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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For this Apollo on Call x W5H Book Club episode, Dave and Luki read Other Rivers: A Chinese Education by Peter Hessler. The book focuses on the quirks and challenges in the education system the author witnessed as a visiting professor in China. At the end, Dave and Luki reflect on an entire year of reading books about China, and how they feel at the end of this journey.

Check out Dave’s Substack for more! 

Web image created by Medhum.

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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Before embarking on my project, I reviewed the literature pertaining to the use of plays in medical settings.  Friedrich Schiller, the German playwright (who was, incidentally, a physician), laid the groundwork for the use of theater as an educational tool in his 1784 essay “The Stage as a Moral Institution” calling it “a great school of practical wisdom, a guide for civil life, and a key to the mind” (Schiller, page 252).  In his view, the theatricalization of the “vices and virtues of men” and of “human woe” not only makes them more palatable, but it also actually teaches the audience to be more empathic. 

I found a wide range of milieus in which plays have been used.  In 1938, The Federal Theatre Project, a program sponsored by the WPA, produced a play entitled Spirochete with the goal of reducing the spread of syphilis (Flanagan, page 144).  More recently, dramatic narratives were used by scientists to provide a forum for learning about human genetics; these have been collected in a volume entitled The Drama of DNA.  

A pioneering program that proved inspirational to me is Medical Readers’ Theater, developed in the 1980s at East Carolina University’s Brody School of Medicine. Stories by William Carlos Williams and other doctor writers have been turned into scripts used to encourage dialogue among medical staff, students and the public about a variety of medical issues. These plays are available in anthologies accompanied by discussion questions.   

There are also numerous popular plays which are natural fits for teaching because they illustrate points of ethics, diagnosis, doctor-patient relationship, etc. at the same time as just being entertaining.  Some of the ones I have used include Wit, A Streetcar Named Desire, and Next to Normal.    

While deciding what to do for my thesis project, I was becoming quite taken with Anton Chekhov’s writing through working with Jack Coulehan at Stony Brook.  Previously, although I knew of course that Chekhov had a reputation for being one of the great playwrights, I had had the impression that his plays were a bit boring because nothing much happens in them.  What can I say?  I must just not have seen the right productions.   

I researched Chekhov’s life, read his short stories, and even plowed through Sakhalin Island, the epidemiological survey he wrote about health conditions in a penal colony. As a result, I became an admirer and gained insight into his method.  It does not matter whether there appears to be anything happening or not.  The author’s job is to record what he observes. It is not by chance that this is also the job of a physician.  One can understand why Chekhov might have wanted to continue to practice medicine even after becoming one of Russia’s most celebrated writers.  Chekhov soon became my personal role model as a doctor writer, and it felt like an honor to dedicate my time and energy to his work, and in my own extremely modest way, to add to his dramatic corpus.   

Chekhov wrote over 500 short stories, and doctors play a significant role in about 25 of them.  I chose “A Nervous Breakdown” (1889) and “A Doctor’s Visit” (1898) “for adaptation.  As “A Doctor’s Visit” has fewer characters and is the shorter of the two that is the one I use to teach.  Some students may even have read the original story already because it is so well known.   

The plot may be summarized as follows:  A doctor has been summoned away from the city to see the daughter of a factory owner, but for some reason he sends his assistant instead.  (Perhaps he just did not want to go out to the boondocks.) The assistant doctor arrives at the house and examines the young lady.  After not finding anything wrong, he concludes that he’s been called for nothing. The patient’s mother, who is depressed and overwhelmed, implores him to spend the night instead of going home to his family.  The doctor is not in a position to refuse, but he feels as if his time is being wasted and he is annoyed.  

However, in the short time he is in the factory town, the doctor gets a sense of what it is like in live in such a place. He sees how unhealthy the environment is for the workers. He sees how, despite having lavished a fortune on expensive furnishings, the inhabitants of the house are miserable. Adding insult to injury, a servant repeatedly contradicts him and gets on his nerves.  

In spite of the prejudices he has brought with him from the city, the totality of his experience makes an impression on this doctor. The next morning, he meets with the patient again. This time, he recognizes that she is a sensitive and intelligent young lady, and he now has empathy for what she must be going through. There is a moment of understanding between them. Although it does not perhaps appear as if the doctor has applied any treatment, the patient responds and shows a sense of hope.  The doctor has also changed as a result of this experience. He leaves the house and heads home in a good mood.   

Like general practitioners today, general practitioners in 19^th-century Russia undoubtedly ended up doing a good bit of psychiatry.  Although Chekhov and Freud were contemporaries, there seems to be no evidence that Chekhov was aware of Freud’s “talking cure. “  But even if not, and even if the doctor in “A Doctor’s Visit” does not think he has done anything, the doctor has in fact unwittingly administered a brief psychotherapy session.  The powerful results he obtains with such simple means remind me of some of my own experiences as a psychiatrist.  Sometimes when one uses one’s psychoanalytic theories to make what one thinks are brilliant interpretations, they fall on deaf ears.  Just being present and listening often produces the best outcomes.   

