The hand’s importance in daily activities is often overlooked even as I look down at my fingers typing these very words. Rudimentary at first glance, the expansive nature of the hand is as complicated as its anatomy and not in the palm reader sense. Its complexity manifests in the intricate duties it performs when acted upon by the user’s brain, and yet there is so much to learn by its simple examination in its resting splendor. The beautiful dichotomy of the hand is illustrated in the simple gesture of hand-holding, a parent’s single finger grasped in their infant’s small palm contrasted with the loose grip of the dying parent with their child. It is in the soft caress that hands are capable of, but also the solid fist of a hard punch, and the complexity of playing instruments, weaving, programming AI and painting.

My office visits begin and end with a post-COVID handshake if the patient is agreeable. The essential job of the clinician begins with listening followed by thorough examination. For it is in examination that the patient map unfurls. From the initial handshake, to how one holds their hands during the visit, little clues are imperceptibly directed at me. The wringing of the patients’ hands is the tip off for anxiety, along with tightly picked nails or scars. The slight hand tremor can be the giveaway of Parkinson’s disease, alcohol withdrawal or thyrotoxicosis. Then there is the yellow-stained thumb and index finger of the habitual smoker. The tiny muscle fasciculations below the skin are the tip off for advanced carpal tunnel syndrome, advanced neck arthritis, amyloidosis or the more devastating amyotrophic lateral sclerosis. The feel and look of the callus distribution on the palm of the construction worker as opposed to the soft and supple feel of the secretary’s palm or those of the computer programmer are all documented subconsciously, while noting the fissuring and hyperkeratotic papules and scale of the mechanic’s hand, or the similar changes on the non-mechanic’s hand suggesting dermatomyositis or anti-synthetase syndrome. Tell me how AI could perceive most of this without the input of touch and observation?

Whether in the office, grocery store or at dinner, examination proceeds whether the person is willing or not, or even aware. Examining the hand is like picking up an oak leaf in the fall with its midrib, venules and variegation all telling you about the health of the tree from which it has fallen. We won’t discuss ornaments that adorn the hands such as rings or nail paintings as this is quite illustrative in and of itself. Rather, I am more interested in scars, irregularities and deformities. Each small finger joint so intricate and important in function, working simultaneously together like the worker bees in a hive or an orchestra.

From the fingertip alone, Terry’s nail, with its loss of the crescent half-moon, ground glass white appearance, and the darker line at the very tip of the nail, suggests underlying liver issues. Move that line of demarcation proximally to affect half of the nail, it transitions into Lindsay’s nail and communicates underlying kidney dysfunction. Should that half-moon crescent change to a blue tinge or even completely change to blue, the patient may be being slowly poisoned by silver or copper. The pale nail bed alone is a tip-off for anemia. A murky longitudinal dark stain, like a comet and its tail tracing from the cuticle to the free nail edge, can be the forewarning of a melanoma. Smaller dark stripes distributed throughout the nail are the potential signs of endocarditis, lupus or vasculitis. Should the patients’ nails look like a pock-marked battlefield, the likelihood of psoriasis as a verdict is greater, especially if they are accompanied by joint aches or a reddish-silver raised skin rash. If the same patient did not choose to paint their nails yellow, and it spontaneously occurred, my pondering moves to lung pathology or autoimmune issues. Lastly, horizontal linear grooves on the nail, named after our friend Joseph Beau, tells me the patient is zinc deficient or enduring chemotherapy. While AI can certainly catalogue each of these physical exam signs and what they indicate, my examination can transpire on a soccer field, train or exam room and without the need for a computer.

Ascending from the fingertips, I look at the profile of the fingers. Do they keep their standard characteristic orientation, straight as an arrow or do they angle? Simply the direction of that angle can tell me so much, as the rearrangement of the interphalangeal joints offers countless clues. Should the patient get angry at all the meddling with his finger and point that finger at me, does his finger hyperextend backwards from the middle joint while the fingertip itself bends forward? Quickly I am carried pondside to see the swan neck of rheumatoid arthritis, lupus or scleroderma. However, should that fingertip hyperextend while the middle joint flexes, this represents the boutonniere deformity of injury or other connective tissue disorders. Moving from the quaint pondside to the opera house, I consider the shortened collapsing finger joints crumpling in a telescoping manner like an erstwhile opera-glass. This is the finger joint destruction of arthritis mutilans or advanced psoriatic arthritis. Now envision that same finger, fat and round like a sausage, and you have the less than delectable exemplar of dactylitis, which may be another sequelae of psoriatic arthritis, lupus or even tuberculosis.

Lest we forget the palm, it can serve as a mirror into superficial and deeper matters both physically and professionally. If there are a collection of cords slowly stealing a digit’s extension, you’ll find the fascial condensations of Dupuytren’s contracture. This patient has either had a long career of intense work with their hands or has been long afflicted with diabetes or may just have one more thing to thank a parent for. Should one of the fingers flex and become locked, trigger finger is now the diagnosis, although no marksmanship is required.

Both AI and I could go on for pages with the exam findings of the hand if necessary, particularly if we wanted to discuss congenital hand deformities or telltale characteristic findings on x-rays such as the appropriately named boxer’s fracture or the hand surgeon’s bane of the scaphoid given its peculiar blood supply. Oh, the many amusing mnemonics to remember the bones of the wrist can be quickly recited, both from AI and by the medical student! Ultimately, the power of observation is vital and a trusted companion of the doctor alone. The world is the clinician’s exam room and once one puts on these glasses and truly observes, it is hard to unsee the pathology vexing us humans. So, I say go forth and learn. Always start with a handshake as this key unlocks so much during the visit and then sit and watch. We physicians are a fortunate few beholden in full to our patients, who are granted access to this vast vocational milieu and this is what sets us apart from machines.

Web image by Medhum.org

Why did you write this book?

I’m encountering more and more people over the last few years, particularly post-COVID, who have the perception that the categories we use in psychiatry have a kind of fixed, objective, and quite rigid reality. Twenty years ago, when I started as a GP, I might have seen somebody who said, “I feel anxious all the time,” whereas now I’m more likely to meet somebody who’ll say, “Well, I have generalized anxiety disorder.” That’s a shift in the way that society talks about mental illness. At the same time, a lot of people are questioning these categories’ usefulness, so there’s a paradox—a sort of polarization.

I wanted to write a book which explains, from my perspective, A, how the way we think about mental illness has always been shifting and evolving. How we think about mental illness changes with culture, time, and geography. And B, if we can adopt a more flexible and humble approach to our current understanding, that actually offers more hope to patients. Because believing “I have generalized anxiety disorder,” rather than “I feel anxious,” can sometimes be helpful, but it can also box you in and become self-fulfilled. I’m seeing that same shift across the whole spectrum of mental illness and suffering, and the book is a call to question that and reassess where we’re at in the mid-2020s—and a plea for a little bit more kindness and flexibility.

What would that look like in practice?

For example, if somebody comes to me saying, “Well, I have generalized anxiety disorder, so I can’t do this stuff,” part of my work is to help that patient adopt a more hopeful perspective: that there are strategies that they can learn, that there are medications that can help, and that our mind is shaped by many different influences. There may be explanations for their anxiety that have to do with the brain and neurotransmitters and so on. But in most people, there are also more influential factors that have to do with their early childhood experiences and their current social setup, the precarity of their relationships or their economic situation, the quality of their sleep, or the substandard nature of their housing. There are all sorts of other factors that are having a bearing on their anxiety that I would seek to help them explore, rather than them just blanketly saying, “I have generalized anxiety disorder—can you give me the pill for that?” I’m trying to encourage my patient to say, “Yeah, there are pills that can help. But there are all these other factors that we need to think about. And do I really find that label helpful?” For some people, once you start to dig into it, they don’t.

