him and, at the same time, maintain a semblance of friendly, human relations–that is, treat him with civility. As soon as the official relations ended, so did all the rest. Ivan Ilyich had a superb ability to detach the official aspect of things from his real life, and thanks to his talent and years of experience, he had cultivated it to such a degree that occasionally, like a virtuoso, he allowed himself to mix human and official relations, as if for fun. He allowed himself this liberty because he felt he had the strength to isolate the purely official part of the relationship again, if need be, and discard the human…

Throughout the novel, Tolstoy compares the professional conduct of Ivan Ilyich with that of lawyers he encounters in court and the physicians he meets at his sickbed. While leaving a degree of ambiguity regarding the author’s potential intent to judge the conduct of physicians, it is not difficult for the reader to apply the comparison. As a physician-in-training, one dilemma that does not appear to have a clear consensus within the profession is the nature of the patient-doctor relationship: how involved should a physician be in the lives of his or her patients? Can a physician develop friendships with her patients? Should she? Is it ever acceptable for a physician to have an intimate relationship with a patient or former patient? The last question should have a clear answer, but there is not complete agreement (i.e. “never” vs. “not while there is a professional relationship”).

Answers to the other questions are less clear and may depend on the physician’s chosen area of practice and his approach. A family physician with strong roots in a community (i.e. other roles within the community, whether as a parent, churchgoer, volunteer, community leader, etc.) may find himself engaging more readily in the personal lives of his patients. Then again, the market demands on family and primary care physicians require that they see a very large number of patients, which may dilute their ability to develop strong interpersonal relationships with their charges. Hospital-based physicians may see patients primarily during acute episodes or extended hospital stays and thus only experience a slice of the patient’s overall personality and life. Nonetheless, the intensity of these hospital visits and stays may increase the likelihood of physicians, patients, and their families developing closer emotional bonds in defiance of sickness and death.

From senior physicians and instructors, I have received advice across the spectrum: some contend that physicians must keep a “professional distance” from their patients at all times and never be their patient’s “friend,” while others welcome friendships and connections with patients when feasible and desired. There are excellent arguments on both sides: cultivating a friendship may compromise patient care if the physician feels obligated to treat the patient differently from any other patient (e.g. avoid giving bad news, altering clinical judgment, etc.), but developing closer connections can help the patient recover faster (i.e. confidence in the treatment and relationship) and work more closely with the physician (i.e. compliance/adherence, taking ownership of one’s health and fate). At this nascent stage, I feel unable to determine a hard and fast rule to fall back on when challenged by the occasion, and yet I suspect that the decision about one’s approach to relationships as a physician is a very personal matter that is unique to each individual.

I am approaching the moment of challenge and significance: this Saturday marks the true end of my existence as a preclinical medical student. Afterwards, I have another three and a half weeks of rest and relaxation before I begin my clinical rotations in July (with my first month on Neurology and my second month on Psychiatry). In the midst of my studying, I have taken time each day to listen to the new adventures and stories of my fiancée, a third year medical student on her Surgery rotation. In some ways I envy her: she is beginning to live the life of a doctor intimately involved in the lives and troubles of real people, no longer restricted to the world of hypothetical situations and clinical vignettes. The sine qua non of the work of physicians is to immerse oneself in the scientific, emotional and psychological complexity of the human body and mind and the troubled souls that inhabit them. This is what attracts me and many of my colleagues to this profession: the privilege and ability to be involved with a positive, guiding, and sometimes interventional role in the transitions and challenges all members of our species must face.

On the other hand, I wonder if I should feel hesitation in welcoming this new transition: in entering this strange new world, am I leaving something behind in my previous routines of comfortable thought and experience? In dinner conversations with old high school friends, I find myself with a narrower repertoire of topics to share. Despite reestablishing roots to communities and friendships outside of medical school and engaging in recreational activities completely unrelated to medicine, the acquisition of medical knowledge has dominated the landscape of my mind. If I do talk about anything vaguely medical, I wonder if my friends are simply indulging me with tolerance rather than interest. Furthermore, and perhaps most astonishing to me, is the notion that perhaps many people (including my friends without a medical or biological science orientation) simply do not want to know more. Since I was boy, I was always curious about the inner workings of the human body, triumphs and failures alike. However, although medicine and health are increasingly topics of open discussion and news coverage, there is a limit that many individuals impose on the role of these topics in their conscious minds. Even my father, a biomedical researcher, is only willing to go so far in seeking to promote his health, address health problems, or simply discuss health issues. It is no wonder that physicians often find frustration in trying to steer their patients toward positive lifestyle changes and seemingly necessary medical interventions! It is not difficult for doctors to perceive health as the underlying fabric of all we can achieve in our human lives and medicine as the thread and needle that repairs and holds that fabric together. My stepmother, a physician, is ecstatic about my emergence into the relatively small club of physicians: now there is someone in the family with whom she can share her experiences in the medical world and her understanding of this life. However, this is only one aspect of what makes us human and meaningful, and in growing in clinical ability and knowledge, I feel myself slowly backing away from this principle. So, when friends of mine do express some symptom or slight sign of distress, I seem to instinctively jump on this opportunity to connect to them across a burgeoning and invisible gap. This is the self-imposed gap of isolation and insulation; we are driven to understand the mysteries of medicine, sometimes at the expense of our abilities to engage others in everyday discourse. While hovering in the liminal space between sickness and health, life and death, we discover levels of understanding achieved only by those who care for the suffering and the sick themselves. However, this understanding is necessarily alienating, because those who have not suffered (or who wish to forget their suffering) do not wish to share in the dark and troubling world we walk into each day as physicians.

I am incredibly lucky to be engaged to a wonderful woman, and it is an added bonus that she is simultaneously pursuing a career as a physician. However, in practicing mindfulness, I hope that our conversations continue to not be limited to the world of medicine, sickness, and suffering. We may find ourselves striking a truer chord with fellow physicians and those we hope to heal, but our relationships are not only defined by our conduct in foul weather. We must also enjoy and full engage our lives outside medicine and the hospital in order to bring some of that life to our friends and patients, to avoid burning out, and to maintain our own human compositions (of a body, mind, and soul).

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