Tony Miksanek, MD

This essay is based on a presentation made at the University of Iowa College of Medicine for the conference

"The Examined Life: Writing and the Art of Medicine" on April 24, 2008.

It isn’t always necessary to take the temperature of fictional physicians to know that they are hot. Three short stories in particular sizzle with the tension between grumpy doctors, tough patients, and worried family members. “The Use of Force,” “Brute,” and “The Steel Windpipe” are all doctor stories – brief tales written by practicing physicians and narrated from the doctor’s point-of-view – where good intentions somehow lead to big trouble. Frustration, fatigue, and fear play key roles in all three stories.


First published in 1938, “The Use of Force” by William Carlos Williams is one of the most celebrated short stories ever written. Williams was a practicing pediatrician and poet. In this story of less than 1,600 words, a doctor’s house call turns into a battle. The Olson family are new patients for the doctor, who agrees to make a home visit for his usual fee of three dollars. Their daughter, Mathilda, has been sick with a fever for three days. She has not complained of a sore throat. The doctor is concerned about the possibility of diphtheria, since cases of the infectious disease have been reported at her school.


The entire family is nervous and maybe skeptical about the doctor. The child is silent as she sits on her father’s lap in the kitchen. She refuses to open her mouth to let the physician inspect her throat. Although the doctor finds the girl attractive and strong, he feels disgust for the parents. A scuffle ensues to inspect Mathilda’s throat. The doctor rationalizes that his tough approach is for her own good. The physician informs the parents that it is their choice whether he proceeds or not. Then he enlists them as accomplices, but they are weakened by the fear of hurting their daughter.


The father restrains Mathilda, who shrieks and knocks the doctor’s glasses off his face. She shatters the wooden tongue depressor by biting hard. Her mouth is bloody and her tongue is cut. The doctor refuses to give up. He is simultaneously furious and infatuated with the girl. He forces a hefty spoon down her throat that elicits a gag from Mathilda. The doctor spots the tell-tale membrane of diphtheria on her tonsils. The child is defeated. Mathilda’s secret is revealed. An important diagnosis is made.


“The Steel Windpipe” is another story about a young girl with diphtheria whose family is also anxious and dubious about the doctor. The difference here is that the diagnosis is immediately evident to the physician. It is the recommended surgical treatment that sets off a skirmish. Mikhail Bulgakov published “The Steel Windpipe” along with many other doctor stories between 1925 and 1927. He practiced general medicine in an isolated area of Russia for eighteen months and then moved to Kiev. Less than two years later, he swapped a career in medicine for the full-time pursuit of writing. Like “The Use of Force,” Bulgakov’s tale also chronicles a tussle. The doctor must not only win the confidence of the patient’s family members, but also defeat his own fear and feelings of inadequacy. In the process, he emerges as a confident and courageous physician.


In a remote region of Russia, a 24-year-old physician is lonely and edgy. He finished his medical training less than two months ago and finds himself in charge of a small hospital. The nearest city and medical colleagues are 32 miles away. It is November and gloomy. At 11 PM, he is woken from sleep to attend a sick child. Lidka is a beautiful three-year-old girl brought to the hospital by her mother and grandmother. The child has already been ill for five days. Tonight she is having trouble breathing. The doctor immediately diagnoses diphtheria. He is angry. Why did the family wait so long to seek treatment? He tells them that the child will likely be dead in an hour. He is cruel in dealing with the family and does not hide his contempt for their ignorance. He argues with them to obtain consent to perform a tracheotomy.


The doctor is worried. In his brief medical career, he has never done a tracheotomy or even observed this type of surgery before. Without the operation, Lidka will surely die. Yet the surgery is no guarantee of survival. She may well die on the operating table. The surgery to insert the artificial windpipe is difficult. Unexpected bleeding occurs and an assistant faints during the procedure. Lidka’s breathing is eventually restored. Two months later, she returns to the clinic and has completely recovered. The doctor never sees her again. His reputation in the community grows and his medical practice flourishes. He is tired much of the time. Sleep is a comfort and an escape.


In contrast to the previous two stories, “Brute” is a four-page parable that includes neither a young girl, distraught family members, nor diphtheria. This story is enthralled with wounds - the acute kind that are readily sutured, and the lingering type that defy healing. Written by surgeon Richard Selzer and published in 1982, the story addresses the relationship between fatigue and anger.