The greatest technical challenge this playwright confronted in dramatizing “A Doctor’s Visit” was figuring what to do about the doctor’s internal thoughts.  There is plenty of spoken dialogue in Chekhov’s story, and I used much of it practically verbatim.   But how to dramatize one’s inner dialogue?  It would be cumbersome to have a narrator describe it, and unnatural to have the doctor verbalize it.  My solution was to create a brand-new character, a young apprentice, someone the doctor uses to bounce ideas off.   I hope audiences and readers feel this was a reasonable compromise on my part.   

My adaptations of Chekhov’s two stories made their debut in 2015.  Since then, “A Doctor’s Visit” has been used to teach students at several medical schools:  Stony Brook, Drexel, New York University, Boston University, Cleveland Clinic, and the University of Pennsylvania.   At all but one of these I introduced the play in person, read the stage directions aloud, and led the discussion.  The text of the play is included in an appendix to this article in the hope that other schools will take it up.  And I am still available to read stage directions! 

References: 
Chekhov, Anton: “A Doctor’s Visit.”  Translated by Constance Garnett.  https://www.ibiblio.org/eldritch/ac/jr/193.h
Coulehan, Jack.  “Cold Eye, Warm Heart: Medicine and Anton Chekhov.” MedHum, October 2, 2025 Flanagan, Hallie. 1940, reprinted 1985. Arena: The Story of the Federal Theatre. New York: Limelight Editions 
Rothenberg, Karen H. and Bush, Lynn Wein. 2014. The Drama of DNA. New York: Oxford University Press 
Savitt, Todd L. (ed.) 2002.  Medical Readers’ Theater:  A Guide and Scripts.  Iowa City: University of Iowa Press 
Schiller, Friedrich. 1784. “The Stage as a Moral Institution.” In Theatre/Theory/Theatre, 250-254.  New York:  Applause 

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A Doctor’s Visit:  An Adaptation of a Short Story by Chekhov

by Guy Fredrick Glass

Downloads of this play may be distributed and performed for educational purposes only, with permission of the author.  Dr Glass may be contacted at gf***@*ol.com 

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In “Mandatory Evacuation Zone,” Felice Aull has gathered 63 beautifully crafted poems in which she examines the intricacies of language and loss, of grief and healing.  Each of the book’s five sections considers these themes in slightly different ways, always in language that is understated, vivid, and exact.  In Section I, we read poems that focus on the author’s complicated family history and her early loss of homeland.  In “Tracings” (page 15), an unknown relative (thanks to online genealogy searches) reaches the narrator and wants to meet her.  She, however, only wishes to learn “. . . how my parents / and my infant self / made our tortuous way out . . . . ” Brought in infancy from Germany to America, the author suffers the loss of both native homeland and native language (“Notes from an Alpine Vacation” page 16).  She searches photos of her mother and ponders museum note cards illustrated by Holocaust survivors (“Museum Notecards” page 18), imagining what she can’t quite know and yet can’t quite forget.  

Section II finds the narrator as a young woman in American, awakening to sexuality (“Gay Blades,” “Camp Counselors Make Out,”  “On the Staircase” pages 29-31), becoming a wife and mother, and then a grandmother.  A grandchild’s birth is both joyful and yet another “slipping toward / the edge of separation” (“Daughter in her Eighth Month” page 37). 

In Section III, the author turns her gaze to observations of the world around her, around us, aware of how many come to loss and death.  “Be prepare to mourn,” she tells us in “Disaster in October” (page 49), and in the moving poem, “I Saw the Smoke,” re-visions September 11th in words stripped of sentimentality and therefore made more powerful. 

Sections IV and V confront bodily loss through aging and illness, noting how, in so many ways, we try both to capture and to let go: “You snap photo upon photo / hoping to grasp and preserve / what cannot be grasped” (Capturing Alaska” page 66).  We learn of the most personal losses in poems of biopsies, surgeries, and chemotherapy.  When facing the unknown, every event might seem to hold a prediction.  In “Stunning Blows,” a doorman stuns a mouse, claims that it’s dead.  But the narrator, aware of the wages of time, writes, “But I still see it, like death, / moving toward me” (page 81).  At the book’s end, we return to language, how it too can leave us (“Forget That” page 90).  Yet in the collection’s final, gentle poems, the poet is “able, finally / to walk past the park’s redbud tree / without weeping” (“Immunity” page 96).

