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A Matter of Life and Death
After
nearly four decades in the operating room, Sherwin Nuland shelved
his scalpel and became a full-time writer. In a series of best-selling
books, he has tried to explain how we live, how we die, but most
of all, how we can heal the medical system by concentrating on the
patient's humanity.
by Bruce Fellman
October 2000
In early
October of 1980, Sherwin Nuland had just arrived at New Haven's
Hospital of Saint Raphael
to begin his evening rounds.
But no sooner had he stepped through the doors than Nuland, a 1955
graduate of the Medical School and a clinical professor of surgery
and gastroenterology at Yale, heard a frantic appeal over the hospital's
public address system. "Any general surgeon! Any general surgeon!"
the announcer cried. "Go immediately to the operating room -- immediately
-- any general surgeon!"
Of course,
Nuland could have just gone about his business in the expectation
that someone else would answer the page, but surgeons are not like
that. As he recalled in his 1997 best-seller, The Wisdom of the
Body, "the clamorous message, at once supplicating and commanding,
part outcry for help and part call to arms, spoke to me like some
suddenly recalled ancestral imperative. Feeling as though I had
been set off by a self-starting high-speed internal dynamo over
which I had no authority, I raced off toward the nearest staircase
and bounded up the steps."
Readers familiar with Nuland's dispatches from the front lines of
medicine -- How We Die: Reflections on Life's Final Chapter (1994), The Wisdom of the Body (1997), and The
Mysteries Within: A Surgeon Reflects on Medical Myths (published in March of this year) -- know what's about to come:
an account of a surgical procedure told in a you-are-there manner
that is at least as gripping as anyof
the dramas found on television. After more than 30 years as a practicing
surgeon in New Haven, Nuland had hundreds of such tales to tell,
and in 1992 when he was 61, he traded his scalpel for a Number 2
Eberhard pencil and took a year's leave from his profession. He
never returned.
Past and
potential patients were no doubt the poorer for this decision. But a wider audience
would soon benefit, for Nuland has not only become a graceful teacher about what
he calls "the wonder that is us," he is also a forceful spokesman for changes
in the way medicine is practiced, particularly at the end of life.
Although
Nuland did not publish his first book for a general audience until he was nearing
retirement age, the writing impulse had emerged long before. "I've always had
a 'gee-whiz' sense of the world, and I started writing about it when I was very
young," he explained. "As an 8-year-old, I remember going to a carnival in the
Bronx, where I grew up, and being so excited that I had to rush home and write
about the experience. But the only thing I had for paper was the blank front and
back pages of this cheap cardboard book on the wonders of the planet. I filled
them with my first bit of nonfiction."
In 1988, Nuland, who by then had become a distinguished physician,
a teaching surgeon, and a scholar of medical history at Yale, wrote Doctors: The Biography of Medicine. The book, "warmly recommended"
by New York Times reviewer John Gross, offered in-depth portraits
of some of the most important figures in medicine over the past
2,500 years. The author "succeeds in bringing his subjects to life,"
said Gross, "and he leaves you with a much better understanding
of what they achieved."
Nuland loved
surgery. In a presentation he once made to first-year medical students, he emphasized
how much fun the profession could be. And yet, the notion of being a full-time
storyteller, of getting down on paper tales he'd accumulated over a lifetime in
operating rooms and in the musty archives of historical libraries, was growing
more and more compelling.
As he passed
his 60th birthday, the physician did not feel that his surgical skills were in
any way eroding, but in the early 1990s, the upheaval in the way medicine was
being practiced made it "easy to step away. The joy of being a surgeon began to
disappear," Nuland recalls, adding that the advent of managed care was "eroding
our relationships with patients."
Worse still, the pressures the Medical
School and the Yale-New
Haven Hospital were under to make every operation a teaching
case-study changed the relationship between the clinical staff,
which is composed largely of private-practice physicians, and the
medical faculty. "I enjoyed operating," Nuland said. "I didn't enjoy
being a teaching first-assistant."
