DAVID HSU: What are you up to these days? What are you working on?

JACK COULEHAN: In terms of creativity, I’m working on a new collection of poems that I’m editing now. I’m also the book review editor of The Pharos magazine, and that takes up an unexpectedly large amount of time.

DAVID HSU: Do you practice medicine at all anymore?

JACK COULEHAN: No, actually, I retired about 12 years ago now, but I do still teach medical students as a volunteer. It’s a class that I began back when I started at Stony Brook in 1991. It’s called Medicine in Society, and it’s a first-year seminar course that deals with human, social, and interpersonal issues in medicine. We use a lot of literature and film in that and so I’m still a group leader. We also have a master’s degree program in medical humanities, and I teach a course in that. So I still keep my hand a little bit in teaching.

DAVID HSU: Given that you’re doing all this work in the humanities, what do you think about the relationship between medicine and the humanities?

JACK COULEHAN: You know, that’s a surprisingly difficult question for me, because I’ve always had this kind of love/hate relationship with the term medical humanities, because I think it doesn’t quite capture the problem or the issues that we’re trying to address and what we do. In a lot of my work, I tend to cite a piece that Rafael Campo wrote in JAMA in 2005, entitled “The Medical Humanities, For Lack of a Better Term.”  What I’ve really always thought is that what we’re trying to do is to teach students and ourselves, really, to become more reflective and more thoughtful…[Campo] used the terms reconnection, renewal, and meaning. . I think we’re not necessarily encouraged in our profession to become aware of our own needs, to become reflective, thoughtful, to become focused on the personhood of patients and so on. And so I think, through discussion, through examples in literature, film, etc., we can really try to address these issues. I guess the term medical humanities is fine as a placeholder, but I wish there was a better term for it. But, aside from reflecting on the name itself, those are the things I think we’re trying to address in medical humanities. 

When I started in this business, pretty long ago, I was thinking about [medical humanities] mostly in terms of becoming a better doctor by improving one’s empathic skills and reflecting on the patient as a person. But as time has gone on, I’ve become more aware that I think it’s really something that makes you a better person and also more able to cope with the stresses and the challenges of modern medicine. So, I think it works both ways.

DAVID HSU: What are your criticisms of the way medicine is practiced now, since people aren’t doing all this [reconnection, renewal, and meaning]?

JACK COULEHAN:  First of all, I think medicine has to be understood in our current overall culture of increasing subspecialization and focusing on narrower and narrower fields [of practice], using more and more technological instruments, tools, and machines. Also, medicine is more and more controlled by larger interests that are not necessarily oriented towards the primary values of medicine.  There are virtually no constraints on the use of technology, the focus is entirely on disease, on narrow perspectives on disease.  

What I’m saying is that all this detracts from the ability necessary to see the patient in terms other than as an object that has a disease or a person who has a specific problem that needs to be addressed.

Just to give my personal examples, when you get to be 81 years old, as I am, you have a lot of opportunities to experience being a patient. I saw a cardiologist a couple of weeks ago who is an older cardiologist, and he was what I would call an ideal physician. He does interventional cardiology, he’s a professor, well-published, and yet his approach, I would consider to be very therapeutic–very positive, trusting and good eye contact. He wasn’t looking at the computer. He was just a genuine person, genuinely interested. I’ve also gone to a urologist who was just the reverse. Equally specialized in the same medical system, but one who was all about the particular issue, the particular organ, and the particular thing that’s happening to that organ.

It’s possible, you know, when you start talking about the kind of values and the kind of stresses that modern physicians are under, the first response you get is that, “Oh, yeah, that’s great. That’s what we should do.”  But you know, we only have 15 minutes [and] we have to deal with the EMR, etc. But that belies the fact that there are physicians out there who are very good at actual doctoring and others who aren’t, and I think that’s because, well, let’s say, look at those two things on a spectrum…I would say that there is the opportunity, even in today’s world, to help students keep their belief, which most of them have, I think, when they begin, that doctoring is really interested in persons. And I think we could increase the percentage of physicians who feel that way and practice that way.