A doctor recalls his own misbehavior during an encounter with an uncontrollable patient in the emergency room 25 years earlier. After a long and hectic day, the ER physician must take care of a drunken man wearing handcuffs. It is 2 AM, and the patient is escorted by four police officers. He has a deep cut on his forehead, nearly five inches long, that will likely require two hours to stitch. The exhausted doctor is intrigued by the large man and his wound. He wonders how the injury happened. Unfortunately, the unruly patient will not cooperate with treatment.


In order to immobilize the man’s head, the doctor tightly sutures each of the patient’s earlobes to the stretcher. Sporting a cruel grin, the physician tells the man that his earlobes will be torn off if he moves his head. It is 5:30 AM when the laceration is finally repaired. With a white bandage wrapped around the head and blood staining each earlobe, the doctor decides the patient now resembles a maharajah rather than a thug. The physician warns the policeman not to be so rough with the man as they usher him out of the ER. Two and a half decades later, the doctor still regrets his rage and his spiteful smile and especially his inability to make amends.


The three doctor-narrators are all competent physicians and good human beings with the best of intentions. Still, their best efforts are sabotaged by a single personality flaw or weakness, difficult patients, and extenuating circumstances. Trouble often arises due to the doctor’s temper, pride, obstinacy, and fatigue.


Little attempt is made to hide or disguise the faults of these doctor-narrators. Sometimes the physician emerges as a hero as is the case in “The Steel Windpipe.” The doctor saves a life through his unbelievable boldness. Yet the physician’s success might just as easily be attributed to sheer luck or the grace of God. Other stories represent the doctor as an anti-hero. By the conclusion of “The Use of Force,” the physician is not merely stubborn, but creepy. The ER doctor of “Brute” savors his wicked ingenuity in the short term but rues it over time. Physicians wield lots of power and authority in these tales, and they are not reluctant to exercise it.


These doctor stories have similar morals. A common theme is the issue of whether the end inevitably justifies the means. Other themes stress the worth of intuition and ingenuity or the value of persistence and audacity. The lessons of doctor stories often involve warnings. Beware of pride. Never lose control. Be wary of caring too much. The fact that these tales are written and narrated by doctors imparts credibility to the stories. There are many reasons why doctors write, but two stand out: Physicians compose stories in an attempt to understand what they do and why they do it. Doctors also write to honor their patients. Perhaps a third important motive is atonement.


The three physicians in these stories respect toughness. Mathilda, Lidka, and the nameless big man, are all resilient human beings. Although their lack of cooperation causes frustration for the doctors, their toughness engenders admiration and even reverence by these physicians for the three patients. In the end, kindness and compassion by themselves are insufficient in the care of patients. Although empathy is important for physicians, these stories suggest that diligence and prompt action are vital. The need for action explains in part why these three doctors have no qualms about using their clout to achieve a goal of diagnosis and treatment. They are stubborn and relentless men. It can be argued that obstinacy is a good trait in a doctor. After all, who would want a physician prone to giving up on them?


Time is a central concept in these three short stories. Time is an enemy. Delay can be deadly. Time is transformative too. The young physician in “The Steel Windpipe” goes from insecure to cocky. The community is initially dubious about his ability but later admires him. The injured man in “Brute” enters the ER as a derelict captured by the police and exits as a prince. The doctor views him as a drunkard in need of stitching but ultimately venerates the man. The ER physician is a changed man too. Early on he is a tormentor but later an advocate and protector of the patient. In “The Use of Force,” Mathilda is transformed from a young patient to an obsession of the physician. The girl becomes the equal of the doctor. Conversely, the doctor’s actions lessen his stature.


These three stories underscore the significance of trust and how it is earned or simply given. Considering that the physician in each story had no prior relationship with the patient or family, the amount of trust bestowed upon the doctor is huge. In the end, trust surmounts uncertainty and subdues fear.


The doctor story is a distinctive form of literature. These narratives often function as parables. They demonstrate how easily things can go wrong between doctor and patient. These brief stories highlight the power of physicians, the vulnerability of patients, and the importance of communication and composure.

 

References

Bulgakov, M. “The Steel Windpipe.” A Country Doctor’s Notebook, translated by M. Glenny. (New York: Bantam, 1975).
Selzer, R. “Brute.” The Doctor Stories. (New York: Picador USA, 1998).
Williams, W.C. “The Use of Force.” The Doctor Stories, compiled by Robert Coles. (New York: New Directions, 1984).

 


 Tony Miksanek is a family physician in Southern Illinois and the author of two collections of short stories - Raining Stethoscopes and Murmurs. He is Co-Editor of the Literature, Arts, and Medicine Database.