We can extend that way of thinking to people who’ve had a psychotic episode. Between 10% and 20% of people who have a psychotic episode will never have another. For substantial numbers of people, their psychotic episode is actually a product of all sorts of stressors that are on them at that time. If you can find a way to modify their stressors, put them in a more supported state, and understand what place that episode has in the story of their life, you can then make a story that makes sense of that episode as the product of a uniquely difficult moment in their life. That can help people get over that episode and also, I hope, make it more likely that they don’t have subsequent episodes. Or, if they do, then they’re able to return fully to their normal functioning in between.

You write, “For the last forty years much Western psychiatry has behaved… as if our thinking is a simple matter of chemical levels in the brain. The truth is far more complicated.” For example, a 2023 study you cite challenged the serotonin theory of depression. [1] Why do you think that the chemical imbalance narrative has persisted?

There’s a number of reasons. That hypothesis came through at a time when our lab technology was starting to be able to measure neurotransmitters, and it offered a good story. If you become depressed, you feel as if you’re lacking something—as if you’re lacking some kind of fuel or energy. That lack translates very easily, in our metaphor-making minds, to the idea that there must be some kind of lack between our brain cells.

At the same time that this technology was becoming widespread, there was the promotion of a drug which seemed to help: Prozac. There’s no doubt that SSRIs do make a difference. Again and again, they’re shown to be better than placebo. The effect is probably a lot smaller than a lot of the drug companies would tend to promote in their materials, but they do help, and I continue to prescribe them. But what that study you’re referring to was saying was that, even if these drugs help, they don’t help by boosting serotonin levels. We can’t find evidence that substantiates that theory.

The first half of the 20th century was governed by Freudian ideas. Psychiatry in much of the West was dominated by those kinds of psychoanalytic ideas. Then, during the ’50s and ’60s, as we started to develop tricyclic antidepressants and experiment with other kinds of antidepressants—the first were anti-tuberculosis drugs—the idea grew that there might be a chemical solution, which fit very well into our technologically and pharmaceutically focused medical culture. Then, from the late ’90s, there was a huge explosion of the idea that, actually, a lot of it was genetic.

Now, even the idea that neurotransmitters are strictly excitatory or inhibitory is starting to be questioned. Essentially, the whole picture is vastly more complicated than the neurotransmitter hypothesis from the ’90s suggested. I don’t take that as a great failure of the hypothesis; it was an attempt to make sense of something very complicated, and the drugs that spoke to that metaphor are useful and are still among some of the most widely prescribed in the world. But the fact that we no longer think that low mood is purely because of low serotonin is a really positive step forward. It encourages us to embrace more fully the biopsychosocial approach to mental illness. The field of psychology and psychiatry is not known for consensus, but one thing everybody agrees on is that it’s not just biology, it’s not just psychology, and it’s not just sociology—it’s all these influences that have an effect on our mental health.

Are there other common assumptions about mental illness that you think deserve closer scrutiny?

Every age uses the metaphor of its highest technology to make sense of the mind. In the 19th century, the mind was famously described as an enchanted loom; the mind was thought to be weaving our experience, moment by moment. We’ve now got these very pervasive metaphors of wiring, which I find quite unhelpful because the brain is nothing like a circuit board. It would be like a circuit board made of jelly that can fix itself. So I think the wiring metaphor, although it has its uses, has gone too far because it’s too deterministic. It’s not organic enough.

Half a century ago, Stanford psychologist David Rosenhan wrote, “A psychiatric label has a life and an influence of its own.” To what extent can psychiatric labels help, and to what extent can they hinder?

There’s a lot of controversy about the Rosenhan experiment. [2] He’s been accused of being a charlatan and fabricating quite a lot of his data. But I think the value of his reflections still stands. I’ve definitely seen in my clinical practice that people will be treated differently because of a label that has been put in their notes, even though that label might have changed several times. I’ve had patients who’ve had four or five different labels in the course of their career, while they’ve had actually pretty much the same kinds of experiences and distress throughout all of those.

What I find really helpful in my conversations with patients is the fact that we don’t always have to give a label. If someone is really keen for one, then I’m happy to explore that with them and tell them, “These are the psychiatric categories that are on offer in the current edition of the DSM. Some people find them really useful, but with every new edition of the manual, they change, so they’re not describing something discrete, fixed, or in the natural order of things. They’re a way of describing and approaching distress, so let’s talk about how much they would be helpful for you.”

Now, in the U.S., I understand that labels can be essential because of insurance-based medical payments. In a U.K. context, a label may not be as useful because our psychiatric services are organized differently. I gently explore with each patient how much for them it’s going to be transformative. If it’s going to help ease their suffering and get them the treatments that they want, then I embrace it and help them get the one that fits best. But if it’s not going to be transformative in terms of how they can access care, then I tend to try to avoid giving a label because that can allow a level of optimism and dynamism about their state of mind. It more genuinely reflects the possibility of change and adaptation, rather than risking somebody changing the way they think of themselves.

As human beings, we’ve got such a huge tendency to put shame on one another. What labels seem to do in our current moment is absolve people of that shame in a really helpful way. I’ve had patients say to me, for example, that until they got their diagnosis of ADHD, they felt so ashamed of not being able to focus properly at work, and what that label did was offer a kind of absolution from that shame because it said, “There is this category of being that is separate from you and which seems to be affecting you, but it’s not your fault.” That can be wonderfully liberating. In those kinds of situations, I’m often keen to embrace the label if it’s going to help the patient cast off their shame. But I’m also questioning: Why have we got that shame? Isn’t it a pity that people often feel that they need to embrace a medical diagnostic label in order to rid themselves of that shame?

What strengths do primary care physicians bring to mental healthcare compared to someone more specialized?

One great advantage of somebody in my kind of role is that I’m embedded in the community. I often know the whole family, and I’m seeing people for all kinds of other problems which have a bearing on their mental health. I’ve become more aware of the connections between families and individuals; a specialist only sees the one individual with a particularly distressing problem—for longer appointments, granted, but removed from that context.

There’s a wonderful GP writer in the U.K. called Iona Heath, who has written a lot about the fact that it’s in the primary care consulting room where suffering is either given a label and understood within a medical model, or not. Some people see primary care physicians as essentially holding a line, or acting as some kind of gatekeeper, between the huge mass of human experiences that are out there and which ones become medicalized. A lot of people will come and see me about something fairly banal—almost to try me out, to try and figure out whether I’m going to be kind, compassionate, friendly, or approachable. Once they’ve tried me with a symptom that they’re not too fussed about, then they’ll risk sharing the one that they’re really worried about.

As a primary care physician, I feel I have a very privileged role: You’re not part of the family, but you’re not part of the establishment—you’re somewhere between the two. I’m often the first port of call for people hoping to make sense of their experience.

One line from your book that struck me: You write that today’s DSM categories will one day “seem as overconfident as the old phrenology charts.” How literal or hyperbolic do you mean that comparison to be?

