Charlottesville, Virginia, United States (Winter 2018)
Author and his doctor bag, en route to a home visit
Up in the intensive care unit an elderly man with a subdural hematoma is dying. His wife has been at his side all night. They are from out of town and were on vacation when he slipped and fell on the sidewalk. The intern has also been up all night. He goes down to the hospital cafeteria for a quick breakfast and brings back a muffin for the wife, soon to be a widow. The next day the patient’s wife calls their family physician to share the news. “A blueberry muffin,” she kept explaining.
A physician is dying at home, with hospice. He is in his bedroom, in his bed, too breathless to talk, too tired to pet the dog lying next to him. He can listen while his wife and his physician make plans. The dog, under the doctor’s hand, rolls on its back – dog talk for “don’t stop.”
Residents, almost from day one of residency, are tired of all the ways patients manage to ruin their health. Resident compassion is finite. One of the attending physicians emails his residents a description of an Alcoholics Anonymous meeting from the novel Infinite Jest by David Foster Wallace. Thus the residents’ reading group begins.
A third-year medical student learns about hypogammaglobulinemia and brain abscess from a sixteen-year-old boy on the teaching service. The abscess occupies the part of the brain where new memory is born. Forty years later that medical student cannot forget how each day of a six week rotation he had to reintroduce himself to the same welcoming patient.
That student’s intern on that teaching service is now his patient and gives him a signed first edition copy of the Michael Best biography of William Osler, the great physician, teacher, and book collector.
A pre-med student is referred for counseling. At the first session he needs forty-nine minutes of the fifty-minute hour to describe his mother’s ongoing terminal illness. In the fiftieth minute the psychiatrist asks what about your father? Later on, as a practicing physician, that student’s patients tell him he is a good listener.
The “S” in a student nurse’s SOAP note states, “My doctor hates me.” That doctor – that eager, sleepless, impatient, efficient, know-it-all, never-say-die intern – never thanked that student nurse. Until now.
Sometimes life stinks. The floor nurse and aide are changing the sheets and cleaning the patient while the intern is trying to help without getting in the way. Each day of a four-week rotation the third-year student volunteers to help the wound team dress a wound that everyone on the hall can smell. During a home visit the doctor helps the hospice nurse disimpact a patient’s bowels. Ninety percent of the job is just showing up – taking a deep breath and showing up.
In clinic a young man has the same complaint visit after visit. His pain turns into a sarcoma that grew inside a radiation field where ten years earlier a lymphoma had been cured. It is easier to talk about the Baltimore Orioles. The cap is a clue. The next visit an authentic Major League baseball, signed by the whole team including the legendary Cal Ripken Jr., earns a smile, a weak smile. The sarcoma grows and grows. The Orioles do not make it to the World Series that season. There are many ways not to abandon a patient.
On Christmas Day a ward team pre-rounds in the hospital gift shop. While making rounds they deliver gifts to every patient.
In The Call of Story – Teaching and the Moral Imagination, Robert Coles, a child psychiatrist, describes how novels helped him become a better clinician, teacher, listener, and person.1 Most of the book is about the call of story and the novels and characters that informed Cole’s life and the lives of his students. The book does not mention moral imagination until the last sentence, when Coles expresses hopes for students’ attempts to “find a good way to live this life” while responding “to the moral imagination of writers and the moral imperative of fellow human beings in need.”
Responding to the moral imperative may not happen until we respond to the clinical imperative, the unexpected and life threatening critical value that the on call doctor has to manage. The serum sodium of 110 needs clinical acumen and diligence. It does not need the patient’s life story or an Eagle Scout of an intern. We do not need moral imagination for the nuts and bolts of patient care; to take a basic medical history and perform an adequate physical examination; to insert a pre-packaged clinic note into the electronic health record; to graduate from medical school and pass licensing exams; to do a decent job and make a decent living as a doctor. The alphabet soup of regulatory bodies that overlook medical education and practice do not need moral imagination to set up and monitor standards of learning and care. Professionalism, in its narrowest and measurable sense, does not need moral imagination to get the job done and get it done safely and on time. Nor, to paraphrase the poet and doctor William Carlos Williams, does anyone need to get the news from poems, yet men die miserably every day for lack of what is found there.2 Robert Coles wrote an undergraduate thesis about Williams’ poetry and medical practice. They did home visits together in Patterson, New Jersey. A home visit is an occasion for poetry and moral imagination.3
When do students like us, lifelong learners, need moral imagination? When science is not smart enough; when digitized health records replace the patient with an icon;4 when the art of medicine is reduced to presence; when presence does not feel authentic; when someone breaks the silence just before it gets interesting; when all that is left is language but the patient is deaf and dumb and blind and relies on his wife to explain where it hurts; when we learn to trust such wives; when the translator has a hidden agenda; when doctors and nurses and patients and families have different agendas; when someone needs to call the family;5 when the family does not answer the phone; when the family cannot make up their mind and day after day ask for more time; when mistakes happen; when someone needs to apologize; when outrage is indicated but postponed till tomorrow; when ethics trips and falls and lands in a puddle of sophistry; when it is impossible to sleep; when it is impossible to forget; when it is time to forgive; when – amidst the routine nuts and bolts of acute and chronic care – we need to reassure patients who are frightened of results, procedures, blood, pain, side effects, commoditization of care, out-of-pocket costs of care, and abandonment.
In mathematics there is no real number that has a negative square, but the imaginary number i allows a solution to the quadratic equation x2 + 1=0. And so the unique solutions, different from cure, to clinical dilemmas. Writers need moral imagination, but so do the students, trainees, practitioners, and faculty who step into their patients’ stories. If, according to Tolstoy, all unhappy families are unhappy in different ways, then all helpless clinicians feel helpless in different ways, and all hapless students are hapless in different ways.6 There might be a novel in a glance at a patient or family, or a short story in all that is left out of the chief complaint, or a poem in the photos the patient keeps on the bedside table. Hemingway’s famous six word story (For sale: baby shoes, never worn.) is now a genre. A patient in the hospital recites a three word novel to a visitor: “It came back.” The visitor sighs and imagines the rest. Regardless of what came back, that patient needs to eat but cannot stomach the hospital food. The visitor comes back with a smoothie from the cafeteria. Regardless of what came back, that patient has nothing to read. The next day some of his favorite authors, from the visitor’s shelves, are on the bedside table. Hospice nurses like to teach doctors to “don’t just do something, stand there.” Imagination adds meaning and purpose and agency to standing there. Don’t just stand there, plot your next move.
- Coles, Robert. The Call of Story – Teaching and the Moral Imagination. Houghton-Mifflin, Boston, 1989.
- William Carlos Williams, Selected Poems, Asphodel, That Greeny Flower – book 1, New Directions Press, New York, 1968, 150-151.
- Becker, Daniel. Home Visit. JAMA 1999;282:217.
- Verghese, Abraham. Culture shock – patient as icon, icon as patient. N Engl J Med 2008;359:2748-51.
- Ombres R, Montemorano L, Becker DM. Someone needs to call the family. J Pall Med 2017;20: 672-675.
- Tolstoy, Leo. Anna Karenina. Penguin Classics, Middlesex, 1954, 13.
DANIEL BECKER, MD, MPH, MFA, practices and teaches internal medicine at the University of Virginia School of Medicine, where he also directs the Center for Biomedical Ethics and Humanities and co-edits Hospital Drive Magazine.