DAVID HSU: Tell me a little bit about this half-marathon business. What’s going on with that?

TONY MIKSANEK: I’ve been running for a number of years, which I truly enjoy, and I’ve done ten full marathons, one ultra marathon, and God knows how many half-marathons. But as I get older, I’m leaning more toward the half-marathon as the longest distance I like running.

DH: So how did this one go? Was it good?

TM: Yeah. This one was in Florida. The weather was beautiful. There were about 20,000 people, and it was at Disney World. So you run through the Cinderella Castle, you’ve got all the characters high-fiving you on the course. It’s great. I think I originally got into running as a sort of release from medical practice, where you can be outside, mindful of your surroundings and your breathing and your foot striking the pavement. Since then, it’s become just short of an obsession. A good one, a good obsession. But I’ve often thought about the similarities between running and medicine. The greatest similarity is that both endeavors require a pair of comfortable shoes because you’re on your feet all day practicing medicine. There’s also a rhythm to running, which is a very individual, personalized thing. And, of course, there’s a rhythm to our practice. The flow of taking care of patients and our style in interacting with them. In running, you have to build up a core. We call it a core of mileage that your body gets acclimated to. In practice I think that core is sort of like developing trust in the physician-patient relationship. You have to work on that. You know that saying, “trust is hard to earn but easy to lose?”

DH: Let’s talk a little bit about medical humanities. You mentioned that running was something that you did to put your head in a different space from your regular work. I assume that medical humanities would also be something that gives you a diversion from your regular work. Is that accurate?

TM: Most of my career was spent as a small town, rural area, solo family practitioner in a former coal mining town with a population of right around 8,000 people. So medical humanities, for me, for most of my life, has always been an individual thing. I read and tried to be involved in whatever peripheral way I could with medical humanities. And I did and still do derive a lot of satisfaction, enjoyment and learning from reading great literature. We can debate what the adjective “great” means when it applies to literature, but I feel there’s so much to gain from literature. When a patient comes into our office, they usually want to tell us a story. Sometimes they’re reluctant, but usually they want to tell us a story. And my belief is that most people, to be healed, need to tell that story. But equally important is they need somebody who is invested in listening to that story, that confirms their importance. and the validity of their illness or what they’re going through. And I think literature is a really great tool to help us learn how to listen intently to patients, more fully understand their stories of life and illness, and to enhance our empathy.

So again, my entry into medical humanities is probably unlike most of the people on our MedHum group. It’s mostly been kind of a solo route for a long time. Currently I’m an associate editor and a book editor for the Journal of Medical Humanities. I don’t know how far back you go with your practice, but once upon a time, the American Family Physician Journal, the AFP, had a regular column called “Diary from a Week in Practice.” And there were four contributors. I was one of them. I guess I was the token rural small-town doctor, because there was somebody from an urban practice and somebody from an academic practice. I forget what the fourth one was. And so we would take turns writing a column that was basically a chronicle of a week of practice like “what were the highlights, what were the lowlights.” I think that was important for me, because at the time, that was probably my version of reflective writing, even though it was produced in a form that would be published. You know, being a doctor is tough, albeit a wonderful, often joyful, profession. Running gave me an opportunity, I think, to kind of put myself in a place where I can sustain joy and the dedication that was required, especially being a small-town doctor where your patients are your neighbors. You run into them at church or the grocery store. The land is the connecting fabric for a small-town doctor. I mean, your kids’ friends are almost always your patients. So it’s a very vivid, organic, dynamic relationship.

DH: How big was your practice? How many patients did you have?

TM: I practiced in our town for a little over 30 years, as a solo family physician, 24/7, unless it was time for vacation or a meeting. And then, you know, I had an agreement with a couple other physicians for coverage if we were gone, but it was a very full practice. The only thing I didn’t do as a family physician was OB.

I loved to make house calls. I used to make them in my Jeep Cherokee. And I’ll never forget the first house call I made. I brought my nurse with me because I was new to town, and I didn’t really know where the address was. And we pulled up in front of this very, very small, weathered house. And I remember as they opened the door to let us in, the floor was dirt. It was a dirt floor. And having been born and raised in Chicago and then later some of the suburbs, I was dumbfounded. That was really my experience — people that were really struggling to make a living. But the dirt floor was, I mean, it sounds like an oxymoron, but it was clean. And the home was well-kept. There were a lot of eye-opening experiences being in a small town.

DH: What’s the name of the town?

TM: Benton. Illinois. Wonderful town. Great people.

DH: How did you stumble across the humanities and arts connection to medicine? Was this something that you were aware of as a student or at some point as you started working you started to realize that novels had something to do with your job? How did you make that connection working solo?

TM: I’ve always been an avid reader, as I think most physicians are. And actually, I got a head start because our medical school, the medical school I attended and where I am now a volunteer faculty in the Department of Medical Humanities, was one of the first medical schools in the country to actually have an independent medical humanities department. So as a student, I was already interested in medical humanities. I guess as a prelude to that, as an undergraduate student at the University of Chicago, we had what they called a core curriculum when that was not a popular thing. Every student, no matter what your major was, had to have competence in basically all the major disciplines. So, if you were going to be a biochemistry major, you still had to take the History of Western Civilization, Art Appreciation, etc.

I’ve always been involved with literature. Once upon a time, JAMA and the New England Journal had book review sections, and I did book reviews for those two journals. The sad thing is, they haven’t had a book review section for a number of years now. There’s no interest, I presume? I don’t know. They just kind of vanished in the night. So, during my early years of clinical practice, I was writing reviews mostly for JAMA. They would send me all kinds of books, some of which were very peripherally connected with medicine. And so I think maybe when they had a book that looked interesting, they would say, “well, we’ll just send it to Tony.” Which was great. But that was in the days even before internet. I remember I would be sitting at my kitchen table with a typewriter typing these reviews to mail to JAMA or New England Journal. And it was kind of wild. But life was so much simpler then, too, on the other hand. Anyway, I would say that medical school, a love of literature, getting involved in book reviewing from early in my career was kind of the springboard for me, into medical humanities.

DH: Can you give us a few medical humanities book titles that we can spotlight for the audience?

TM: One book that I really was impressed by was Do No Harm. There’s an aphorism in medicine, “do no harm.” That’s the title. And it was written by a neurosurgeon in England by the name of Henry Marsh. It’s a beautiful book because like the very best memoirs, he presented his vulnerability as an individual and as a physician, a surgeon, so beautifully. You couldn’t help but be moved by his sincerity. In fact, he had a line, I’m paraphrasing it, but the line was something like, “I am a vessel for my patients to pour their misery into.” And you know, on the one hand you can say, “well, that sounds a little pontificating, a little arrogant,” but on the other hand, it’s like, “isn’t that part of the job description?” So that would be one: Do No Harm. Another by a physician author is Cutting for Stone.

DH: By Abraham Verghese.

TM: He’s out at Stanford and he’s written a lot. The Tennis Player, and others, but Cutting for Stone is one of these lengthy novels that you’re reading and you’re like, “this author’s all in.” He’s not saved any good stuff for another book. It’s just all there. So that’s another one I would recommend to people.

I’m also a very big fan of Richard Selzer because first of all, most are short stories or short essays you can read in a single sitting. I’ve met him a number of times and he admits that he lies, because these are not true stories necessarily, and they may have had their genesis in some kernel of truth. So there is a lot of exaggeration and hyperbole but there’s still something that he’s able to successfully impart to the reader about a doctor’s vulnerability. When I trained, we were told to suppress our emotions and have clinical detachment. You can’t survive if you get too involved with your patients. And of course there is truth to that. It can get to the point where you lose yourself in someone else’s situation and it’s not healthy for you or them. But I think we’re in a renaissance of saying, “Okay, maybe you can’t be too empathetic, but it’s okay to be vulnerable.” We’re not superheroes. I still struggle with that.