Phrenology was debunked about 130 years ago. By the late 19th century, it was already starting to lose its traction because good thinkers were realizing it was a load of rubbish. If I could fast forward to 2176 and ask the doctors of that time what they’ll make of the DSM-5, I don’t think they would see it as phrenology, but they would certainly see it as utterly obsolete and unhelpful to them because it’s a cultural document of the West in the early 2000s. We can’t imagine what Western culture is going to look like in 2176. I’d argue that it’s quite likely that it will be very different from our current culture, that our neuroscience and genetics will have progressed in huge leaps and bounds, and that the organization of our society—while it may not have progressed—will have changed utterly. The DSM-5 will be of purely historical interest. When I was born in the ’70s, they were using the DSM-II, which is now considered very much a historical document—and that’s within my lifetime. I’m hopeful that the DSM-6, if and when it ever appears, is going to be an improvement on the DSM-5.

What inspired the book’s title?

From my chair in the clinic, I don’t see people’s minds as brittle and fragile. I see people as immensely resourceful, resilient, adaptive, and dynamic. People are incredible; they always amaze me with their ability to get over even the most extraordinary difficulties, suffering, and traumas. In my seat, I see the mind as far more unfragile than a lot of the rhetoric in our culture suggests.

The Unfragile Mind: Making Sense of Mental Health
Gavin Francis
Publisher: The Experiment, New York. 2026. 256 pages.

[1] Moncrieff, J., Cooper, R. E., Stockmann, T., Amendola, S., Hengartner, M. P., & Horowitz, M. A. (2023). The serotonin theory of depression: A systematic umbrella review of the evidence. Molecular Psychiatry, 28, 3243–3256. 
https://doi.org/10.1038/s41380-022-01661-0

[2] In the 1970s, Rosenhan and eight pseudo-patients feigned auditory hallucinations to gain admission to a dozen psychiatric hospitals across the U.S. Once inside, Francis writes, they “declared themselves free of the hallucinated noises, but found it very difficult to be believed, and be discharged” (p. 47).

Web image created from book cover by Medhum.

Jurecic’s astutely researched, nuanced answers to those questions propose a corrective to the extreme skepticism of “disembodied criticism.” Such criticism, she claims, dismisses testimonial writing from “a position of distance and privilege.”  At the same time, her answers affirm that intellectually “rigorous” responses to texts are central to the critical humanities (15). To support her position, she offers attentive readings of illness narratives by Virginia Woolf, Reynolds Price, and Jean-Dominique Bauby, as well as the theoretical writing of literary and other scholars.  For instance, Jurecic speculates that the condition of a reader’s body aligns with their responses to texts. In a chapter called “Theory’s Aging Body,” she observes that as skeptical scholarly readers aged—think of Stephen Greenblatt, Michel Foucault, Judith Butler—they turned their attention to “illness, vulnerability, and mortality” (93).  Jurecic also suggests that criticism’s function to expose cultural conditions turns illness stories into critiques of the effects of contemporary medicine on our experiences of vulnerability and mortality. The relatively new concept of living “at risk” is a case in point. Stories about living with the risk of experiencing a particular illness in the future leave potential patients with uncertainty,” prompting narratives that seek the “personal meaning of the impersonal statistics” that medical encounters now regularly deliver (18).   

Jurecic also reflects on the ways theorists have understood the possibilities of representing and responding to pain in the varied approaches of philosophical thinkers Elaine Scarry, Martha Nussbaum, and Richard Rorty, along with anthropologists Jean E. Jackson, Byron Good, and Veena Das. In an exceptionally comprehensive and nuanced reading of Susan Sontag’s theoretical, fictional, and journal writing about suffering, Jurecic uncovers Sontag’s inconsistent, yet revelatory positions on the human capacity for responding to representations of pain. The chapter on Sontag is enriched by Jurecic’s reading of Annie Lebovitz’s controversial photographs of Sontag’s final days (included in A Photographer’s Life: 1990-2005) and David Reiff’s responses to Sontag’s suffering in his memoir about his mother’s illnesses (Swimming in a Sea of Death).   

Illness as Narrative closes with examples of what Jurecic calls reparative writing and reading practices. Reparative writers, such as Jean-Dominique Bauby (The Diving Bell and the Butterfly), Jurecic claims, both create “a more coherent sense of themselves” and dislodge culturally “fixed ideas and narratives” about illness or disability (109). Her discussion of reparative reading considers the limits of two competing readings of Anne Fadiman’s The Spirit Catches You and You Fall Down. One assumes that readers will empathically and unreflectively imagine those who are culturally different from themselves. The other looks skeptically at the assumption that what medical educators call cultural competence can be acquired by reading a book. Jurecic suggests that strategies for reading and teaching informed by Janelle S. Taylor, Eve Kosofsky Sedgwick, and Rita Felski encourage more complex habits of response, such as Taylor’s concept of “’empathic curiosity’” (122).    

Illness as Narrative poses questions so central to discussions in the medical humanities that it should be read by those who teach in the health professions and disciplines. Jurecic’s book advances the groundbreaking case made by Arthur Frank that illness narratives contribute not only to medicine, but also to contemporary culture and individual lives. Since Illness as Narrative rigorously addresses questions of how to respond to and teach the literature of suffering, it has consequential implications for literary studies and the critical humanities more generally. It exemplifies how a marginalized sub-field can offer a perspective that the dominant theories in the larger discipline fail to notice. Perhaps the most urgent professional question Jurecic asks is what we lose if writers and readers attuned to the ill or suffering body are not heard in critical discussions. Fortunately, Jurecic’s clear, jargon-free prose and the texts she writes about also welcome readers in disciplines beyond literary studies and health humanities into the conversation.  

Illness as Narrative: 
https://upittpress.org/books/9780822961901/

Arlene Croce: 
https://www.newyorker.com/magazine/1994/12/26/discussing-the-undiscussable

Arthur Frank:  
The Wounded Storyteller: Body, Illness, and Ethics, 2^nd ed. Univ of Chicago Press, 2013. (Orig. 1995) 

Illness as Narrative 
By Ann Jurecic 
University of Pittsbugh Press: 2012, 192 Pages 
Web Photo by Mostafa Saeed 

Alive: Our Bodies and the Richness and Brevity of Existence by Gabriel Weston 

Boston: David R. Godine, 2025, 304 pages 
ISBN 9781567928235 

The physician experience, medical history, motherhood, anatomy, and worries about her diseased mitral valve are tenderly sutured together by ENT surgeon Weston in her exploration of “the poetry of the body.” In thirteen chapters, she eloquently contemplates “the strange, unbridgeable gap that exists between the body science describes and the one each of us is living inside right this moment” (p194). In describing the anatomy of bones, brain, breasts, genitals, gut, heart, kidneys, liver, lungs, skin, and womb, Weston writes with a wit and intense curiosity reminiscent of popular science writer Mary Roach. But the book’s splendor arises from its attention to the art of doctoring. Weston notes how good physicians require a kind of “bifocal vision” that allows them to see the generalities of the human body but also the unique details of an individual patient. She extols empathy and elevates vulnerability: “We are not separable from those we care for, just as our strength is not separable from our vulnerability” (p263). Melding science and sentiment, mixing professional life with personal life, Weston enlivens anatomy and pays homage to the physician-patient relationship.  