DAVID HSU: I’m curious because you mentioned that you’re 81. You’ve been around the medical system for decades. How has the system changed from when you first started in it until now? Is it getting worse, or has it always been like this?

JACK COULEHAN: Well, that’s tough. I definitely think it’s worse, but I also think it’s romanticism, you know, to look back and say, “Oh the good old days.” 

I graduated from medical school in 1969 and graduated from my residency and fellowship in 1975. Those were the days when I was learning to take a history. Taking a history–that’s another phrase that I dislike. But we had a little black book, that had 100 or 140 questions to ask in it. There was no concept of medical interviewing, nor the  teaching of it. I had the feeling that a lot of the values of good doctoring were kind of implicit and not necessarily taught in those days.

And so we’ve gone through a whole phase of learning that the medical interview is a therapeutic tool, and now I think we pay a lot of lip service [to it], but I don’t know that we necessarily carry it from its place in the curriculum to its place in the clinic or the hospital.

But there’s no question that it’s gotten worse [although] the technological advances are just so incredible. I remember at some point, as a student, you have this idea that the CT scan will give the answer, or the lab result will give the answer. The patient’s story is secondary. And I remember some instructors saying, no, no, wait a minute, you should know 80% of the time what the answer is before you even request the test. The test is not meant to be, the be-all, end-all of everything, but, definitely, that is the case now. Even within practice, every advancement that happens in technology kind of nudges us closer to thinking of the computer as a solution for everything.

Let’s say, one patient comes in with chest pain or nausea. I think the tendency now is to focus on those symptoms, to think of what disease might cause them, and to do various tests, rather than sitting down with the patient and trying to understand what their situation is.

DAVID HSU: You mentioned this earlier, and I wanted to follow up on this little comment you made about how the practice of humanities and writing has a self-care component to it, and that as you’ve practiced it more, it’s helped you handle stress and different challenges. Can you elaborate a bit about this?

JACK COULEHAN: As a high school, college, and even a medical student, I had this inexplicable urge to write poetry, which I did. It’s pretty juvenile. But anyhow, I did it. Then of course, I gave it up because I was a doctor. I was practicing, I was doing research, etc. And in my mid-40s, I was reaching, I think, what you might call burnout. That might be a little too dramatic, but I felt that there was something missing in my life, in my career, and I happened to have a patient who was a professor of poetry at the University of Pittsburgh, where I was teaching at the time. And one thing led to another, and she encouraged me to start writing again. And I did, and I found very quickly that by writing about…my experiences in medicine, I was able to…work through them and understand my reactions better, and so I think that poetry is a reflective practice that in a sense provides occasion for you to grapple with experiences, issues that have been troubling you, or that on the other hand have been very happy. It can work both ways.

Getting back to medical humanities, I think what we’re trying to do in medical humanities is to stimulate that kind of process in young physicians or young clinicians, whether it’s through poetry, through writing journals, through just meeting in small groups…that kind of thing…and to use not only personal experiences, but literature, poetry, film, etc. as stimuli for that.

DAVID HSU: Let’s wrap up with what you would like to see medhum.org do? How would you like to see it grow in the months and years to come? What type of topics or articles do you want us to tackle? 

JACK COULEHAN: I like the concept of being provocative. I’d like to encourage people to come in through material that’s kind of leading edge. I’d like to see people have conversations, comments and so on.

DAVID HSU: Thank you, Jack for participating in “Meet the MedHum Editors.”   It’s been a pleasure to speak with you.

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Cyrus aspires to be a poet but is drowning in self-pity and drug use. He wants more than anything to achieve renown and martyrdom and to die after having made a lasting mark in the world. Interwoven with these tragic human circumstances are antic elements that collide with this depressing narrative. The novel opens abruptly with a humorous but disconcerting encounter between Cyrus, who is working as a surrogate patient in an introduction to medicine class, and a student, who is clearly in the early stages of her education. Cyrus is having a bad day and cynically takes on the role of the difficult patient, nearly driving the student to tears. There is a zany episode when Cyrus and a friend take on a home maintenance and wood chopping job for a man who lives alone and who monitors their work wearing only his underwear.  