I had a lot of older folks in my practice who were huggers. Early on, I was always like taking a step backwards as they were lunging toward hugging me. But then my nurse, in her wisdom, said, “You know, they need to hug you.” That’s how they’re acknowledging your value to them and what you mean to them. I’ve done a lot of thinking about vulnerability and physicians. What is the optimum amount of being vulnerable? In the old days, if we had a very difficult situation, we would just go in our office, close the door, and have a cry. I mean, we would weep. We would never think of demonstrating our sorrow in front of a patient or something. And I think that comes from the training back then. But as you know, there’s no template for being a good physician. And it’s kind of a learning experience for all of us.

DH: It has something to do with how to be a good human being.

TM: Yes, exactly. And I think the whole point of medical humanities, as I alluded to earlier, is about that soul, that spirit of medicine, which is not just about how we practice medicine and interact with other people, but also with being self-aware of who we are, what we can offer, what our strengths and our weaknesses are, and trying to embrace both. Understanding that there are things we don’t do as well as we’d like, things we could do better. But again, it goes to that understanding of our vulnerability and accentuating our strengths and trying to minimize our weaknesses, while understanding that all human beings are some unequal combination of both.

DH: Switching gears a little, as a retired family physician, what’s your view of medicine today? Is it pessimistic? Is it optimistic? Do you think we’re moving in the right direction or are things worse than they were back when you were going through it?

TM: I think medicine is a completely different enterprise now than it used to be. I remember the joy of holding a paper chart and writing my notes with a pen on paper. I think my notes were adequate or good, but they had just the right amount of information that was necessary. There was nothing superfluous when you had to write your own note because you had a certain amount of time that you wanted to get the note done in. And I understand the utility of the electronic health record and its portability. But I think there’s something about looking a person in the eyes, giving them 100% attention, and even though back in the day I used to scribble down some notes so I wouldn’t forget certain things, 90% to 95% was just one-on-one. And then after the visit, I would write the note in the chart, or later I had the ability to dictate a note, which was great. So I think the electronic health record, on balance, has been a detriment to the practice of medicine.

Also, the amount of time you spend with a patient has become very restricted. For example, I was very cognizant of people waiting in the waiting room. Back at my peak, I was seeing 30 to 35 people a day in the office. In addition, I admitted and cared for all my patients requiring hospitalization. The local hospital that we have, 50 beds, still does not have a hospitalist. And so you had to make rounds. You took care of people in the ICU. You saw your patients in the ER. It was a full-service experience for patients and the physician. It was hard. There’s no question. But there was something very gratifying about being able to do all those things right and being a small-town doctor. People just called you at home. We had one rule in the house, and the rule was that as a family — we had three children — we would all have dinner together and that one hour was just for us. What happened with the kids during the day at school and their activities and how work for my wife went. And I just remember laughing and laughing, but we carved out that time. But otherwise, it was all hands on deck all the time. SoI think medicine is different. Whether it’s better or worse, I don’t know.

I really do feel sad that we’ve become such a technological profession. You hear students saying, “Well, what’s the point of trying to listen to a murmur? We’ll just get an echocardiogram.” Back in the day, you relied on your clinical acumen and you formulated your differential diagnosis. And then you thought, “well, what is the most likely diagnosis?” And then you would do testing to support that diagnosis or refute it and move on. And now I feel it’s like people immediately get tested.

We used to have to listen to people. You probably have the same experience. I think all medical students do. You have some wise professor that says 90%, 80%, 85% of the time, the patient will tell you exactly what’s wrong. You just have to listen to them. You may have to nudge them a little bit to give you more information. But now I don’t know that we’re giving people enough time to tell us what is really wrong with them before we kind of take the leap to do these tests. And I think, unfortunately, patients are getting so comfortable with the notion of getting tests that that is all they want. I’ve had patients that say, “Well, can we do a CAT scan? Can we do this or that?” Of course we can do it, but tests come with risks. False positives, incidentalomas, radiation exposure in some cases and so on. So on balance I’m going to say, although it was not Nirvana or Eden back in the day, and we had our own issues and problems, it seemed closer to the aim of healing.

DH: Well said. What would you like to see MedHum do in the coming months and years?

TM: I think what I would like to see is just MedHum continue on its trajectory and grow to become a go-to resource for people interested in medical humanities or just people that are curious about medicine in general. I would like to see the website continue to grow and become a valued resource where people, if they’re interested in the depiction of medicine in the humanities and in the culture of medicine, they can read articles, they can listen to podcasts. There’s a lot of interesting material on the website already. I think as we grow and expand and include more contributors, the possibilities are limitless for what it can become.

DH: That was great. I had a good time. We should do this again.

TM: Me too. We’ll look forward to talking again.

Posts Written by Dr. Tony Miksanek

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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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The artist depicts Chekhov as he was in the early 1890’s, soon after he had purchased a small, dilapidated estate and moved there from Moscow with his family. In addition to serving as country doctor and public health official in Melikhovo, Chekhov at that time was composing many of the stories and plays that made him one of Russia’s most well-loved writers and a major influence on 20^th century literature. How was he able to pursue two such different and demanding careers? Several years earlier, at the height of Chekhov’s early literary success, his friend Alexi Suvorin had urged the young writer to give up medicine. Don’t spread yourself too thin, he said. You’ll never reach your potential unless you concentrate on writing. In response, Chekhov wrote, “You advise me not to chase after two hares at once and to forget about practicing medicine. Well, I don’t see what’s so impossible about chasing two hares at once… Medicine is my lawful wedded wife and literature my mistress. When one gets on my nerves, I spend the night with the other. This may be somewhat disorganized, but then again, it’s not boring, and anyway, neither loses anything by my duplicity.” (1) In this famous passage, the 28-year-old writer dances lightly over a fundamental truth of his life and identity. In fact, Chekhov’s career was not so much a matter of jumping from one bedroom to another, as was the case perhaps with the poets Wallace Stevens and T. S. Eliot, or the composer Charles Ives. Rather, Chekhov thrived on the effective, if not always seamless, integration of the arts of medicine and writing, which reinforced one another throughout his creative life. This essay explores that integration, and the manner in which Chekhov’s cold eye (objectivity) and warm heart (compassion) reveal themselves in his medical and literary lives. 

DOCTOR CHEKHOV  

“Medicine Is My Lawful Wife” 

When he graduated from the Moscow State University School of Medicine in June 1884, Chekhov was already earning his living as a professional writer. The grandson of serfs, Anton was the third of six children in a poor merchant family from Taganrog, a southern provincial town on the shore of Sea of Azov. His father had moved the family to Moscow after going bankrupt in 1877. By the time Anton entered medical school on a scholarship in 1879, the Chekhovs were living in squalor. His father had a dead-end job. His older brothers were alcoholics and generally unemployed. Anton soon discovered that he could ameliorate the situation by selling comic sketches to local magazines for eight kopecks per line. This was a type of moonlighting he loved. He wrote obsessively, often knocking off a story or two each night, after spending the day listening to lectures or working in the hospital. Chekhov ultimately published more than 200 pieces while a medical student, most of them under his preferred pseudonym, Antosha Chekhonte. 

Chekhov was a natural storyteller. Thus, it wasn’t surprising that the newly minted Doctor Chekhov continued to write, even after he opened his office and patients began to arrive. “Continued to write” is an understatement. Chekhov published 54 stories in 1885, 76 in 1886, and 57 in 1887. His work evolved from humorous sketches to longer, more serious stories for leading literary journals. In 1888 Chekhov won the prestigious Pushkin Prize and published “The Steppe,” his longest and most innovative story to date. Ivanov, his first full-length play, had a successful premiere in St. Petersburg in January 1889. By that time the young doctor had become one of the best known writers in Russia. 

Yet Chekhov always saw himself as a physician, even though in 1889 he did, in fact, retire from a normal paying practice; after that, he offered his medical services at no charge, even though the generous Chekhov often found himself financially strapped. He took care of the peasants near Melikhovo (as depicted in the painting), donated his services to the government as a district physician, and engaged regularly in public health initiatives. In less than five months in 1891, Chekhov reported seeing 453 patients at a district health center and making 576 house calls, in addition to his home practice. (2) Throughout his life, Chekhov also was heavily involved in grass roots activism, building schools for peasants, raising funds to help famine victims, and, later, near the end of his life, supporting the establishment of a sanitarium for tuberculosis victims at Yalta.  