The Land in Winter by Andrew Miller 

London: Sceptre, 2024, 384 pages 
ISBN 9781529354270 

Andrew Miller’s remarkable 1997 debut novel Ingenious Pain chronicles the complex life of an 18^th century highly skilled English doctor incapable of feeling pain. Twenty-seven years and many novels (Oxygen, Pure, The Optimists) later, Miller’s latest book spotlights a main character who also happens to be an English physician – but this flawed human being hurts (especially emotionally). Eric Parry is a 36-year-old country doctor having an extramarital affair with a married woman while his wife Irene is pregnant. Next door to their cottage is a farm owned by Bill Simmons and his pregnant wife Rita who suffers from mental illness and enjoys reading science fiction. It is winter (December, 1962 – January, 1963) and for a time the rural community is paralyzed by a brutal blizzard. Happy endings are in short supply here. One of the pregnant women has a miscarriage while sitting on the toilet. Characters get injured. Some patients die. Eric’s infidelity is exposed. Still, compassion and empathy occasionally sprout amidst the bleakness and the cold. Irene is cognizant that her husband’s work is hard as he “had to deal with people’s suffering all day” (p55). Eric excels at examining patients with a manner that “calmed” them. Secrets, loneliness, belonging, complicated personal relationships, and poor decision-making are essential elements of the plot. The story asks readers to contemplate whether virtuousness is a necessary requirement to be a “good doctor.” 

Doc or Quack: Science and Anti-Science in Modern Medicine by Sander L. Gilman 

London: Reaktion Books, 2025, 320 pages 
ISBN 9781836390152 

Bloodletting and purging (“heroic medicine”) employed for a wide array of diseases. Laetrile (a chemical present in apricot seeds) used for treating cancer. Hydroxychloroquine and Ivermectin prescribed for COVID-19. Spanning centuries, the list of wacky, ineffective, and sometimes dangerous remedies for illness is quite lengthy. In this standout history of scientific medicine from the mid-19^th century to the present, Gilman navigates “the ever-shifting boundary between good medicine and quackery” (p15). He reviews the rise of allopathic medicine that resulted from “following the science” as discovery and knowledge migrated from the laboratory to the bedside. He writes about the model of the physician-healer, the placebo effect (along with the morality of deception), superstitions (of both doctors and patients), and the faddish nature of medical practice. Gilman is rightly concerned about physicians experiencing burnout and patients feeling disconnected from their doctors in truncated office visits. He wonders if empathy and efficacy can coexist in contemporary healthcare. Three “case studies” are presented: peptic ulcer disease, the development of ophthalmic surgery, and acupuncture for back pain. A thoughtful study of historically “good” and “bad” medicine and the occasional blurring between the two. 

Additional recommended books published in 2025: 

The Mind Electric: A Neurologist on the Strangeness and Wonder of Our Brains
by Pria Anand 

The Age of Diagnosis: How Our Obsession with Medical Labels Is Making Us Sicker
by Suzanne O’Sullivan 

Web photo by Bermix Studio 

Mrs. Lin is a fifty-five-year-old woman who has lived alone in Canada for many years while her husband lives back in China. Her two sons are both working and out of the house. Last week, she discovered a new breast lump while showering. A few days later, she’s in my clinic to get the lump checked. As her family doctor, I order a mammogram and an ultrasound. When the results of these tests come back a few days later, the report indicates that the findings are suspicious for malignancy and a biopsy is necessary. 

Mrs. Lin returns to the clinic and I relay the information to her. I try not to mention the word “cancer” to her, but it hangs between us, powerful even if it remains unsaid. I urge her not to jump to worst case scenarios, but we both know that one way or the other, this is life altering news. I promise to order a referral to the breast diagnostic clinic at the community hospital nearby and that the breast centre will reach out to her in the next week or two. 

Later in the week, I receive a fax from the breast clinic. They’ve been trying to reach my patient by phone but with no success. Do we have another way of contacting her? 

I instruct my office staff to try to reach the patient. They call repeatedly for a few days. The breast clinic appointment is scuttled but I’m not actually worried. I’ve seen this pattern many times before. I am certain the patient has already flown the coop. 

A few days later, my hunch is proven right. My nurse manages to reach one of Mrs. Lin’s sons. His mother is safely back in China, seeking medical attention there. They’ll call us when she returns sometime next year. 

When my father boarded a plane in Taiwan in 1967 to come to Canada on a one-way ticket for graduate school, my grandmother saw him off at the airport. She gave him $1000 and said, “I’ll see you in about ten years.” 

She wasn’t far off. In fact, he didn’t return to Taiwan until 1974, for his wedding. 

That was what being a Chinese-Canadian immigrant was like back in those days. A journey to the other side of the world was truly a journey into an unknown abyss. Letters marked “airmail” with the blue and red checkered envelope edges took weeks to circumnavigate the globe. If my father wanted to call his parents, he’d reserve the call for special occasions like Chinese New Year because long distance rates were exorbitant. And even then, he’d be careful to limit the call to one minute and fifty seconds because exceeding the two-minute mark meant paying unnecessary fees. 

Immigrating was essentially a one-way trip. Immigrants like my father rarely considered the prospect of flying back home because it was something most of them simply couldn’t afford. There were only two acceptable occasions to fly home: your own wedding or a death in the family. 

The journey for today’s Chinese-Canadian immigrants is different. Not only can they communicate easily with those back home using apps like WhatsApp, WeChat and Line on an hourly basis, but based on my observation of my Chinese Canadian immigrant patients, even those who struggle financially, seem to have a reserve fund that they can dip into and use to return to China on a moment’s notice. Home is never more than a one-day airplane flight away. 

And people fly back for all manner of reasons now: family illnesses, Chinese New Year, summer vacations, and most definitely, for expediting medical investigations. 

The fluidity with which patients move back and forth speaks to a difference in what motivates immigrants to come to Canada. When my parents’ generation left China or Taiwan or Hong Kong, often it was to trade a future bleak of possibilities for a possibly prosperous future. But for many of today’s Chinese immigrants, it’s a trade of one hopeful future, for possibly, a slightly better one, but with the option to go back if this future in the West doesn’t work out. 

Health care has become part of this back-and-forth fluidity. It used to be that the health care trade off would have been clear–Canadian health care was more advanced than that in China in the sixties and seventies. But that’s not entirely true anymore, and today’s immigrants arrive with a great deal more reticence about our health care system. 

Health care always presents unique challenges to an immigrant population. Illnesses imply a degree of immediacy and urgency. They play out on their own timetables – they don’t wait for people to become comfortable with the language or culture of a place before occurring. 

So the new immigrant is forced to face the health challenges of regular life—acute illnesses, chronic diseases, bodily injuries, babies being born, and even the occasional life-threatening-situation without the social support structure that they would have had back home. All this is part of the bargain that the new immigrant strikes with their adopted country. And so they pray that nothing major will befall them, but when something invariably does, what do they do? 

In the previous generations, immigrants here had little recourse but to seek out solutions in the Canadian health care system. Whether their English was up to snuff or not, they were forced to navigate the system here. Many Chinese immigrants like my parents flocked to Chinese-speaking doctors like me in the hope that at least less would be lost in translation if they found a Chinese person holding the stethoscope. 

The modern immigrant though, has the luxury of straddling the line between the Canadian and Chinese health care systems, keeping one foot in China’s health care system and another foot in Canada’s. 

Unhappy with the wait times for elective knee surgery in Ontario? No problem. A doctor in Taiwan or Hong Kong will have you on the table in the OR in a few weeks, not months. 

New discovery of lymphoma? No need to wait for your family doctor to refer you to an oncology clinic and for that clinic to send you for imaging before finally making a decision on treatment—a process that can easily span into months. If you fly back to China, you can walk into a specialty clinic the next day, see a doctor by lunch time and have imaging and an oncology plan done by the end of the week. 