Dream sequences in which Cyrus receives guidance from figures ranging from Kareem Abdul Jabbar to a thinly disguised, now President Trump materialize without warning. An uncle, his mother’s older brother, passes through the story several times appearing as a figure draped in a black hooded cape and riding on horseback across the blood-drenched Iran-Iraq war battlefields. His mission is to reassure the dying soldiers that they will ascend to paradise. Yet, despite these disparate elements, the book has a powerful coherence and momentum. One of the most striking features of the book is its extraordinarily imaginative similes– “he was skinny in a scrawny way, not like a runner but like a mathematician who forgets to eat,” “the middle school teacher… offered him a racial slur, like a juicy orange they might peel together and share.” These phrases demand that you slow down the pace of your reading and take note of the author’s creativity.  

Engagement with language and its communicative limitations emerges as a key theme of Martyr!. Cyrus comments frequently on the arbitrariness of language and the terrifying consequences that can arise from the words we use. Akbar embeds this idea in his writing by implying that plain words alone are inadequate to capture the essence of things, and the only reliable way to convey meaning to readers is by creating vivid and arresting comparisons. The plot of the book takes off when Cyrus is encouraged by a friend to go to the Brooklyn Museum and visit a featured exhibit, DEATH-SPEAK. It consists of an artist who is dying of cancer sitting on a chair and talking with the visitors about death during the final weeks of her life. An unanticipated bond is quickly established between the artist named Orkideh and Cyrus. He feels compelled to return and speak with her over the next four days. Their conversation is genuine and moving. There is more to the artist and her art than meets Cyrus’ eye, and those unexpected twists drive the story to its blazing finish.  

What is one to make of this wholly original and emotionally charged novel? I will restrict myself to three thoughts that have had staying power after finishing the book a month ago. First, as mentioned above, Martyr! raises provocative questions about the limitations of language and our ability to communicate with one another. Cyrus (and Akbar) questions the capacity of words alone to express meaning, as if each of us has our own private language. If we can firmly ground our language with references to concrete, real life experiences, which is precisely what Akbar does with the beautiful and jarring similes that are interwoven into the entire book, then we may be able to convey meaning. That Akbar can introduce such a recondite idea, a variant of playing language games, into a best-selling novel is a feat worth noting.  

Second, there is a yearning to be healed that drives Cyrus’ quest. Martyrdom is the outer expression, but it is a quest for meaning that is the true driving force that motivates Cyrus to take healthy action in the novel. He attends a group therapy program and has a tough-minded supervisor to help him detox from his drug use. Ultimately, it is the new awareness that Cyrus gains about his parents that enables him to achieve psychological equanimity and peace of mind.  

Finally, what is the martyrdom that Cyrus longs for? He is not looking to wrap himself with explosives, kill the infidels, and gain entry to paradise. One could say that what he so desperately wants is lasting fame and renown for an act or artistic creation that will be seen as unique and cherished, that will survive after him, and that will keep his name eternally alive. The Book of Martyrs, a fictional collection of poems written by Cyrus that are interspersed in the text, could conceivably represent this hoped-for act of martyrdom. However, the ending of the novel suggests that Akbar may have a less explosive and more intimate notion of what martyrdom means. The knowledge that Cyrus gains over the course of the novel and his interactions with Orkideh spur him to finally achieve the martyrdom he seeks. His ultimate fate on the final page is actually a bit murky. But the vision that one is left with is that Cyrus has indeed achieved a life of meaning because it is a life of meaningful interpersonal connections.  

Martyr! 
Kaveh Akbar 
Alfred A. Knopf, 2024, pp 332 
Web image by Levi Meir Clancy