“My Debt To Medicine” 

One of the best known of these public health efforts was his 1890 epidemiological survey of health and social conditions in the prison colonies on Sakhalin Island. Traveling by himself, Chekhov journeyed six weeks by train, steamboat, and horse-drawn carriage across Siberia to reach the 1000-km long Pacific island on which the Czarist government had recently established a notorious gulag. There, he embarked on a one-man, three-month survey of the population, tenaciously picking his way from settlement to settlement and from house to house, often by foot.  

Biographers have long tried to pinpoint his motivation for this perilous journey. During the year prior to the trip, Chekhov had undergone a crisis of confidence. In a letter to Suvorin, he opined, “I don’t love money enough for medicine, and I lack the necessary passion—and therefore talent—for literature. The fire in me burns with an even, lethargic flame; it never flares up or roars… I have very little passion. Add to that the following psychopathic trait: for two years now, seeing my works in print has for some reason given me no pleasure.” (3) He reported symptoms suggestive of clinical depression, perhaps precipitated by grief over the death of his brother Nicholas from tuberculosis. There was also a literary issue. The master of the short story had promised himself that he would create a Tolstoy-like novel that would confirm his status as a serious writer. But he was unable to do so.  

Undoubtedly a major factor for choosing Sakhalin was Chekhov’s desire to pay his debt to medicine. He had recently developed a scientific interest in penology and had read about the dismal conditions in the Siberian gulag. He saw an opportunity to influence this situation by obtaining accurate data on the health status of Sakhalin convicts. He had never completed the research thesis (the equivalent of a Ph.D.) that would make him eligible to be a medical specialist or professor. Hence, his notion of “my debt to medicine”—he would perform a survey, write his thesis, and become a teacher. 

Ultimately, Chekhov claimed to visit every settlement and survey every household on Sakhalin Island, using a 12-item data collection form. He said he completed over 10,000 of these forms in three months, a feat that (if true) qualifies Chekhov as the speediest shoe-leather epidemiologist of all time. After his return to European Russia, the author found it difficult to organize his data into a coherent study. While he had planned to write a strictly scientific monograph, his creative spirit struggled with the limitations of science. What about his personal experience? What about the interesting stories? After struggling for years, in 1895 Chekhov published The Island of Sakhalin, a curious (but engrossing) mixture of journal, geography, history, medicine, statistics, and travelogue. (4) Unfortunately, the faculty of the University of Moscow was unimpressed.  

“As I Grow Older, the Pulse of Life in Me Beats Faster” 

Picture the mature Chekhov—a middle-aged bachelor, longish face, rather neatly trimmed beard, a prince-nez clipped to the bridge of his nose. His household included his aging parents and his sister Masha, an unmarried schoolteacher who had become his confidant and secretary. His three surviving brothers looked to him for guidance and financial help. Anton was popular, witty, and generous. Among the guests at Melikhovo, there were frequently female admirers. Chekhov’s encounters with women were flirtatious and obviously enjoyable. He had teasing, sexually charged relationships with several women, but whether any of these liaisons are actually “affairs” is uncertain.  

The doctor in the painting already suffered from the tuberculosis from which he would die at the age of 44 years. In fact, he first coughed blood as a medical student. Yet, Chekhov dismissed that episode and each subsequent episode that occurred with disheartening regularity as “influenza” or “bronchitis,” steadfastly refusing to label himself consumptive. As a physician Chekhov must surely have understood the meaning of his symptoms. Was his denial simply a face to show others? Or was his denial so great that it made him unaware? The cat finally came out of the bag in early 1897. While dining at a restaurant in Moscow, Chekhov had a violent spell of hemoptysis that left him critically ill. For the first time, he sought medical treatment and entered the clinic run by Dr. Ostropov, one of his medical school professors. Chekhov’s chronic illness progressively worsened. At the insistence of his doctors, Chekhov left his beloved Melikhovo after 1898 and lived mostly at a new home in the sunny Black Sea resort of Yalta. 

It was also during these last years that the bachelor writer courted and married Olga Knipper, an actress with the Moscow Theater Arts Company. Even after their marriage in 1901, Olga remained at work in Moscow during much of the year, while the invalid Chekhov lived in Yalta, theirs being perhaps one of the earliest examples of the modern two-career commuter marriage. Chekhov found himself able to devote less and less of his waning energy to writing, especially since he refused to give up his social and philanthropic activities. Nonetheless, between 1898 and his death in 1904 Chekhov completed some of his greatest work, including several stories, two novellas (“Peasants” and “In the Ravine”), and his last plays, The Three Sisters (1900) and The Cherry Orchard (1903).  

COLD EYE, WARM HEART 

Chekhov’s Doctors 

Several characteristics of Chekhov’s work reveal the influence of medical training and practice. He used clinical knowledge to lend accuracy to his descriptions of disease and medical situations. This characteristic is perhaps most clearly seen in the characterization of mental disorders. For example, the title character in Ivanov is a subtle portrait of a man suffering from clinical depression, who eventually commits suicide. The young heiress in “A Doctor’s Visit” presents symptoms we would now label as generalized anxiety or panic disorder. The title character in Uncle Vanya appears to have a neurotic depression, a condition that meets today’s DSM 5 criteria for Persistent Depressive Disorder. In the peculiar story called “The Black Monk,” Chekhov describes a psychotic condition, presumably schizophrenia.  

Chekhov also drew from his medical experience in creating a multitude of physician characters. Doctors play significant roles in nearly 30 stories and in all of his major plays, except The Cherry Orchard. The author’s sensibility as a medical insider gives insight and poignancy to these characters, who range from committed altruists to lazy bureaucrats to burned out cases. Chekhov knew too much about the contemporary state of medical science to portray his doctors as curing many people. Thus, they often appear impotent. Yet, at their best Chekhov’s doctors convey the seamless fabric of tenderness (compassion) and steadiness (detachment) that lies at the heart of good medical practice. They also demonstrate courage, altruism, and self-effacement. For example, in “The Grasshopper” (1892) Dr. Dymov dies as a result of contracting diphtheria from a patient. Dr. Kirilov in “Enemies” (1887) demonstrates extraordinary devotion to duty by leaving his distraught wife and dead son in order to make an emergency house call.  

Perhaps Chekhov’s most textured portrait of a good physician appears in “A Doctor’s Visit” (1898). The protagonist, Korolyov, is a young doctor substituting for his boss, the professor of medicine. During the course of the story he moves from being a careful observer (detached concern) who ascertains that his young patient has nothing wrong but a “case of nerves,” to making an imaginative leap by which he connects more deeply with her. This empathic connection allows him to relieve some of her suffering by re-framing her illness. While he cannot solve her existential problems, his demonstration of solidarity leads her to trust him and to gain insight. Korolyov is like Chekhov himself. Dr. Pavel Archangelsky, who supervised Chekhov’s first job as a physician, captured the author’s ability to listen carefully when he later commented: “… he did everything with attention and a manifest love of what he was doing, especially toward the patients who passed through his hands. He listened quietly to them, never raising his voice, however tired he was and even if the patient was talking about things quite irrelevant to his illness.” (5)  

At the other end of the spectrum, some of Chekhov’s doctors are insensitive, incompetent, or impaired. Mayer, the callous medical student in “A Nervous Breakdown” (1889) is a disaster. Mayer can rattle off statistics on the number of whores in London and Moscow, but he is unable to “see” (empathize with) the suffering of the living-and-breathing whores he encounters. Shelestov in “Intrigues” (1883) and the public health doctor in “Darkness” (1887) are examples of self-centered physicians a little further along in their professional lives. The former is superficial and pompous; the latter is narrow-minded and detached.  