When the
surgeon took his sabbatical in 1992, he quickly discovered that he missed the
"easy companionship" that came with membership in the medical community. "It's
more than just being part of a surgical team," he said. "You can be in x-ray or
pathology and wind up in a complicated clinical conversation in which everyone
is contributing and learning something, or you might run into a colleague who
asks, 'How's Mary?' and wind up discussing the state of the universe. This place
is jam-packed with bright, interesting, articulate people, and conversation -- as I wrote on my application to medical school -- is my hobby."
But in his quiet, book-lined study in Hamden, and in an office at
the Historical
Library at the School of Medicine, Nuland realized that he also
"loved the writing life." In the Bronx tenement on 2314 Morris Avenue
where he grew up, he was "enchanted by the conversations I heard every Friday night when my grandmother would hold court. For me,
writing is simply another form of conversation."
It would soon become apparent that Nuland was exceedingly good at
his alternate craft. In 1994, the results of his efforts were published
by Alfred A. Knopf, Inc. How We Die examines in uncompromising
detail the biology of infections, cancer, heart disease, AIDS, Alzheimer's
disease, and other fatal afflictions. It is not a book for the faint-hearted,
but it amazed the publishing world, staying on the New York Times
bestsellers' list for 17 weeks. It has been translated into 17 languages,
and in 1994 it received the National
Book Award for nonfiction.
One reviewer
spoke for many in calling the book, which features a mixture of memoir, operating
room high drama, mea culpas, and a heartfelt cry for a more humane kind of medicine,
"brilliant, touching, and oddly uplifting" -- no easy accomplishment in what is
fundamentally a ceaseless litany of systems failures. But other readers complained
that Nuland went too far and was "almost sadistic in his candor." Indeed, in a
chapter called "Murder and Serenity," his account of precisely what happened when
a 9-year-old girl was attacked and killed by a knife-wielding paranoid schizophrenic
is more than most people could be expected to bear.
"A specific
sequence of events takes place in people who bleed to death," the
author notes in the course of the description, and then calmly proceeds
to delineate the physiology of what is technically called exsanguination.
The words, cold and clinical, are made all the harder to read because
the subject under scrutiny is a child, not a nameless cadaver.
And yet
read on we do, for the writing is compelling, and when Nuland is on a roll, his
prose is nearly impossible to put down. Consider his description of cancer: "The
disease pursues a continuous, uninhibited, circumferential, barn-burning expedition
of destructiveness, in which it heeds no rules, follows no commands, and explodes
all resistance in a homicidal riot of devastation," he writes. "Its cells behave
like the members of a barbarian horde run amok -- leaderless and undirected, but
with a single-minded purpose: to plunder everything within reach."
The writing evokes at once Shakespeare and the Bible in its combination of richness
and resonance, and that, it turns out, is entirely deliberate. "I
grew up the son of poorly assimilated, old-style shtetl Jews,
and the stultifying aspects of Old World orthodoxy were always in
conflict with the richness of my background," he explains. "I wanted
to be an American, and to me, the ultimate freedom was the English
language. It was my liberator and my oxygen."
Nuland fondly remembers the first book he ever took out of the Fordham
branch of the New York Public Library near his home in the Bronx -- it was Ab the Caveman; he was 7 years old -- but it wasn't
until he enrolled at New
York University that he embarked on a serious exploration of
literature. Shakespeare's plays found a receptive student, but oddly enough, the King James version of the Bible -- that most Protestant
of books -- reached deepest into Nuland's literary consciousness.
"There's an exalting beauty to the sound of the words, and the King
James version has this amazing combination of simplicity and grandness
to it," Nuland says. "I tend to write out loud, and the Bible's
cadences and flow, particularly in the Old Testament books of Ecclesiastes
and Psalms, have had a profound influence on my writing style."
But however enamored Nuland was with literature, his upbringing would lead him
in a very different career direction. In the close-knit world of
his Bronx tenement community, disease and death were always present.
A brother had died before Nuland was born, and his mother lost a
painful battle with colon cancer when he was 11. And then there
was his grandmother, with whom he was forced by the family's meager
circumstances to share a bedroom for eight years, a period during
which he would watch the health of his beloved "Bubbeh," as she
was known in Yiddish, fail. (The story of her gradual and steady
decline is told in "Three Score and Ten," a chapter of How We
Die.)
