Passages from the Masters: Leo Tolstoy’s “The Death of Ivan Ilyich” (part 1)

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.

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