Chekhov’s most complete insensitive and acquisitive social climber is found in “Ionych” (1898). Dr. Startsev, when the reader first meets him, is a young physician setting up practice in a provincial town. After surviving an unrequited infatuation with the daughter of a wealthy townsman, Startsev devotes himself entirely to work. His practice prospers and he branches out into real estate. As he grows corpulent and wealthy, Startsev loses touch with his patients (and his own humanity): 

“Probably because his throat is covered with rolls of fat, his voice has changed; it has become thin and sharp. His temper has changed, too; he has become ill humored and irritable. When he sees his patients, he is usually out of temper; he impatiently taps the floor with his stick, and shouts in his disagreeable voice: ‘Be so good as to confine yourself to answering my questions! Don’t talk so much!’” (6) 

“Ionych” traces the progressive destruction of a medical practitioner who finds that medical affluence is more to his liking than the emotionally and physically difficult path of medical virtue.  

Some of Chekhov’s most interesting doctors are tortured by existential or spiritual conflict. Chekhov accurately depicted professional burnout, a syndrome characterized by depletion, detachment, depersonalization, denial, and depression. (7) Dr. Kirilov, who chooses to “go to the office” instead of mourning with his wife, may illustrate the relatively early phase of emotional detachment. Dr. Ovchinnikov in “An Awkward Business” (1888) demonstrates the more advanced symptom of depersonalization when he slugs his assistant in response to the man’s incompetence. The overworked Ovchinnikov reacts to his personal depletion by objectifying and dehumanizing his assistant, a response that compromises the medical care he is trying to protect. Chebutykin in The Three Sisters (1900) illustrates the extreme of alcoholism. Though still employed as a military physician, Chebutykin convincingly asserts that he has forgotten all the medicine he ever learned.   

Ragin in “Ward #6” (1892) and Nikolai Stepanovich in “A Dreary Story” (1889) are complex characters in whom depression and burnout are superimposed on a deep sense of existential failure. Like many of Chekhov’s characters, these physicians suffer from a lack of self-knowledge; they move through life relying on one form of self-deception or another. When they were younger, they committed themselves to noble ideals—Stepanovich to teaching and Ragin to practice in a provincial hospital. But in the long run they never “found” themselves. Professor Stepanovich yearns for a unifying moral principle that would knit together the fragments of his life. Dr. Ragin experiences his failure as emotional numbness. He yearns to suffer, assuming that if he experienced pain, he would be freed from his inability to feel. Thus, the academic physician pines for salvation in the cognitive sphere; the practitioner yearns for emotional redemption. In each case the focus remains inward, rather than turning outward to others, in whom salvation might actually be found.  

Medical Sensibility 

Medical attitudes and methodology play a larger role in Chekhov’s work than does medical knowledge. He believed that his duty as a writer was to present his observations clearly and accurately; in other words, to lay out the data in an objective fashion and allow readers to reach their own conclusions, rather than providing an author’s interpretation. He wrote, “The artist should not be a judge of his characters and what they say, but only an objective observer.” (8) 

This objective attitude put him in conflict with most other Russian writers of the time. It was a major source of conflict with Tolstoy, who was widely revered at the time as a living saint. The two men enjoyed a close personal bond but approached writing with radically different philosophies. After his mid-life religious conversion, Tolstoy viewed literature as a way to communicate his moral vision. He preached the gospel of a radical Christianity, in which all men work together to achieve economic and social equality. However, he rejected the concept of material progress and was particularly skeptical of medicine and doctors. Chekhov, on the other hand, strove to be objective, to present people as they are and the world as it is. His medical training taught him to be a careful observer; his medical attitude made him leery of judging others.  

Other Russian writers and intellectuals spoke out against the czarist government’s repressive social institutions. While this protest was disguised in various ways in order to satisfy the state censors, late 19^th century Russians (like their 20^th century counterparts) learned to speak and understand a subtle code of insurrection. The intellectuals addressed “big issues”—democracy, education, social revolution. They wrote articles, organized meetings, and gave speeches. Here again, Chekhov found himself on a different wavelength. He rarely engaged in theoretical discussion and did not advocate radical social change. Rather, he preferred a pragmatic, case-based approach. His goals were relatively limited, but achievable. Treat the sick patient. Document and publicize the abysmal condition of prisoners. Contain the cholera epidemic. Provide financial assistance to keep farmers afloat during the famine. Raise money for a new school. On and on, but always specific and personal.  

In “About Love” (1898), the narrator speculates on the essence of love. Are there universal characteristics that identify love wherever it occurs? “What seems to fit one instance doesn’t fit a dozen others,” the narrator concludes. “It’s best to interpret each instance separately in my view, without trying to generalize. We must isolate each individual case, as doctors say.” (9) Indeed, Chekhov’s stories and plays rigorously follow this dictum. While many of his Russian contemporaries used fiction to advance moral or social theories, Dr. Chekhov focused on the complexities of human interaction. In Chekhov’s world, biology and circumstance constrain freedom. People often do not listen. Acts performed with good intentions frequently result in hurtful outcomes. And yet occasionally and in unexpected places, one finds a glimmer of love, courage, spirituality, or healing. “Never generalize,” Chekhov tells his readers. “Never theorize. Pay attention to the particulars. Focus on the concrete.” In this respect, the 19^th century physician-storyteller presages the 20^th century physician-poet, William Carlos Williams, who coined the aphorism, “No ideas but in things.”  

In the long run, Chekhov’s objectivity and aversion to theory played a major role in the development of modern literature, as 20^th century writers followed Chekhov in attempting to describe the world of human character and relationship objectively, and allowing that world to speak for itself. To the extent that Chekhov’s “lawful wedded wife” contributed to his sensitivity, skills, and attitudes, perhaps medical education and practice played an unanticipated role in the history of literature, his delightful “mistress.” 

Adapted in part from Coulehan J. (Ed.) Chekhov’s Doctors, Kent State University Press,  2003

Sir Luke Fildes’ “The Doctor,” is in the Tate: File:The Doctor Luke Fildes crop.jpg – Wikimedia Commons 

Portrait of Chekhov: File: Chekhov 1898 by Osip Braz.jpg – Wikimedia Commons 

REFERENCES 
1, Chekhov A. The Selected Letters of Anton Chekhov, translated by Sidonie Lederer, New York, The Ecco Press, 1984, p.  
2, Coope J. Doctor Chekhov. A Study in Literature and Medicine, Chale, Isle of Wight, Cross Publishing, 1997, p.  
3, Chekhov A. The Selected Letters of Anton Chekhov, translated by Sidonie Lederer, New York, The Ecco Press, 1984, p. 81. 
4, Chekhov A. A Journey to Sakhalin, translated by Brian Reeve, Cambridge, Ian Faulkner Publishing, 1993.  
5, Coope J. Doctor Chekhov. A Study in Literature and Medicine, Chale, Isle of Wight, Cross Publishing, 1997, p. 27. 
6, Chekhov A. Ionych. In: The Tales of Chekhov. Volume 3, translated by Constance Garnett, New York, The Ecco Press, 1972, p. 91. 
7, Coulehan JL. Being a Physician. In: Mengel MB, Holleman WL (Eds.) Fundamentals of Clinical Practice. A Textbook on the Patient, Doctor, and Society, New York, Plenum Medical Books Company, 1997, pp. 73-101. 
8, Chekhov A. The Selected Letters of Anton Chekhov, translated by Sidonie Lederer, New York, The Ecco Press, 1984, p. 54. 
9, Chekhov A. About love. In: The Tales of Chekhov. Volume 5, translated by Constance Garnett, New York, The Ecco Press, 1972, p. 290.