"I'd had
devastating contacts with disease, but I was always interested in what made people
tick," said Nuland. "It seemed like a natural thing to study biology."
He did so at the Bronx
High School of Science and at NYU, but when he entered the Yale
School of Medicine in 1951, the intellectual environment there triggered
a latent interest. "Several of my professors had a passion for medical
history and referred to the subject on rounds," Nuland explained,
adding that it was easy for him to get hooked. "I'm a Jew after
all -- we're made of the memories we've inherited from thousands
of generations. My sense of history is a sense of continuity."
That fascination
produced Nuland's first books, and medical history is woven into
the fabric of his human body trilogy, as well as into his latest effort, Leonardo da Vinci, which is being published this
month as part of the "Penguin Lives" series of brief biographies.
This intellectual bent, said Nuland, had him leaning in medical
school towards specializing in either psychiatry or internal medicine.
Ironically enough, he had no interest in surgery.
"In the early 1950s, surgeons were all big men who drove fin-tailed Cadillacs, smoked
cigars, and talked about women -- a bunch of gregarious guys who were into only
the pragmatic things of life. People who considered themselves sophisticates didn't
go into surgery, which was regarded pretty much as a coarse craft," Nuland explained.
But one
day as he was working in the old Tompkins Pavilion of Yale-New Haven Hospital,
chief surgical resident Bob Chase called him over and said that another intern
had had to leave suddenly. "I've had my eye on you -- you're just terrific," said
Chase, who asked Nuland to fill in.
The physician's
praise, Nuland would learn decades later, had been a complete fabrication. "They
needed somebody then and there, and I was a warm body," he said.
But as a result, he would work closely with a surgeon named Jose
Patino, who later became Colombia's minister of health and founded
a medical school there. "Jose had an aesthetic approach to surgery,
a certain romance," said Nuland. "I was captivated by him and by
the inside of a living body, which was so different from that of
a cadaver."
Nuland was
hooked, and as a result of what he calls this "fortuitous and transforming experience,"
he decided to become a surgeon, eventually specializing in gastroenterology. "We
have had a rewarding relationship, the belly and I," he says.
In part,
Nuland's books are a celebration of that relationship -- an intimate, fascinating,
and often hair-raising look at how medical battles have been fought, and won or
lost, both in Nuland's experience and over the past 2,500 years. Surprisingly,
his tales from the operating room do not come from notes penned immediately after
the surgery was over. "I've never kept journals, and I didn't deliberately set
out to collect these stories," he said. "When I write, I sit down with a pencil
and a pad and let things happen. I first try to capture the feeling and the emotion
of the time, and then the words just flow. The most basic thing in the human mind
is emotion, and from it comes formed thought, then the language of the intellect,
and finally the language of the mouth and tongue. So a single word can set off
a train of memories, and I'll remember an entire sequence of events: how things
felt, who was there with me, where they were standing."
The process
results in powerful chronicles of cutting, curettage, cardiac arrest, and, in
the case of the emergency call over the P.A. system that Nuland was impelled to
answer, the successful stanching of a burst aneurysm and the dramatic rescue of
a young mother from certain death. There is a tender account of the birth of one
of his children, with a detailed description of the precursors: the physiology
of sex, conception, and gestation. And there are solutions to medical mysteries,
such as Nuland's discovery of just what kind of bizarre growth was blocking an
infant's digestive system.
But what
lingers after the anatomy and medical history lessons dispensed in his books is
the feeling that Nuland is precisely the kind of doctor you'd want on and by your
side when things go very badly.
"A surgical
training program bleaches out the sense that you have in front of you a fellow
human being in travail, and all the rituals of surgery are designed to distance
you from the humanity of your patient," says Nuland.
He is quick
to add that this separation is usually both good and necessary, because it helps
a surgeon remain calm and clear-headed when blood is gushing out of some unseen
artery or a heart valve has to be "cracked" open with a finger, an exquisitely
delicate procedure, described in a harrowing chapter of The Mysteries Within,
that can either kill or cure a person. But he explains that the distancing process
also has its negative side.