When it comes to China, the western world has a tendency to see things in stark black and white terms: e.g., freedom is good and communism is bad. As a Chinese Canadian physician, I find that this type of thinking carries over to our view of the health care system. Medical students in Canada, are taught that the Canadian health care system is a virtuous, humane social experiment, one of the country’s proudest achievements. It’s drummed into us that it delivers world-class care to the majority of its people. And we’re proud to be trained in it. Sure, it has its problems, but nothing’s perfect. 

There is a hidden side to this curriculum though. If we’re world class here, what about health care systems in other places? What about Africa? What about South America? What about China? 

Perhaps unintentionally, we’re taught to look down on the systems of other countries. We use words like ”developing“ and “evolving” to describe health care systems in these places. But in private, we often shake our heads in exasperation and use far worse language than that. 

These stereotypes were only reinforced when I started practicing medicine about fifteen years ago. The requests of my Chinese patients, often rooted in their own experiences with the health care systems they had left behind, drove me batty on a daily basis. 

I’d try to explain to my patients that, “Yes, that might be the case there. But you don’t really need any of those things.” But it’s hard to convince someone that everything they’ve accepted as truth may not be correct. 

The worse complaint was always about the wait times. This was one that I could not refute. It’s well-known that wait times for medical procedures in Canada are criminally lengthy. But whereas my Canadian patients had nowhere else to go and would just vent to me about the breaking down of our country’s beloved health care system, or try to drive a few hours to Buffalo to get an MRI, my Chinese patients had the luxury of options. They could hop on a plane, land in China or Hong Kong or Taiwan by the end of the week and get whatever they wanted within days, not weeks or months. 

I should point out that the feedback from patients about the Canadian health care system wasn’t always negative when compared to back home. I learned that the fifteen to twenty minutes I allocated to speak to each patient was approximately twelve to eighteen minutes more than they got in the typical Chinese hospital. 

Still, there were many frustrations that I was unprepared for. Patients would return to my clinic armed with reams of paperwork (all in Chinese), documenting checkups and physical exams that they had done overseas: lab tests and CT scans that had no indication for being ordered, medications that they had been prescribed that were not really indicated. 

If modern medicine in the West suffers from an over-reliance on medical imaging and pharmaceuticals at the expense of a more prudent and holistic approach to care, then modern Chinese medicine has become Western medicine’s adopted twin, with all the same problems we have, except with even less sense of restraint and caution. 

Mr. Zhang is a middle aged, Chinese man with diabetes. In China, people routinely retire in their early fifties and one of the perks of retirement is long term health insurance, so even though Mr. Zhang has lived in Canada for almost fifteen years, he still can access Chinese health care whenever he is back home. 

Mr. Zhang isn’t alone in returning home to seek health care. Even those without health insurance often choose to pay out of pocket to access health care in China on a regular basis because the costs aren’t prohibitive 

Because Mr. Zhang travels back and forth between China and Canada on a regular basis (after all winters in Canada are cold), he needs doctors on both sides of the world to help him manage his long-term diabetes. What he’s discovered is that the quality of care in both countries is, for him at least, comparable. The general procedures for diabetes, routine blood testing, and medication adjustments, are similar in both places. But there are some noticeable differences. 

He informs me that in China, the health care system is heavily incentivized by the profit motive. Hospitals make more money if they achieve certain revenue quotas, and this is passed on to the doctors, who in turn pass this mindset down to the patients. 

At the same time, it’s well known to him and all his friends, that in Canada, with a public health care system, cost-cutting is much more of an issue. 

The doctor as gatekeepers of the health care system is sometimes a difficult concept for patients to understand. Doctors in China are not really gatekeepers of the system the way they are in Canada, where doctors spend a great deal of time being instructed on not over-ordering tests. Not all medical investigations are necessary. Extra tests beget extra costs and may engender unnecessary anxiety and have deleterious consequences for the patient-just think about the patient who worries about a lung nodule that will never cause them problems once it’s been spotted on an unnecessary chest X-ray. These are hard lessons that even medical practitioners in the West struggle with at times. For my patients from China, this concept is irrelevant. In a privatized system where patients can pay for what they want, getting an unnecessary MRI is no different than spending money on a fancier car or an extra helping of dessert: nobody really needs it, but if they can afford it, then why not? 

So if I try to explain to my patients why I don’t think they need that MRI they really want, they think I am just trying to save the government of Canada money. If I am really hard-nosed about it, they just might turn around, get on a plane and have the test done in Shanghai or Taipei by the end of the week. 

In China, if I want an MRI and can afford to pay for one, then who is anyone to stop me from getting what I want? If a cardiologist makes more money for pushing a certain type of stent at a patient, who is going to stop them from recommending it to patients who might do just as well with a less aggressive intervention? 

To be sure, these are problems that exist in many parts of the world, even here. But reviewing the stacks of lab results and CT scans that my patients lug back to Canada from overseas, I can’t help but feel that my patients have stumbled upon the Wild, Wild, West of health care-except it’s in the Far East. 

There is of course a downside when patients straddle two countries for their healthcare. Countless times, I’ve had patients return from overseas after having had a major health calamity. Maybe they had breast cancer diagnosed in China, or a screw placed in their hip after a fall, but now that they’ve returned to Canada, no specialist office will see them.  

Dutifully, the patient brings copies of their hospital notes from China, copies of their CT scans and MRIs, but nobody here is willing to read them because nobody here trusts what the report says. If the documents are written in Chinese, Canadian doctors usually can’t read it. Even if they could and wanted to trust it, can they really do so medico-legally? And so it’s the patient that gets left in the lurch.  

In the end, armed with a Chinese-Canadian dictionary in my early years in practise, or more recently Google translate, I’ve learned to muddle through. With my admin staff translating the documents for me, I can usually piece together what procedure a patient has had done overseas. Then we try to match them with the appropriate follow up here, often repeating the testing and imaging so that patients can access care here. 

But it’s getting better. In my early years, I couldn’t find any oncology clinics willing to follow my patients who had started their chemotherapy overseas. Many of these patients flew all the way here to use their hard-won Ontario health care card, only to have to fly back home shortly thereafter when they realized they weren’t going to receive timely care in Canada. These days, I’ve seen more care handoffs take place here smoothly. Truly, the health care world is becoming a little friendlier to immigrants. 

It used to drive me crazy when my patients sought out health care overseas. In medical school, we’re taught a very idealized version of medical care, something akin to the traditional country doctor’s life straight out of the 19th century. A patient feels unwell. They seek out a local physician. The physician solves the problem or directs them to someone else who can. The problem is solved, and life goes on. 

But in real life, I saw that patients didn’t always stay in one place. Sometimes they asked me for help first. Then they’d go overseas. At other times, they came back from Asia and needed my help deciphering what had happened to them there. And back and forth they went. 

Sometimes I’d get exasperated that they were receiving substandard care overseas. At other times, I’d gain an appreciation that they really could get better, faster treatment for certain things in China that in Canada would have taken ages. In time, I developed a grudging respect for health care in China. 

As I worked with patients who were navigating these two systems simultaneously, I felt myself drawn into a curious, political dilemma. Which health care system is better? 

Sometimes patients would pull me aside and ask me what they should do, fly back to China and seek urgent care or wait a bit longer to see their specialist here in Canada? 

The issues were always some variation of the same theme, a weighing of trade-offs: comfort with the language, wait times, medical expertise, as well as the family support system, all bundled into one massive equation that boiled down to a simple binary question: China or Canada? 

I’ve found my own stance on the issue change over time. When I first graduated from medical school, armed with all my pro-Western biases, the answer was almost certainly Canada. 