Reviews of Chekhov’s Stories

Cold Eye, Warm Heart: Medicine and Anton Chekhov  

Aug 6, 2025 6036

An Awkward Business by Anton Chekhov 

Jun 11, 2025 1253

The Grasshopper by Anton Chekhov

May 11, 2025 1072

Ionych by Anton Chekhov 

Mar 11, 2025 1880

A Doctor’s Visit  by Anton Chekhov 

Mar 11, 2025 1545

Ward No. 6 by Anton Chekhov

Mar 11, 2025 3034

A Nervous Breakdown by Anton Chekhov 

Feb 11, 2025 1270

Enemies by Anton Chekhov

Jan 11, 2025 1393

Painting an Ideal: Luke Fildes’ The Doctor with Hannah Darvin

Dec 28, 2024 1050

As The Ghost Road begins, Prior has been cured of shell shock and is preparing to return to the front in France. Rivers takes care of his patients and his invalid sister, amid memories of his experience ten years earlier on an anthropological expedition to Melanesia (Eddystone Island). He befriended Nijiru, the local priest-healer who took Rivers on his rounds to see sick villagers and also to the island’s sacred Place of the Skulls.

Rivers entertains very un-British thoughts about the morality of these headhunting people, and about the power of symbolic healing. As these thoughts intrude upon his consciousness, Rivers is himself in the process of curing by suggestion a soldier with hysterical paralysis. Meanwhile, Billy Prior returns to the front. It is the autumn of 1918 and the last inhuman spasms of the war are in progress. In a futile battle that takes place a few days before the Armistice, Billy and his friend Wilfred Owen are killed.

To me The Ghost Road, which won the Booker Prize in 1995, is the most gripping and fastest paced of Pat Barker’s trilogy. The first two novels are Regeneration (1991) and The Eye in the Door (1993). As W. H. R. Rivers reflects on the culture of death on Eddystone Island, World War I, a culmination of the culture of death in Europe, grinds to a close, taking with it the poet Wilfred Owen. Of course, the characters in The Ghost Road are unaware of the new heights (or depths) that the culture of death will attain later in the 20th Century.

The Ghost Road
Pat Barker
Dutton, 1995
New York, 256 pages

Web image by  Claudio Carrozzo 

Mental Cases by Wilfred Owen

Carol Donley Aug 11, 2025

Owen’s stark poem portrays shell-shocked soldiers haunted by war, exposing both their torment and society’s complicity in their suffering.

Dmitry Ionych Startsev, a physician in a provincial town, is frequently entertained by the Turkins, the town’s most cultivated family. He falls in love with their daughter, Yekaterina, who teases the doctor by asking him to meet her in the cemetery at 11 PM and then doesn’t show up. Finally, she completely rejects his advances, saying that she must go to Moscow and study at the conservatory.  

Four years later, Startsev has gotten corpulent, built a big practice, become affluent, and lost all interest in romance. Yekaterina returns and tries to rekindle their affair, but Startsev gets irritated and says to himself, “What a jolly good thing I didn’t marry her!” In the end, he just keeps getting fatter and more irritable, and he shouts at his patients.  

Startsev is one of Chekhov’s insensitive and psychologically ignorant physicians, the type of doctor decried by Nikolai Stepanovich in “A Boring Story”. He has little or no understanding of the Turkins’ inner lives or turmoil, nor can he distinguish real artistic talent, which the Turkins lack, from mere show. He becomes hardened in the face of suffering and devotes his life to financial reward. This is reflected in his deplorable treatment of patients.  

Ionitch by Anton CHEKHOV | FULL Unabridged AudioBook

Jack Coulehan (Ed.) Chekhov’s Doctors, Kent State University Press, 2003. Translated by David Magarshack. 
David Magarshack (Ed.) Lady with Lapdog and Other Stories London, Penguin Books, 1964. Translated by David Magarshack.  
Originally Published 1898 

A previous version of this review was published in the NYU Literature, Arts, and Medicine Database (Litmed).
Web image by Artem Labunsky 

Reviews of Chekhov’s Stories

Cold Eye, Warm Heart: Medicine and Anton Chekhov  

Jack CoulehanAug 6, 2025

An Awkward Business by Anton Chekhov 

Jack CoulehanJun 11, 2025

The Grasshopper by Anton Chekhov

Jack CoulehanMay 11, 2025

Ionych by Anton Chekhov 

Jack CoulehanMar 11, 2025

A Doctor’s Visit  by Anton Chekhov 

Jack CoulehanMar 11, 2025

Ward No. 6 by Anton Chekhov

Jack CoulehanMar 11, 2025

A Nervous Breakdown by Anton Chekhov 

Jack CoulehanFeb 11, 2025

Enemies by Anton Chekhov

Jack CoulehanJan 11, 2025

“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 renowned English social realist and portrait painter, Luke Fildes (rhymes with “childs”), created The Doctor in 1891 after Henry Tate commissioned a painting from him for his new museum, the Tate Britain. The subject of the painting was Fildes’ choice. Despite a poor reception among art critics when it was first exhibited, the painting quickly became iconic as the physician ideal. Over its 133-year history, the painting has been used for a variety of purposes, including inspiration, education, propaganda, and politics. During that time, the ways in which the painting represents the physician ideal changed. We talk about these aspects of the painting with Hannah Darvin from Queen’s University in Kingston, Ontario, Canada. She has conducted extensive research into the painting and its creator.

Links
Image of The Doctor from the Tate Britain Museum.
About Hannah Darvin at Queen’s University.
Hannah Darvin’s description of her research for the Harvey Cushing/John Hay Whitney Medical Library at Yale University.
John Brewer Eberly’s diptych rendering a modern version of The Doctor in which computer technology is interjected between doctor and patient. 

Feature image from Wikicommon

Cold Eye, Warm Heart: Medicine and Anton Chekhov  

Jack Coulehan Aug 6, 2025

A moving portrait of Anton Chekhov, whose dual life as physician and writer reveals the deep interplay between healing and storytelling.

At bottom, these two categories of judgment largely overlap. My concern here is the role of the physician’s own emotions (or, as we like to say in medicine, in order to sanitize them, affects) in judgments of either category. Do the physician’s own emotional responses contaminate her judgment when making clinical or moral decisions in patient care? Or, rather, do her emotional states constitute essential components of medical judgment? 

Clinical Judgment 

Medicine has a long tradition that attributes a special quality to the diagnostic and therapeutic thought processes of good clinicians, an attribute independent of intelligence or medical knowledge. Traditional views of clinical judgment included personal experience, received knowledge in the profession, and evidence from empirical studies. Emphasis was put on developing the “clinical eye” or clinical intuition as a result of personal experience, perhaps guided by role model physicians. In 1967 the Yale clinician and epidemiologist Alvan Feinstein published his book, Clinical Judgment, which was the first (as far as I am aware) systematic and scholarly analysis of judgment in medicine.¹ What Feinstein added to the mix was a firm grounding in epidemiological methodology; notions like prevalence, sensitivity, specificity, predictive value. What constituted evidence became more scientific and less subject to bias. However, Feinstein acknowledged the important influence of a personal relationship with the patient in good clinical judgment. 

In this sense he was following a tradition that has been prominent among physician writers for over 250 years and was often expressed metaphorically by reference to the heart. For example, John Gregory, Professor of Medicine at the University of Edinburgh wrote in 1772: “Of the physician’s character, the chief quality is humanity, the sensibility of heart that makes us feel for the distress of our fellow-creatures, and which, in consequence, incites us… to relieve them.” Physicians “by being daily conversant with scenes of distress, acquire that firmness of mind so necessary in the practice of physic.”² Yet he warned his readers to maintain “a gentle and humane temper” because “rough and blustering manners generally accompany a weak understanding and a mean soul.”² In 1803 Gregory’s student, Thomas Percival, instructed physicians to, “Unite tenderness with steadiness in your care of patients and cultivate the tender charity that the moral practice of medicine requires.” He warned his readers that medical practice makes the practitioner vulnerable to “coldness of heart,” and he concluded: “This coldness of heart, this moral insensibility, should be sedulously counteracted before it has gained an invisible ascendancy.”³ 

Physicians reiterated this dynamic throughout the nineteenth century. Morril wrote that “the study of medicine has a peculiar tendency to harden the disposition,” which makes it incumbent on students to cultivate “an affectionate sympathizing spirit,” while Jones reflected on medicine’s “manifest tendency to harden and corrupt the heart.”⁴ And famously, in his 1889 graduation address at the University of Pennsylvania, William Osler encouraged the graduates to cultivate the virtue of “aequanimitas,” which would assist them in meeting, “the exigencies of practice with firmness and courage without, at the same time, hardening the human heart by which we live.”⁵

In the early twentieth century, Francis W. Peabody, chief of the Harvard medical service at Boston City Hospital, published an influential description of this tension between the “intensely personal” values needed in caring for patients and the “entirely impersonal” aspects of treating disease. Peabody recognized that the hospital setting creates a hostile environment for humanism, but urged students to commit “time, sympathy, and understanding” to creating a “personal bond” with their patients, which will make them more effective healers, as well as give them personal satisfaction.⁶ This tradition was most recently and eloquently summarized in A Flag in the Wind, Thomas Inui’s now famous report to the American Association of Medical Colleges (2003).⁷ Each of these writers emphasized the importance of tenderness or sensibility of heart, while warning students and practitioners against the tendency of medical practice to chill, harden, or corrupt the heart. 

