Jan-16-09
Can anyone tell me what nerve is making my heart race right now? And where its cell body is found?...(I'm moving the podium around hoping that my palms will dry up and that my voice will refrain from any cracking; you probably know that's a problem of mine that failed to resolve itself post-puberty). I was sort of volunteered to share some thoughts with you today, and I sort of volunteered to speak today.[i]
There are times when ideas fill your mind like water rushing from a geyser, and there are times when the ideas appear more like dew on the morning grass. The water from the geyser is strong, and direct, the dew is ubiquitous but very difficult to collect. I felt like I was gleaning dew as I prepared a few words to share today. An idea appeared in my head a couple months ago as we started the anatomy lab. Like the dew, I was certain it appeared; but when I took a moment to articulate the idea, it was difficult to gather. I moved on with life, and into block II[ii] and the idea came back. I tried then to give it a little structure but again, I came up with nothing. This process went on for the remainder of our time in HSF, which could mean one of two things, either 1) the idea itself was of little substance, or 2) it just needed some more patience and attention from me to develop into something meaningful. My hope is that the latter is the truth, but don’t hesitate to let me know if it was the first.
I remember feeling pretty nervous about the anatomy lab. There was anxiety about how it would feel to skin the back, the arm, the hands of another human being, to look at this person on the inside, literally. Was this OK? Seeing a person on the inside was supposed to be just a symbolic thing, right? I had never cut into a human back before; knowing that anatomy lab was an inevitable part of the curriculum, I tried to reason away the uneasiness. Was it ethically OK? Yes. Would I be capable of the lab work? Yes. I couldn’t find a reason why this would be wrong, so I ruled any anatomy dissection from here on out, OK and attributed any uneasiness to the fact that running a knife through a human body for the first time was not supposed to feel OK. Whatever the reason for the concern, in less than one lab, my nervousness was fully replaced with fascination. I quickly realized that this donor would submit to everything I and my tablemates deemed beneficial to our learning. There was mild protest at times manifest through a stiff arm or extra tough fascia, but that was negligible. The donor let us cut open her back on that first day, just as she would soon open her arms to us. And she did, just as she gave up her lungs. And after beating its final beat, she gave up her heart, shedding the pericardial sheath to share it in the flesh for the very first time. And then came the neck, the head, and of course, the brain. Dr. Piekut was at my side to help cut free the remaining cranial root as I lifted the brain up and yelled, “It’s a girl!”
These were exciting moments. We were seeing the human body in ways that we never had and may never again see. An author once described the anatomy experience as an intimate connection with another human being because we see the body in its entirety. The author claimed that the experience was more intimate than making love. Is that true? Did I get to know this donor as deeply as the author suggests? I just described some very intimate experiences with the donor, but is that really getting to know the person?
This question about “knowing a person” first came to me, albeit from a slightly different angle, while studying one afternoon in the anatomy lab. I was carefully going through the nerves and muscles of the forearm. I sat on one of the steal stools beside the donor with my left hand separating the muscles to better understand what was there and where it was going. With my right hand, I picked up the donors left hand to appreciate the underside. And there I was, high-fiving with the donor. But there wasn’t anyone on the other end, right? Well, who’s hand was I holding up if there was no one on the other end? I was obviously holding a hand that was attached to an arm that was attached to a torso where a neck and head attached. Judging by everything I could see there was a person on the other end of this high five. At one point, that was true, but despite what my eyes told me in the anatomy lab, there was only the body of a person, but not a person. I could touch, poke, smell, see, even taste this body but it would not allow me to truly know this person.