But in recent years, I’ve watched medicine advance in China from afar, through what my patients tell me, and through the medical records and histories that they bring back to me. Perhaps there’s still a lot of overkill in investigations on the other side of the ocean, but often the quality of medicine isn’t that different from what it is here. And it’s almost certainly faster. And if you can pay for quicker care, why not? Moreover, many of these Chinese immigrants have family support networks back home that simply don’t exist here. For them to return home for their care simply makes rational sense. Nothing reminds someone of how foreign they are as being in a cold, sterile hospital environment where nobody speaks your language. 

More than a year after she departed, Mrs. Lin returns to my clinic. Following a lumpectomy and ten rounds of chemotherapy, the doctors in China have instructed her to remain on estrogen receptor therapy for the next five years. 

Why did she return to China for medical care? Despite living in Canada for more than a decade and having a passable command of the English language, she still felt that for something as serious as this, she wanted to be someplace she could speak her native tongue. Plus, she would have family members there to support her. Left unsaid is that the entire medical procedure in China took days to arrange not weeks as it would have here. 

I refer her to a medical oncologist, who reports back to me that she is overall, in agreement with the patient’s treatment plan. She replaces the patient’s estrogen treatment with an alternative agent that is available in Canada. 

Web photo by Zac Ong 

Additional Chapters from A Chinese City Doctor’s Notebook

When Your Body Isn’t Yours 

01.12.26 808

From Tigers to Otaku

09.16.25 1687

The Happiest Couple

07.28.25 1423

The Things We Don’t Talk About When We Talk About Dying 

05.13.25 2005

One Patient, Two Systems 

02.24.25 2691

It is one thing to read about bipolar disorder in a textbook, and another thing to observe it firsthand. Some of us have friends or family members whom we have seen in the throes of a manic episode. As a psychiatrist, I have witnessed mania at close range literally hundreds of times. But to be an audience member and to experience it in a way that manages to be both educational and entertaining is a rare privilege. And to do so as a multimedia event, fusing theater with visual arts, is surely unique.  

Sam Kissajukian’s one-man show 300 Paintings is a must-see that is currently enjoying a return engagement at the Vineyard Theatre in New York. (It is purely a coincidence that the theater, just off Union Square, is a block away from my former psychiatric office of eighteen years.)  

Kissajukian is an Australian stand-up comic. In 2021, during the pandemic, he experienced a five-month bipolar manic episode. During that time, despite having no previous background in visual arts, he decided to become a painter. Moving into a warehouse, he began to paint. He barely slept, frequently turning out multiple works a day. By the end of the episode he had created three hundred paintings, documenting his mental state.  

Kinssajukian has created the show he calls 300 Paintings as the culmination of his personal and artistic journey. The show has won numerous awards, including Best Comedy at Sydney Fringe 2022 and 2023, and the Mental Health Awareness Award at Adelaide Fringe 2024. It has played at the Edinburgh Fringe Festival, and it first came to the Vineyard last fall. He has also had several exhibitions of his paintings, and has come out as a strong advocate for mental health awareness. 

While 300 Paintings calls on the author’s experience as a comic, it is no mere stand-up routine. At 80 minutes it has the dimension and scope of a play. There are serious undertones, yet there are many undoubtedly funny parts: We hear how at his most grandiose Kinssajukian thinks of himself as a “Pisscasso” who goes through a blue period in days, rather than years. At another point he describes how he affected a beret. Funny or serious, he is always charming and engaging, and he breaks it up by showing projections of his work.  

There are times when the dialogue takes on the rapid, pressured speech of a person who is manic, and his thought process shows the jumping from topic to topic that a psychiatrist refers to as “flight of ideas,” But this feels intentional. At no time do you worry that the performer does not have it under control. And he readily attributes this to his rapid diagnosis and treatment by a psychiatrist.  

At the end of the performance, Kissajukian announces that a curated exhibition of his paintings is on view in the lobby, and that he will be available to meet the audience.  

Two Paintings by Kissajukian

Podcast

Web image provided by Sam Kissajukian

The phenomenon sometimes referred to as “baby blues,” a mild transient state affecting as many as 80% of new mothers, had been recognized early on. In his influential 1946 book on baby care Dr. Benjamin Spock advised that one could snap out of it by just going “to a movie, or to the beauty parlor, or [getting] yourself a new hat or dress” (p. 29). If a new dress did not do the trick, the implication in that era was that you were a defective woman. In the 1962 edition, Spock still repeated the same advice verbatim. The notion there could be a persistent mood disorder requiring treatment required far longer to catch on. In her book, Moran elucidates some of the factors that rendered it difficult to accept the existence of postpartum depression and explain why persistent advocacy was necessary.  

One such factor involved organized psychiatry. While early editions of the DSM (the Diagnostic and Statistical Manual of Mental Disorders) had proposed psychodynamic causes for mental illnesses, in an attempt to be neutral about their origins the DSM-III did not include postpartum disorders as discrete entities. One implication of this was that there was no code to use to get health insurance to reimburse for medical care. The result, according to James Alexander Hamilton, a psychiatrist who had written the first modern monograph on postpartum mental illness, was that “many thousands of very sick women [were] very badly treated” (p. 67). It took several editions of the DSM until this was addressed. And even in DSM-V, postpartum depression would still be coded as Major Depressive Disorder with peripartum onset.  

Eventually the idea there was something more serious than” baby blues” yet still relatively common took root in the public consciousness. One began to hear about it on television talk shows. Yet these appearances often featured extreme cases such as that of Andrea Yates who had drowned her five children: “Tragedy and insanity got ratings. This still allowed advocates a chance to raise awareness on a massive national platform. But it also made postpartum depression frightening and unclear” (p. 166). It took celebrities such as Brooke Shields to come out about their experiences to change the national conversation. After publishing a memoir about her postpartum depression, in 2005 the actress went on the Today Show where she was criticized by Tom Cruise for using antidepressants. When the public rallied behind Shields, this proved to be a turning point for the movement. 

When national bipartisan legislation was proposed to increase awareness and to fund research for postpartum depression, the issue became a political football. Anti-abortion activists coined a brand new “disorder” they called “post-abortion syndrome” and would not consider supporting one without the other. It was not until the passage of the Affordable Care Act that the MOTHERS act went through, and not even then without the concession to abortion politics.  

If Moran’s book breezes through the science behind postpartum depression somewhat rapidly, its chronicle of an important advocacy movement for women’s health makes it worthwhile, and its extensive use of oral histories within the context of the author’s own history ensures it is an interesting read.  

Blue
Rachel Louise Moran
University of Chicago Press, 2024, 304 pages

Web image by Alexander Grey 

See https://www.postpartum.net/ for information about Postpartum Support International, one of the advocacy groups profiled in Blue.  

“Prof. William Osler, of the University of Pennsylvania, was summoned by telegraph this afternoon to go to Walt Whitman’s bedside. The aged poet had a relapse, and it was feared that he was dying. When the doctor came away from the little frame house at 328 Mickle Street, Camden, at 8 o’clock tonight, he said the poet was resting easily and about holding his own.” 