A second tradition, almost diametrically opposed to the first, experienced a growth spurt in the mid-twentieth century and has become the most prominent model for medical education and practice in recent decades. In terms of diagnosis and therapy, the ascendency of randomized clinical trials, statistical techniques for the metanalysis of multiple studies, evidence-based medicine, algorithms, and clinical decision rules has progressively reduced the role of judgment in medicine because decisions are presumably to be based on complete, rather than incomplete, knowledge. Judgment is to be replaced by decision rules that can be applied without the adverse influence of spooky elements like intuition, biases, experience, emotion, or idiosyncratic beliefs. 

In tandem with this, the doctor’s proper stance toward her patient became detachment, rather than personal engagement, and the doctor’s emotions became stumbling blocks, rather than beneficial to care. This tradition holds that emotional experience decreases objectivity, which harms the patient because it compromises clear thinking and harms the physician because it makes her vulnerable to emotional stress, depression, and burnout. In summary, what was once a pernicious tendency to harden the heart is no longer considered pernicious, but rather a positive development that should be fostered by medical education.^8-11 Clinical judgment, according to this tradition, should ignore the heart and focus exclusively on the mind. 

Moral Judgment 

Medical morality originated in ancient writings from Greece, India, and China that specify the personal traits and moral duties of medical practitioners. These documents include such duties as honoring their teachers, acting in their patient’s best interests, and keeping “whatever I shall see or hear in the course of my profession” confidential. These admonitions were later incorporated into a Judeo-Christian-Islamic framework that added a theological dimension (e.g. respect for human life, compassion, fidelity, and vocation) to medical morality—for example, in the Oath of Maimonides: “May I never see in the patient anything but a fellow creature in pain.” Or, in the Islamic oath, “I swear by God to be . . . an instrument of God’s mercy.” This work was secularized in the eighteenth and nineteenth centuries by writers who adapted Aristotelian virtue theory to the profession. The basic idea, then, was that learning to be a physician involved a process of character formation in which certain defining virtues were incorporated as personal traits or qualities, thus enabling physicians to make correct moral judgments in their professional lives. 

This work was brought up-to-date in recent decades by philosophically-minded physicians, like Edmund Pellegrino¹² and Eric Cassell^{13, 14}, who argue that judgment in medicine should be an instantiation of the Aristotelian intellectual virtue called phronesis, or practical wisdom.⁹ They remind their readers of the moral goals intrinsic to the profession, and that certain physician character traits or virtues further those goals, e.g. compassion, fidelity, integrity, courage, humility, self-improvement. They argue that, in fact, that all clinical judgment is informed by moral judgment. 

Although moral judgment was thought essential in deciding what to do for patients, it was proscribed in making decisions about the intrinsic value of patients. The ethos of medicine strongly warns against judging the patient’s personal worthiness or value, even if the physician considers the patient’s beliefs or actions hateful. Thus, professional ethics dictates that you remain detached from any behavior that would compromise treatment of enemy soldiers, criminals, terrorists, or patients that you find personally hateful or disgusting. 

Beginning in the 1960s and 1970s, the professional virtue tradition was supplemented by (or challenged by, depending on your perspective) a new moral framework that generally goes by the name biomedical ethics. This development became necessary for a variety of reasons, most notably (a) technological advances in medicine that enhanced the ability to prolong life and especially to harm, as well as to help, patients; (b) new societal emphasis on individual and civil rights; (c) increasing opportunities for conflicts of interest in medical practice; (d) revelations about medical research conducted without the subjects’ knowledge or adequate consent; and (e) concerns about the lack of equity in the provision of health care services. 

The biomedical ethics movement involved a concerted response to these issues by a great number of moral philosophers, theologians, legal theorists, and physicians. In the United States the movement acquired its canonical form as a result of the publications of two bodies, the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1974-78) and the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (1978-1983). The former developed the ethical framework (i.e., Common Rule) that has since guided all research involving human subjects. The latter delineated and elaborated four basic ethical principles: respect for autonomy, beneficence, nonmalificence, and justice. 

In biomedical ethics the focus is entirely on explicit justification of individual decisions (i.e. who should make them, what principles should be invoked), rather than on the qualities or character of the decision maker. Importantly, the model is one of shared decision making between patient and clinician, with adult patients having the determining voice, unless they lack decision making capacity. 

The notable aspect, for my purposes here, is that principles, like respect for autonomy, are intellectual constructs rather than personal traits, like virtues. There is no explicit role for such traits in biomedical ethics. I take it that virtues like compassion, empathy, humility, or courage cannot be actualized without an emotional component. You cannot act compassionately without experiencing some feeling. Thus, while traditional medical morality highlights sensibility of heart, biomedical ethics (at least in theory) exclusively involves intellectual considerations. Principle-based biomedical ethics is often labeled “thin” because, theoretically at least, it leaves out particularistic features of the patient’s community, culture, beliefs, and personal story. Advocates of care, feminist, and/or narrative ethics maintain that such features have great moral relevance to health care decisions. They argue for a “thick” form of health care ethics that takes particularities into account.

“Thickness” in decision making applies to physicians in decisions about the best (or most virtuous) way to allocate their time and effort. Part of this thickness relates to the physician’s feelings, emotions, or “tenderness,” to use Thomas Percival’s term. Consider the following case example. 

Case Example 

The case is an excerpt taken from “Narrative Medicine and Negative Capability,” an essay by the cardiologist Terrence Holt.¹⁰  Holt illustrates his discussion of the complexities of moral judgment in medicine by describing a situation he once experienced when he was a resident in the cardiac ICU: 

“It is about eleven in the morning, and I have been up since six in the morning the day before. The patient has been under my care eleven days… About fifteen minutes earlier, in response to her request and after several days of discussion, I had asked the nurse to turn off the pump that had been keeping her alive. The family members are around the bedside. The patient is awake… She will probably be dead within the hour. 

Tears are coursing down my face. I am being very quiet about it, but in a very quiet way I am sobbing as freely as I know how. I’m determined to stay with the patient during this ordeal. But meanwhile I am thinking: This is crazy. I’ve got several unstable patients who need attention. And there’s that arterial line in twenty-four that needs changing… At the same time I am utterly sad, haunted by memories of my father’s… death ten years ago. 

But somewhere a voice is also thinking: I’ll never get to lunch at this rate. I’m so backed up I’ll never get out of here on time.”¹⁵

Reflections 

I want to reflect on several aspects of Dr. Holt’s judgment in light of the clinical and moral traditions that I have outlined. First, the writer appears to combine deep emotional experience with a sense of detachment. He experiences (a) feelings of sadness and compassion, (b) awareness that at least in part those feelings arise from grief over his father’s death, and (c) detached reflection about his own needs and the work he has to do that afternoon. This combination appears consistent with older admonitions that physicians should maintain “sensibility of heart,” but to be at variance with the contemporary belief that emotional connection with patients is incompatible with good judgment—assuming, of course, that his current choices constitute good judgment. Do they? 