With managed
care and its single-minded stress on cost-cutting has come an emphasis on so-called evidence-based medicine. "We've created algorithms that dictate treatment, and every person has to fit in a standardized pigeonhole," says Nuland.
Such a medical
model may make a certain amount of economic sense, but it violates an ancient
tenet of caregiving: that every patient is unique. "This is the old Hippocratic
tradition, and we're in danger of losing it," says the surgeon.
Losing the
idea that there's a person, not just a piece of ruptured intestine or diseased
pancreas, under the surgical drapes may be temporarily fine, Nuland continues,
but this mindset has made it difficult for today's doctors to recover a sense
of their patients' humanity once people in their care are in recovery, or, as
also happens, beyond it. "Surgeons are activists, and when they feel they can
no longer do anything, many of them turn away, first emotionally, then physically,"
he notes, adding, with no small amount of regret, that he was also guilty of this
collective sin of his craft. "Many times, I'd be making rounds with students and
when we'd come upon a dying patient, I'd say, 'let's go on to the next room.'
I didn't know what I should do. I felt impotent."
But surgeons have more at their disposal than just the physical
tools of their trade. "A surgeon is a healer, and sometimes you
may be able to help best simply by sitting there and holding someone's
hand," says Nuland, whose book on the biology of death came out
when pathologist Jack Kevorkian was publicly providing the means
for assisted suicide. Nuland quickly became caught up in the national
debate over how doctors should respond to patients whose lives had
nearly run their natural course. He was an uneasy spokesman, for
Nuland and his wife, Sarah, director of humanities and education
at Long Wharf, had two teenaged children, Will, now 18, and Molly,
16, still at home (Nuland has two other children from an earlier
marriage: Victoria, 38, deputy ambassador to NATO; and Andrew, 35,
a business executive in China), and the sudden demands on his time
that came along with fame "took a toll" on his family life. But
on paper -- he writes a regular column for the American Scholar and is in constant demand as an essayist for publications ranging
from the New
Yorker to Surgical Oncology Clinics of North America -- as well as on-line and in personal appearances, Nuland has
offered a compassionate counterpoint to Dr. Kevorkian's suicide
machines.
Modern medicine,
which until recently has emphasized an intervention-at-all-costs strategy, has
no doubt helped make life harder than ever to leave. But the ideal, suggests Nuland,
is not simply to abandon the dying or work actively to hasten their end. "By and
large, death is a messy business," he acknowledges, pointing out that physicians
can certainly help minimize the messiness by curbing the tendency to always try
to do something, even if it would be futile, and by taking the hospice approach
to minimize pain.
However,
this by itself is not enough, says Nuland. "The skill with your hands, the skill
with a diagnosis -- these are a kind of magic -- but the ideal doctor, the true
caregiver, also needs the skills of the heart: the ability to create the aura
that a patient is important to the physician and they're both enmeshed in a journey
they're taking together."
In How
We Die, Nuland advocates a return to one facet of an almost
Norman Rockwell-esque notion of medicine: "the resurrection of the
family doctor. Each of us needs a guide who knows us as well as
he knows the pathways by which we can approach death." This is not,
he hastens to point out, a call to abandon high-tech medicine. Rather,
it is a prescription that would temper today's medical wizardry
with a dose of humanity and help patients achieve that much sought-after
prize: "death with dignity."
For all
too often, ars moriendi -- the art of dying -- proves artless.
"The dignity we seek in dying must be found in the dignity with
which we have lived our lives," Nuland explains. "Ars moriendi is
ars vivendi: the art of dying is the art of living."
As Nuland
sees it, the journey is made easier if patients, dying or otherwise, know that
they can count on traveling in the company of someone who understands the values
with and for which they've lived. To be sure, there are times when physicians
with superspecialized skills are required, but at the end, "it is not the kindness
of strangers we need," says Nuland. Rather, it is "the understanding of a longtime
medical friend."  |
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