Prescribed Reading

By JEROME GROOPMAN
Medicine engages life’s existential mysteries: the miraculous moment of birth, the jarring exit at death, the struggle to find meaning in suffering. But medicine is practiced in the mundane world and involves concrete issues like the imbalance of power between physician and patient; the role of quackery, avarice and ego in molding a doctor’s behavior; and the demand for perfection in the face of human fallibility. No insight into its more existential aspects is found in clinical textbooks, properly devoted to physiology, pharmacology and pathology. Rather, it is literature that most vividly grapples with such mysteries, and with the character of physician and patient.
Each spring, I address these nonscientific dimensions of medicine with 12 freshmen at Harvard College in a seminar called “Insights From Narratives of Illness.” We read about a dozen works, from short stories by Turgenev to Samuel Shem’s Rabelaisian hospital novel “The House of God.” The students are generally surprised to learn how the experience of illness touches every corner of human emotion and behavior. But they are even more surprised to discover that even as they read the assigned books, they are often reading, in the background, one of the world’s oldest books. That book is the Bible. Whether read as revealed truth or as a literary work, the Bible is a sourcebook of human psychology and an enduring inspiration for authors trying to capture the drama and dilemmas of medicine.
The seminar begins with the Tolstoy novella “The Death of Ivan Ilyich.” A magistrate in 19th-century Russia, Ilyich leads a life guided by external expectations, steadily climbing the social ladder and relishing his control over plaintiffs. With no warning, he develops a painful condition that none of his celebrated physicians can diagnose, and he begins to slip from life. The narrative mirrors Christ’s Passion, with the climax following the three days before the Resurrection. These allusions are not subtle, nor is Tolstoy’s solution to the apparent meaninglessness of suffering and death: God’s abiding love. Yet each year, only one or two students recognize the resonance of the Passion in this novella, or the Bible’s influence in subsequent readings. The idea that the soul must be cleansed through pain, prevalent in Tolstoy’s era, unsettles most of the class. They wonder whether such extremes of suffering are needed to shock a complacent character out of his narcissism. But I have seen this happen in the clinic, again and again.
We move on to Turgenev, Chekhov and Kafka before reaching Richard Selzer’s “Letters to a Young Doctor,” a set of autobiographical essays first published in 1982. Selzer, a retired Yale surgeon now approaching 80, helped usher in the modern genre of medical writing in which the physician puts his experiences under the microscope for the lay reader’s scrutiny. Medicine, Selzer contends, is an almost holy calling, a priesthood in which the “sacred process of divination” called diagnosis occurs. Indeed, for centuries the healing arts were largely the provenance of priests and other holy men.
In one story, Selzer tells the tale of Imelda, a young woman with a grotesque harelip and cleft palate whom he encountered as a medical student working in Honduras. Imelda is described as “still attached to the unshaped clay from which she had been carved,” a metaphor that recalls Genesis and God’s creation of Adam from the earth. Hugh Franciscus, an eminent plastic surgeon scheduled to operate on her, is depicted as a deity, omniscient and omnipotent. As he prepares to make the first cut, Imelda has a toxic reaction to the anesthetic and dies on the table. The next day, when Imelda’s mother arrives to take her body for burial, Selzer notices that the facial defect has been fixed; in the middle of the night, Franciscus secretly operated on the dead body. After they return to the United States, Selzer observes that his mentor is changed. “He seemed vaguely convalescent,” he writes, “as though a fever had taken its toll before burning out.” Franciscus “operated a good deal less, then gave it up entirely.” Patients seek perfection in a physician, and often we pretend to have achieved it. It precedes our fall from grace.
Later, Selzer himself falls. In “Brute,” another story in the collection, it is he who is in charge as the surgeon in the emergency room. A delirious, combative man is brought in by the police with a large gash in his head, perhaps the result of a beating by the lawmen. Exhausted and unable to restrain the struggling man, Selzer snaps. He sews the man’s ears to the mattress.
The students are repulsed by the story. But as an intern, I tell the class, I often felt at the end of my tether, and though I never had a violent response, at least once I made a grave error out of irritation. An older woman complained of discomfort under her breastbone, and I assumed it was indigestion. The antacids I prescribed afforded only meager relief. Her voice soon sounded to me like a nail scratching across a chalkboard. My mind closed to her complaints, and I dismissed her as a whiner. Several weeks later, I was urgently called to the emergency room. The woman was in shock. She had a tear in her aorta, the large vessel that carries the blood from the heart. She died. Although my fellow physicians told me that such a problem can be hard to diagnose, and is usually fatal, their words provided cold comfort. Like Selzer, I have never forgotten my mistake, or forgiven myself.
Later in the semester we shift to New Age writing, examining the message of books like the surgeon Bernie Siegel’s “Love, Medicine and Miracles” and, new this spring, Rhonda Byrne’s “The Secret,” the runaway best seller that asserts you can solve all your problems, including “eradicating disease,” by correctly aligning your thoughts and aspirations. The psychological underpinnings of these popular books are hardly “new,” I tell the students. The ancient redactors of the Bible also saw disease as a kind of punishment for sin, a consequence of flawed character. Consider the story of Miriam, who gossips about Moses with her brother Aaron. Her words of envy bring on a case of leprosy. Although later theologians took her transformation as a metaphor for the way slander and jealousy eat away at a person and at the social fabric, more literalist readings still see sickness as the wages of sin. Most people may associate this view with the likes of Pat Robertson calling AIDS divine punishment for sexual transgression, but the concept is also at the core of many more benevolent-seeming books. Both Siegel and “The Secret,” for example, suggest that even cancer arises from anger, resentment and other “negative” emotions. Miraculous cures occur when sick people fix their disease-causing psychology.
Magical thinking is a common malady as we strain to find moral or metaphysical explanations for why, say, some cells mutate and grow abnormally. But there is not a shred of scientific evidence to support the enduring view that patients bring such events on themselves through incorrect thinking. While the Bible contains the seeds of this idea, later religious thinkers like Maimonides, who was deeply influenced by Greek and Roman physicians, drew sharp distinctions between magic and empirical medicine. The New Age writers confuse them anew.
This semester, the class will end with a short novel that can be seen as a modern-day “Ivan Ilyich,” Philip Roth’s “Everyman.” In contrast to Tolstoy, or the medieval morality play whose title Roth borrows, there is no religious consolation for our encounter with decline and death. At the novel’s climax, the unnamed protagonist addresses the bones of his parents at their grave site. “Between him and those bones,” Roth writes, “there was a great deal going on, far more than now transpired between him and those still clad in their flesh. ... The bones were the only solace there was to one who put no stock in an afterlife and knew without a doubt that God was a fiction and this was the only life he’d have.” This echoes Hamlet’s pondering of Yorick’s skull, and also, ironically, Ezekiel’s prophesying over the dry bones of the dead; the only solace for the secular man, Roth says, lies in memory.
Some of the students will go on and become doctors, others journalists and teachers, mathematicians and financiers. All will one day be patients. They will then consult clinical textbooks or the Internet to learn about their disease, and some may also turn to self-help books. But it is in literature that they will find the sharpest revelations about the dilemmas of physicians and the yearnings of a patient’s soul. And, for believer and atheist alike, the Bible should be a book to turn to.

Jerome Groopman is a staff writer for The New Yorker and the author of “How Doctors Think.”