And this is the idea that I want to share, that we cannot truly know a person, a disease, a whatever, if all we go on is observation. What we observe is never what is truly there; it is only what we are able to observe. In other words, observation is not capable of bringing us to a full knowledge. This is certainly the case in the art of medicine. Look back at the cancer screening lectures of yesterday and the day before. After all of the meta-analyses, the only certainty is that we certainly don’t know what to do about screening. Any search in Up-to-Date will show the same thing, one anecdote followed by a recommendation that replaces the previous collection of anecdotes and recommendations. What is unsettling and true is that all of what we are learning in medicine is grounded in observation. Which leads us to a postmodern predicament: how can we say to our patient that we know what is going on with them if all we go on is grounded in an incomplete modality: observation.
I’m going to leave medicine for a minute in its little quandary and now ask if it is also true that to know a person we must supersede our faculties of observation. I am sure that many of you can relate to a mental flash where a classmate from grade school pops into your head. Their name, face, maybe even one particular interaction suddenly comes to mind, and then you realize that although you went to the same school for four, six, ten years, their memory is reduced to that one interaction or maybe just a face or name. Did you really know this person? Can you say that you know this person anymore?
Every observation you made of that person was added to a mental file and stored until updated by a future observation. Just as in Up-to-Date, our brain is busy adding to the mental files we store on the people in our life and with each new anecdote comes a revised recommendation e.g., avoid this person, love this person, listen to this person, laugh at what this person says, etc. Our knowledge of this person and therefore our behavior is based on a very limited set of data. How can we be sure that we actually know our colleague? How can we be sure we know our patients? It doesn’t seem like we can. We will continually operate on incomplete information, our biased and short-sighted observation, leading us to act with incomplete understanding.
Recognizing this state brings to mind the words of the apostle Paul to his fellow saints in Corinth, “Now we see through a glass darkly.” It was true then, and despite all of the wonderful innovations in the world, your glass and mine remains dark. Our understanding of medicine is incomplete, and we don’t fully know our neighbor.
So what? You might be thinking. “Thank you for pointing out that my glass is dark. Is that it? Well, yes, but there is something we can do as we look into medicine and look into people through our shaded glass. Paul, in his same letter to the Corinthians, identifies three things that will enable us to overcome the limitations of our darkened glass i.e., our incomplete understanding. These are faith, hope, and charity. Faith is recognizing that there is more to this person than what we now see. It is acting on this belief to discover more about them; it is basing our judgments not only on anecdotes but on the eternal nature and goodness of the person. We can have faith to research and discover more about a disease. We can have faith in our classmates; in our professors; in our patients. Hope gives direction to our faith. We hope that good things will come out of our actions and our interactions. We hope that the treatment will work; that the grant will be accepted; that greeting our patient with a smile will help them feel at ease; we hope that a nod to a classmate across the lecture hall will communicate something, we hope it will communicate that we are glad to share this space and this experience with them. Charity is forgetting about our self, it is leaving the self-interest at the door. With charity, we stay until all of the patients are seen. We forgive the person who was harsh towards us. Out of charity, we fill out our course evaluations. I have faith, and I hope that you get the idea here. I will now exercise some charity and end this talk.
In closing, I believe it is through faith, hope, and charity that we can move beyond observation and truly know a person or a disease. These principles enable us to observe as God observes all things in their true and complete state. I give thanks to the donors who through faith in us, hope in our future, and charity in their soul shared everything they could. Now let’s try to apply these principles to enrich our experiences in life with a more full knowledge and to enrich the life of those around us. Thank you.
[i] Our anatomy professors who were in attendance were known for their zeal in testing our knowledge of nerve fibers. They loved to point to an organ of the body and ask what nerves innervated said organ and where the nerves originated. Thankfully, this opening that did in fact come to me just before I got up to speak got the audience laughing and helped me feel a bit at ease—I was really nervous, sweaty palms and all, pathetic, huh.
[ii] The class that involved the anatomy lab was called HSF. It was organized into four blocks that covered a little over three months time.
2 comments:
That was a fine speech, very well done. One wonders how well the inclusion of scripture went over when directed to a room full of scientists, or in other words empiricists?
Med school is kind of like that verse in Revelations, you can be hot or cold; just don't be luke warm er you'll get spit out.
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