Osler first visited Whitman in 1884, shortly after moving to Philadelphia to take up his position as Professor of Medicine at the University of Pennsylvania. Dr. Maurice Bucke, a Canadian psychiatrist and mutual friend, had asked Osler to look in on Whitman, who was complaining of dizzy spells and fatigue. The professor obligingly ferried across the Delaware River to Camden and made a house call. Osler reported that the poet had no residual neurological deficits from his earlier stroke. He was unimpressed with Whitman’s current symptoms and, in fact, later described him as “a fine figure of a man who had aged beautifully, or more properly speaking, majestically with a large frame and a well-shaped, well-poised head…“ ^{1, p. 21} 

However, four years later the situation was more serious. On June 14, 1888, Whitman developed slurred speech, prostration, and confusion “such as we know are not uncommon with sclerosis of the arteries of the brain.”^{1, p. 178} When Osler was called in, he recommended general supportive care and issued a cautiously optimistic prognosis (as the Times reported), but evidently did not present his patient with a specific diagnosis or discuss pathophysiology. Whitman recovered over the following weeks, but his health gradually deteriorated over the next several years until his death in 1892. 

During the years Osler served as the poet’s primary care physician, their relationship was respectful, but not ideal. Whitman frequently complained about the great clinician’s rosy bedside manner. “Osler made light of my condition,” the poet wrote. “I don’t like his pooh-poohs. The professional air of the doctor grates on me.” ^{1, p. 50} On another occasion he told his friend Horace Traubel, “I confess I do not wholly like or credit what he (Osler) says. I do not fancy the jaunty way in which he seems inclined to dismiss my troubles.” ^{2, July 3, 1888} Evidently, Osler continued to speak in generalities, rather than addressing specific concerns that Whitman raised as he became progressively feebler.  

This situation contrasts with some of the poet’s earlier medical experience. For example, shortly after his stroke in 1873, Whitman consulted Dr. Mathew Grier who must have explained the etiology of the problem. Whitman later wrote to his friend Peter Doyle, “Did I tell you that Dr. Grier here says that my real disease is the brain not being properly furnished and nourished with blood…” ³ The poet’s other physicians included Drs. Silas Weir Mitchell and his son John Kearsley Mitchell. The famous neurologist and champion of neurasthenia made house calls on Whitman twice in 1878 when the poet reported symptoms of rheumatism and prostration, which he had self-diagnosed as a recurrence of his previous stroke. Mitchell assured him that the stroke, which had resulted from a ruptured blood vessel in the brain, was not responsible for the current symptoms. These, Mitchell claimed, were caused by chronic stress, perhaps exacerbated by anxiety over a public lecture that the poet was just then preparing to give.³ In other words Mitchell considered the illness a manifestation of neurasthenia. He prescribed travel, mountain air, and vigorous outdoor activity, which was Mitchell’s generic regimen for neurasthenia in males, quite the opposite of his more famous regimen of complete bed rest for female neurasthenics. ³ The poet took Mitchell’s advice seriously and embarked on a trip to Colorado, after which he professed himself cured.  

While Osler’s optimistic persona must have pleased many patients, it irritated Whitman. He judged his doctor’s cheerfulness to be insincere, or at least questionable. The elderly poet was an eccentric who fiercely valued his independence. While at times he showed a sweet and gentle side, he could also be touchy, irascible, and assertive. As the poet grew progressively frailer during 1888 and 1889, Traubel recorded a series of house calls during which Osler assured him that he would soon recover. “Do not take a gloomy view of Whitman’s case,” Osler told Traubel, “he will come around.” ^{2, July 3, 1888} In this short poem, I try to resurrect the poet’s attitude toward his famous doctor: 

Walt Whitman Reflects on His Doctor’s Bedside Manner 

As an old rat that must be allowed to die 
in his own way, I start with a prejudice 
against doctors. Never mind worrying 

about your sickness, he scolds me,  
I’m seeing to all that. The man tinkers  
with platitudes and conceals his thoughts.  

In his gospel of encouragement 
I’m supposed to be agreeable and dumb 
while he puts the best construction  

on what’s happening. What does he know 
about Whitman, the old rat? A shoemaker  
tells his customer the shoe fits just right 
but the shoe pinches the fellow wearing it.  

Whitman was a master of self-promotion. He appeared to encourage members of his inner circle who viewed him as a prophet, as well as a poet. Dr. Maurice Bucke even wrote a book claiming that his friend was one of the few humans who had achieved “cosmic consciousness.” The others included Jesus, Mohamed, and the Buddha. Did Osler fail to understand that his one- size- fits- all approach to physician-patient communication might not be appropriate for a patient with Whitman’s complex and eccentric personality?  

Although dissatisfied with Osler’s bedside manner, the poet respected his doctor’s clinical abilities. Several months after the medical crisis in 1888, Whitman wrote, “As for Osler: he is a great man—one of the rare men. I should be much surprised if he didn’t soar way, way up—get very famous at his trade—someday. He has the air of something about him—of achievement.”^{2, December 26, 1888} Indeed, by that time, Osler had already accepted the position of Professor of Medicine at the new Johns Hopkins medical school in Baltimore.  

Osler was a sensitive, cultivated man, but also a rationalist, who initially looked askance both at Whitman’s exuberant poetry and the cult that had grown up around its author. Although he admired the man, he had no wish to become a disciple. He loved poetry and enjoyed quoting passages from Shakespeare and the Romantic and Victorian poets. Regarding his first impressions of Leaves of Grass, Osler later wrote, “Whether the meat was too strong, or whether it was the style of cooking—‘twas not for my pampered palate.” ^{1, p. 22} He found his new patient’s long, unruly poems and earthy subject matter self-indulgent and lacking in discipline. The boisterous persona reflected in Whitman’s poems jarred Osler’s methodical mind. In the following poem, I imagine the clinician’s response to his early encounters with the Good Grey Poet: 

Dr. William Osler Remembers His Call on Walt Whitman 

I took the ferry that day and found him 
in the front room of a small house 
on Mickle Street, buried to his chest 
in papers, magazines, and musty  
brown bundles. Push yourself a path, 
he said. I reckon you’re a friend of Bucke’s. 

His famous head had aged majestically— 
unkempt white beard; smooth, clear cheeks; 
a fissured, geographic forehead. 
His voice was pitched a shade too high,  
but strong like the rest of him. Of symptoms 
he said but little–remarkable 

for a man of 65. For a moment 
I felt that sweet aromatic presence 
his disciples spoke of–for me, though, 
the edge of chaos. I sometimes wish 
the man had made a difference in my life, 
opened me up, but how could I forego 

my restraint? Or professional kindness? 
For a man like me, a man of substance, 
what could be worse than falling in love 
with Whitman? I listened to the music 
of his tongue, but could never cross the line 
that reads, Who enters here, abandons discipline. 

Yet, in his later years, Osler grew to respect his one-time patient’s poetry, as well as his charismatic personality. In fact, at the time of his death from pneumonia in 1919, he was in the process of writing an appreciative reminiscence of his encounters with Whitman. 

The uneasy, but respectful, relationship between these giants in their respective fields provides interesting material for reflection. If the poet was so dissatisfied with Osler, why didn’t he go back to Weir Mitchell or his son, who were more easy-going and communicative? Mitchell’s reputation as a clinician easily equaled Osler’s, and he was a poet as well. Could it be that Whitman benefited in some way from Osler’s staunch optimism, or had developed deep trust in Osler’s judgment, despite the constant complaints he issued to Traubel and others? Alternatively, why didn’t Osler modify his paternalistic approach, since it seemed clear that Whitman preferred to play a more active role in the relationship? And those time-consuming house calls that required taking a ferry across the river! Why not recommend a more pliable colleague?  