Second, from the perspective of contemporary biomedical ethics, Dr. Holt had already fulfilled his ethical duty when he respected the patient’s right to refuse treatment, and consequently withdrew mechanical ventilation. In addition, he may have consciously employed the principle of nonmalificence if he believed that the respirator was only prolonging the patient’s suffering. He has no moral duty to maintain a compassionate vigil. In contemporary terms, his actions would be considered supererogatory—commendable, but not a moral duty. 

Third, but how commendable is his behavior? It is clear that Dr. Holt’s course of action could have arisen, at least in part, from unresolved emotions related to his father’s death ten years earlier. He admits to strong feelings of sadness, loss, and grief, even to the extent of crying. Is this a case of countertransference, a psychological defense mechanism, rather than a true expression of moral virtue? We need to consider the extent to which the emotions about his father’s death are nurturing appropriate compassionate behavior, or, alternatively, contributing to a form of hyper-compassion that is preventing him from attending to other duties. 

Fourth, this brings us to the question of harm. Given the level of criticality among his ICU patients, Dr. Holt’s compassionate vigil has a reasonably high risk of negatively impacting the others’ care. He does, after all, have an established duty to provide the best medical care he can to each of his other patients in the ICU. They all have identified and pressing needs. To what extent, if any, does his behavior represent an abrogation of his duty to others? In bioethical terms, he may well be discounting the ethical principles of beneficence and justice in his desire to demonstrate compassion. 

To demonstrate this, we can take the narrative a step further. Suppose the man whose arterial line needed to be changed (e.g. nurses have noticed local redness and swelling) develops septic shock shortly after the first patient dies. Dr. Holt has spent more than an hour in the room with the dying patient and his family. Did his delay in removing the infected arterial line precipitate the septic shock? Perhaps it could have been averted had he changed the line earlier that morning? Has his compassion for one patient and his family caused a life-threatening complication in another? 

This leads to a fifth consideration. Let’s return to the concept of clinical judgment as being informed by phronesis, a type of wisdom relevant to practical things, requiring an ability to discern the right or virtuous action in a given situation. Thomas Aquinas considered phronesis to be equivalent to prudence, and medical writers like Pellegrino tend to use the terms interchangeably. Pellegrino and Thomasma, in The Virtues of Medical Practice, describe prudence as the virtue that fosters the ability to choose the right way of acting.11 From this perspective, was Dr. Holt’s decision a prudent decision? Would it have been more prudent to excuse himself and go tend to his other duties? 

Sixth, let’s look briefly at Dr. Holt’s situation through the lens of narrative ethics, which is a relatively new perspective that highlights medicine’s traditional focus on particular cases or stories as providing the context for individual judgments.12 In this framework, Dr. Holt’s actions make for an engaging story. There is little doubt that his response to what is going on with the patient and his family suggests a more affirmative and inspirational narrative than had he chosen to continue with his ordinary duties. This version is more comforting for the patient and his family, it is more personally fulfilling for the doctor himself, and more compelling for the reader than the more prudent alternative. For better or worse, heroic or passionate behavior is generally far more interesting than prudent behavior. Does that make it right? 

Conclusion 

Judgment in medical practice is complex and omnipresent, involving decisions that range from diagnosis and treatment of illness to the assessment of relevant patient characteristics and choice of appropriate words. A great deal of this judgment has an important moral dimension. In this paper, I have argued that medical judgment also frequently integrates emotional content into the decision-making process; and the role of emotion can be important and beneficial, rather than damaging. In fact, traditional medical virtues – e.g., compassion, fidelity, courage, humility – are habits of the heart that are intrinsically associated with emotion, as well as rational cognition. 

The case I have presented illustrates this complexity. It also illustrates the role of incomplete knowledge in medical judgment. For example, if we knew more about the benefits and risks of Dr. Holt’s actions, we might come to a more definitive judgment about whether, under the given circumstances, his clinical/moral judgment was right or wrong, correct or incorrect. Surely, respecting the patient’s decision to discontinue the ventilator was morally right, but what about his subsequent decision to spend considerable time with the patient and his family, while postponing other duties? Well, that is a question of judgment.

References

1. Feinstein A. Clinical Judgment. Baltimore, Williams & Wilkins, 1967.
2. Gregory J. Lectures on the duties and qualifications of a physician. London, W. Strahan and T. Cadell, 1772. [Reprinted in McCullough LB (Ed.) John Gregory’s Writings on Medical Ethics and Philosophy of Medicine. Dordrecht, Kluwer Academic, 1998.]
3. Percival, Thomas. Percival’s Medical Ethics. Ed. C. D. Leake. Huntington, NY: Robert E. Krieger, 1975.
4. Warner JH, Rizzolo LJ. Anatomical instruction and training for professionalism from the 19^th to the 21^st centuries. Clinical Anatomy. 2006; 19: 403-414.
5. Osler W. “Aequanimitas,” in Hinohara S, Niki H (Eds). Osler’s ‘A Way of Life” & Other Addresses With Commentary & Annotations. Durham, Duke University Press, 2001., pp. 21-29.
6. Peabody FW.  The care of the patient. JAMA. 1927; 88: 877-882.
7. Inui TS. A Flag in the Wind: Educating for Professionalism in Medicine. Washington, DC: Association of American Medical Colleges, 2003.
8. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994; 69: 861-871.
9. Coulehan J, Williams PC. Vanquishing virtue: The impact of medical education. Acad Med. 2001; 76: 598-605
10. Coulehan J. Williams PC. Conflicting professional values in medical education. Cambridge Quarterly of Healthcare Ethics, 2003; 12: 7-20.
11. Coulehan J. Today’s Professionalism: Engaging the Mind, but Not the Heart. Acad Med. 2005; 80: 892-898.
12. Pellegrino ED, Thomasma DC. The Virtues in Medical Practice, Oxford University Press, 1993.
13. Cassell EJ. The Nature of Suffering and the Goals of Medicine, 2^nd edition, Oxford University Press, 2004.
14. Cassell EJ. Doctoring. The Nature of Primary Care Medicine. Oxford University Press, 1997.
15. Holt TW. Narrative medicine and negative capability. Lit. Med. 2004; 23(2): 318-333.
16. Jones AH. Narrative in medical ethics. Brit Med J. 1999; 318: 253-256/
17. Lothe J, Hawthorne J. Narrative Ethics, Value Inquiry Book Series, Rodopi, 2013

EDITOR’S NOTE:  This essay is taken from a paper presented in 2020 by the author at the Joske Colloquium, a gathering of physicians, philosophers, historians, lawyers, social scientists, and creative writers that met biannually at the University of Tasmania from 2002 to 2020 to discuss broad topics of human experience and flourishing.  We feel that it nicely supports and illustrates some of the philosophical underpinnings, multidisciplinary nature, and real-life applications of the field of medical humanities.  

Photos from Wikimedia. CC BY-SA 3.0.

Born in Berlin to a Jewish father and a Christian mother, Harry Benjamin (1885-1986) became a physician in 1912 at a time when German physiology and medicine had much to celebrate. He ended his days in New York City more than a century later, a much lauded, if controversial founder of the entirely new field of transgender medicine. The path was not easy as his own transitions were often painfully turbulent: bullied as a schoolboy for being neither Jew nor Christian, shunned in wartime America for being German, accused of quackery for being an advocate of glandular therapy. And he transited the Atlantic many times always both at home and alien on two continents. Nevertheless, he kept his faith in the miraculous effects of hormones and held fast to an undiminished will to help people live happier lives. 

Using intimate diaries, letters, and interviews in both German and English, Alison Li has written a sensitive, insightful biography that not only traces this remarkable life, but also tracks the birth of endocrinology and the advent of an unprecedented discursive consciousness that challenged social norms. Her earlier biography of J.B. Collip, biochemist of insulin fame, provided her with extensive knowledge of emerging hormones; she handles the technicalities with deft, accessible prose.  

From witnessing the “resurrection” of a moribund patient with dried thyroid medication, Benjamin was captivated by the potential of hormones to bring even the sickest of people to perfect health. Initially intent on the rejuvenating possibilities, he thought of his work as “gerontotherapy” –treatment of the elderly – not so much to live longer but to live better. He became a devoté of Eugen Steinach and his procedure – which aimed to enhance hormone production of the gonads by suppression (through X-irradiation) of their competing elaboration of eggs or sperm. As the female and male hormones became commercially available as pills, they were added to the protocol. Inevitable slippage led to equating (or reducing) these goals to enhancing sexual prowess and attractiveness. 

Along the way, Benjamin encountered many prominent figures, and we read their impressions of each other. Havelock Ellis, Alfred Kinsey, Robert Masters, and Robert A. Wilson make appearances. The semi-autobiographical novel Black Oxen (1923) of his ever-loyal Californian patient, Gertrude Atherton, proclaimed the power of glandular therapy to a wide public and cemented Benjamin’s reputation for dealing with problems of sexuality. From listening carefully to each patient, he realized that the socially pervasive male/female binary failed to reflect individual identifications and orientations; gender was not a duality but a spectrum. Language had to evolve too and that is another theme of the book.  

Married to a much younger woman, Benjamin consulted Sigmund Freud when his desire for her waned; however, thinking of himself as a courtly ladies’ man, he was offended by Freud’s suggestion that he could be a latent homosexual. The experience conditioned his mistrust of psychoanalysis. Choosing physiology over psychology, both men, we learn, underwent Steinach’s treatment.  

With an office in New York City and later a satellite in San Francisco, Benjamin moved in a heady circle of artists, writers, politicians, and intellectuals—striving to find comfort in their own identities. He viewed the source of what became gender dysphoria as something biological.  Instead of fixing the mind, he sought to repair bodies to match minds. For some, peace came from simply living as one of the opposite sex, for others it was hormones, and eventually, for some, it was surgery. Benjamin befriended Christine Jorgensen and collaborated with a few surgeons willing –even eager–to develop operative interventions that resulted in physical sex change. After their transition, he continued to follow his patients to understand if and how the procedures had helped their quality of life. 

Always in private practice, never associated with academe except through research organizations of his own creation, Benjamin was dismayed by how his work was shunned by the medical establishment. From 1929 to 1935, he waged a lengthy lawsuit against Morris Fishbein the crusty leader of the American Medical Association for having disparaged him and his work. Benjamin wanted a retraction and an opportunity to explain in the pages of JAMA how his treatments were based in scientific research. He never got it. 

Nevertheless, at the end of his long career Benjamin witnessed the establishment of gender identity clinics at universities beginning with John Hopkins University and extending to some twenty sites by the late 1970s. He also witnessed their numerous closures in the 1980s as a struggle was waged between those who saw gender dysphoria as a mental illness– not deserving of physical intervention, and those who followed Benjamin’s pragmatic, biological approach.   

With curiosity and tolerance, Li probes the convoluted path of Benjamin’s career. She recreates the atmospheric ambience of exotic pre-war Berlin and the heady optimism of post-war America. She privileges the stories and perspectives of well-known trans people –Renée Richards, Reid Erickson, Jan Morris and many others. Without defensiveness, she presents the current criticisms of Benjamin and his so-called “standards” that had been generated to guide the medical approach to people with gender dysphoria. She treats the critics with the same attentive balance and consideration that Benjamin gave to his patients.  

As a physician, Benjamin could scarcely formulate solutions to the distress of those who sought his help in any way other than through a disease model. His efforts brought their plight out of the shadows of deviance and crime to the attention of well-intentioned minds who applied pills and procedures to serve their complex needs, empowering them to live openly, and enabling them to eventually reject the disease model entirely. Trans is diversity—one of many to populate the postmodern world. This is a very good book. 

Wondrous Transformations: A Maverick Physician, the Science of Hormones and the Birth of the Transgender Revolution   
Alison Li
Chapel Hill NC: University of North Carolina Press, 2023 

https://uncpress.org/book/9781469674858/wondrous-transformations
https://alisonli.com

Rearranged by Kathleen Watt is subtitled “An Opera Singer’s Facial Cancer and Life Tranposed.”  At the outset of the book, the author feels on top of the world.  She can hardly believe she has the opportunity, as a member of the Metropolitan Opera Extra Chorus, to share the stage with some of her biggest idols.  She has a wonderful partner and a warm and close family. 

Then, one day, Watt discovers a bump in her mouth.  She is found to have a rare and aggressive oral cancer that is “breathtakingly tailored to obliterate my profession and my raison d’être, never mind my face” (p. 51).  She undergoes multiple reconstructive surgeries, some of which are unsuccessful or become infected.   While she is initially reassured she will be able to sing again in a few months, that goal proves unrealistic.  Watt’s partner is emotionally supportive for years, but even for her there is a limit.  When the author is unable to pull her own weight financially and develops an addiction to alcohol, the relationship unravels. 

The greater part of Rearranged chronicles Watt’s medical ordeals. Previously an active and productive person, she is now at the whim of her doctors’ schedules.  She gives up all hope of performing again. As anyone who has experienced an illness or the illness of a loved one knows, navigating the health care system can easily become a full-time job.   

The book ends optimistically as Watt’s condition stabilizes. She realizes she is lucky to be alive and accepts her “rearranged” looks.  She reconciles herself to a future where she will “henceforth sing mostly for myself “(p. 304), and redefines herself as a writer specializing in the performing arts. 

Rearranged is a book which teaches valuable lessons.  Watt endures extreme hardship, has her dreams shattered, and acquires wisdom that will benefit providers and patients.    

One lesson learned is that unempathic caregivers may compound a patient’s suffering.  “A multi-gigging freelancer with catastrophic coverage at best” (p. 31), the author has a miscommunication with an endodontist and is threatened with a lawsuit for presumed nonpayment.   And when she dares to question another doctor, he snaps at her: “Ha, ha!  I’m not going to teach you surgery” (p. 57).  Fortunately, other providers have a manner that is more conducive to healing: “Because he [the doctor] conveyed neither arrogance nor impatience, his confident command allowed me to trust him easily.  And at that moment, nothing mattered more to my successful outcome” (p. 55), and “Alone among my doctors, he had thought to lament my loss.  A helium cloud filled me at this simple expression of kindness.  Nothing at that moment could have been more restorative” (p.108).    

One can understand how traumatic it must be to have one’s facial features distorted as the result of illness.  For a singer it can be career-ending, not only because she needs to show her face to the public but because the vocal cavity may be damaged.  But, beyond this, because “the face is the single most important organ of human communication” (p.105), the author feels she has lost her identity: “I felt as bereft of myself as I was of my voice…I missed seeing my reflection in the faces of others.  I began to lose track of my own subtexts, and myself” (p.237)    

The author relates a vivid and frightening memory of experiencing post-operative delirium (sometimes called ICU psychosis). When she comes out of surgery and suddenly realizes she cannot talk because she has had a tracheotomy, she pounds on the wall.  She wishes she had had “healthy people to paste accurate information alongside my cockeyed perception, so I could avoid drawing mistaken conclusions from my misperceptions” (p.146).  Instead, she overhears attendants saying “Boy, she’s really out of it” (p. 149) and referring to her as “a royal bitch” (p.140).  At no time does anyone think to help “confirm her sanity, quell her fears” (p. 150).  Hopefully, health care professionals will read this and think about it the next time they see a patient right out of the OR.    

In closing, it bears mentioning that at one point Kathleen Watt consults with surgeon Iain Hutchison in London.  Hutchison is the initiator and sponsor of the Saving Faces Art Project, a series of paintings by artist Mark Gilbert which “portray the faces of patients before, after and in some cases actually during their surgery for injury, deformity or cancer” and whose purpose is to “communicate the strength of spirit which can enable people with facial disfigurements and trauma to lead full and happy lives.” (from https://savingfaces.co.uk/our-mission/art-project/ )  Likewise, the author of Rearranged inspires the reader by her strength of spirit in the face of inconceivable adversity. 

REARRANGED
An Opera Singer’s Facial Cancer And Life Transposed
Heliotrope Books, New York, 2023   
384 pages 

Kathleen Watt’s website: kathleenwatt.com