References 

1. Philip Leon, Walt Whitman & Sir William Osler, ECW Press, Toronto, 1995. 

2. Horace Traubel, With Walt Whitman in Camden, vol. 2, at http://whitmanarchive.org/criticism/disciples/traubel (accessed December 30, 2024) 

3. Feinberg CE. Walt Whitman and his doctors. Arch Intern Med 1964; 114: 834-842. 

Photo of Sir William Osler and Walt Whitman from WikiCommons.

The narrator has enjoyed a mostly healthy life. He has traveled to Europe and once was treated for syphilis while there. He has been together with L for seven years. Both men are writers who teach at the university. Now, the pain that grips him defies exact description (even for a professional writer). The closest comparison that he can conjure is having someone’s hand plunge into his body and twist his guts along with the sensation of being kneed in the groin. He’s reluctant to seek medical attention since medical facilities are especially risky during the pandemic. So he waits and hurts. The pain is soon accompanied by fever, chills, and aching of the limbs. 

He decides to go to urgent care. After a brief evaluation, he’s referred to the university medical center ER. Covid testing is negative. A CT scan reveals an aortic dissection (tear in the aorta) associated with aortitis (an inflammation of this large blood vessel). He is told that such a tear is frequently fatal. He’s lucky to be alive. The narrator is placed in the ICU and treated with IV antibiotics, fluids, and antihypertensive medications. The vascular surgeon recommends holding off on any operation (either a stent or a graft), hoping the tear and inflammation will stabilize and heal. 

Hospitalized for a week and a half, the narrator confesses his feelings of helplessness, shame, bewilderment, and fear. He is intrigued by the bustle of the hospital – almost electric with human energy – but despondent over the seemingly omnipresent suffering there – his own, that of fellow patients, and even the distress of healthcare workers. He is most impressed by and appreciative of his ICU nurse, Alivia. As for the physicians involved in his care, the narrator notes the stark clinical detachment of many doctors. Reflecting on a visit from a rheumatologist, he concludes, “I was nothing to her, really, I was her job, she would clock out and enter her real life” (p124). He craves to sense some vulnerability and genuine concern emanating from his physicians. As for empathy, the narrator reveals some of his own when he decides, “it must be hell to be a resident” (p129) in training. 

The search for possible rare etiologies of his condition comes up empty. As his condition slowly improves, the narrator still worries about his current predicament and the future: “I was an enigma, they said, a conundrum, they were running out of ideas” (p121). The waiting for and indecision about any kind of surgical intervention wears on him. He wonders if it might be best to have an operation. 

But the narrator never has surgery. A repeat CT scan confirms stability of the aorta and resolution of all inflammation. He is discharged home on oral medicines and continued IV antibiotics. Frequent follow-up appointments with his doctors and imaging studies of his aorta are scheduled. His partner L lovingly tends to his needs. His sister G arrives to help too. The narrator’s prognosis is murky. Did he dodge a bullet? Or are further problems with his aorta inevitable? How does a person cope with such chronic uncertainty. Although the narrator is weak and emotionally rattled, he is happy to be alive, pain-free, ambulatory, and home with his lover. Shouldn’t that be enough? 

The novel reads more like a memoir than a work of fiction. It is impressively authentic and accurate about medical matters – the lingo and professional behavior of physicians, nursing care, clinical procedures, what it feels like to be a patient. Readers will rightfully consider whether the book’s author is perhaps recounting his own experience with a serious health problem.  

In this novel, the human body is depicted in many ways: sensuous, serviceable, surrendered to others, surreal when sick. The narrator’s experience of illness includes a warping of time, the pull of memory, the weight of regret, the need for truth, and the magic of love.  

The poet-protagonist is occasionally irritated by the language and metaphors spewed by doctors and nurses. The use of broad-spectrum antibiotics is explained to him as a “carpet bomb approach.” He is warned about the caustic effect of IV drugs and that his veins might “burn out.” This medical lexicon prompts the narrator to ponder “who taught these people, who gave them their vocabulary, their stock of images” (p86).  

We don’t need a novel (even an exceptional one like Small Rain) to remind us about the randomness and chaos of ordinary life, the uncertainty of health in the future. But we can look to great literature for inspiration, to help us understand and cope with those looming, difficult experiences. The word rain is both a noun (drops of moisture or a spiritual blessing) and a verb (something sent down in abundance). Whether it is tears (of pain and emotion), love, or gratitude, the rain in this story is hardly small.  

Small Rain: A Novel 
by Garth Greenwell 
New York: Farrar, Straus and Giroux, 2024, 320 pages 
ISBN 9780374279547 
Web photo by Pawel Nolbert 

German physicist Wilhelm Roentgen discovered X-rays in 1895 and received the inaugural Nobel Prize in Physics in 1901. One of the earliest X-rays he took was of his wife’s left hand. Her initial reaction to viewing the image was fright, accompanied by the proclamation: “I have seen my death!” Roentgen did not want the mysterious rays named for him. Instead, the letter X was chosen. Lobdell intriguingly contemplates the power, allure, value, and mystery conjured by that letter. X is employed as a warning symbol, a sign for measurement (2” x 4”) and multiplication, an indication of deletion. There is an X chromosome, X-rating, X-Files, the X-Men, and of course the platform X (formerly known as Twitter).

After their discovery, the use of X-rays spread rapidly even though pioneers of the technology tragically suffered from (often) fatal radiation poisoning and cancer. During World War I, Marie Curie designed mobile X-ray units placed in vans (dubbed “Little Curies”) that delivered the technology and its ability to rapidly diagnose injuries to the battlefield. 

Beyond the significance of establishing an accurate medical diagnosis, Lobdell explores the impact that X-rays have on so many aspects of human culture – literature, cinema, art, language, and even political cartoons. Society now had a different way to view life. Looking inward took on a new meaning. Notions of transparency and exposure merited rethinking. Getting an X-ray was paradoxically an impersonal and intimate act that raised concerns about voyeurism and privacy. Yet a desire to “see inside oneself” became quite popular.

For a time, a kind of X-ray “mania” swept America. The comic book hero Superman made his appearance, and X-ray vision was one of his many super powers. The shoe fluoroscope was a popular device to visualize how a customer’s feet fit properly into shoes during the 1920’s -1960’s. Chest X-rays were widely utilized to screen for tuberculosis from the 1930’s thru the 1960’s. Cabinet X-ray machines to view the contents of luggage and backscatter passenger scanning became fixtures at airports (examples of how X-rays suggest “security”).    James Bond sported X-ray glasses in the film, The World is Not Enough. In 2021, an emoji of a chest X-ray became available. 

X-ray, a small book that punches above its size and weight, is part of the Bloomsbury Academic publisher’s series titled “Object Lessons” that explores “the hidden lives of ordinary things.” Other medically-relevant texts in this series include Doctor, Pill, Pregnancy Test, and Tumor. 

These days, most people are accustomed to being X-rayed – radiographs taken in the ER following an accident or fall, routine dental X-rays, getting X-rayed at the airport, a chest X-ray done for a persistent cough. Some folks are reasonably concerned about the risks of radiation and the overutilization of this technology. Yet ultimately, subjecting yourself to X-rays is a risk-reward calculation that promises diagnosis, maintenance of health, or security in exchange for limited exposure to radiation and permission to intrude on privacy. Lobdell pens a clear, big picture of a surprisingly many-sided subject. The result is a glowing and penetrating examination of the importance, meaning, and influence of X-rays on not just health but all facets of life.  

X-ray by Nicole Lobdell
New York and London: Bloomsbury Academic
2024
121 pages
ISBN 9781501386701