Although there are many poems that confront loss both recalled and experienced. grief for self and others, illness and the unknown in this collection, there are also poems of great acceptance and ultimate joy: “These gifts and losses, every year, mine” (“The Key to Gramercy Park” page 98).  The poems in “Mandatory Evacuation Zone,” show us how poetry can help us to “declutter” (see “Divesture” page 99) and release, and at the same time, hold on to and embrace.

Kelsay Books, California 2017: 100 pages

Felice’s website: https://www.feliceaull.com/

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A previous version of this review was published in the NYU Literature, Arts, and Medicine Database

While only in nascent forms, organizing a method for understanding artificial intelligence (AI) as it’s currently structured for broad application is important but daunting. Shannon Vallor, a philosopher and ethicist, suggests using a mirror as a metaphor in her book, The AI Mirror. The book stems from her work as both an academic philosopher and as an AI ethicist at Google.  

Vallor describes her book as a “polemic,” and that it is when she says AI “in its dominant commercial form, endangers our humanity.” (p. 4) I’m leaving her polemics aside, mostly. My interest is her use of the mirror as a metaphor for AI, large language models (LLMs) in particular, and how she constructs the metaphor, some of the consequences of AI seen through her metaphor, and some suggestions she makes based on what the metaphor reveals about AI and ourselves.  

Reflections on the Mirror Metaphor  

The mirror as metaphor for AI came to Vallor based on its content source, that is, us: our words, our computations, our images, our sounds, and all the other digestible forms of our creations. What AI regurgitates from our prompts is based on an algorithmic mixing and matching of the collective creations it ingests.  

We often think of a “mirror image” as an exact replica of what faces it, and so the mirror metaphor for AI could convey that AI outputs are true and objective. To the contrary, Vallor hastens to caution, “mirrors do not merely reveal things as they are: mirrors also magnify, occlude, and distort what is captured in their frame. Their view is always both narrower and shallower than the realities they reflect.” Consequently, her metaphor is as much about what “AI mirrors do not show us: what they hide, what they diminish, what humane possibilities for self-engineering are lost in their bright surfaces.” (pp. 13-14)  

Throughout the book, Vallor emphasizes how nothing much of the human essence is to be found behind the AI mirrors, especially that which could contribute to AI analytical output.   

An AI mirror is not a mind. It is a mathematical tool for extracting statistical patterns from past human-generated data and projecting these patterns forward into optimized predictions, selections, classifications, and compositions…Minds depend upon the brain for their reality…[but] our mental lives are driven by other bodily systems as well: our motor nerves, the endocrine system, even our digestive system. (pp. 38-40)  

Vallor extends the metaphor when adding the myth of Narcissus. In the myth, Narcissus catches his image in a pool and becomes so enamored with its reflected beauty he can’t extricate himself before he wastes away into oblivion. Vallor worries that we risk the same fate when AI has us “fixated, confined, immobilized, held captive.” (p. 5) Vallor points to another character from this myth that makes it more poignant yet. Echo, a nymph, only parrots the last few words she’s heard. In applying Echo’s trait to AI, Vallor contrasts how Echo returns the words she has taken in while “a large language model returns to us not our own recent utterances, but a statistical variation on the collected, digitized words of untold millions.” (p. 34) This trait of large language models underlies some of the consequences the metaphor reveals. 

Truth of Consequences 

The metaphor helps us see that what we get from AI results is based on statistical probabilities of words occurring in a certain order without regard to how true any of it is. So, to Vallor, AI models are “like the human bullshitter. They aren’t designed to be accurate—they are designed to sound accurate.” (pp. 120-122) She does not use the term bullshit blithely. She refers to Harry Frankfurt’s treatise on the subject in which he distinguishes bullshit from lying by its indifference to the truth and its indiscriminate application. AI users often see this consequence in the form of the erroneous answers they get, which are referred to colloquially as “hallucinations;” Vallor calls them, “fabrications.” These consequences range from humorous and annoying to unproductive and deadly.  

As the AI source for content is mainly us, Vallor warns it’s not all of us who contribute content, but rather just a small subset of us, and certainly not a subset of us that is representative of the human race in all its variations. Referring to her metaphor, then, a mirror cannot reflect what it cannot see, which produces consequences around what we can expect from AI predictions. The complete reliance on what it has seen limits its predictions to what can be inferred from the historical data that exists and it can reach, “what humans valued enough to describe or record in data. But not all humans.” (p. 133) And, with no input from broad-based human experience, wisdom, imagination, and purpose, she wonders how we can have any “hope of making ourselves more than what we have already been.” (pp. 90-91) There’s nothing new under the mirror. 

The consequences of AI Vallor details that are polemical concern the commercial entities controlling what the mirror sees and what it shows. In particular, given the weakening of regulatory functions over the previous decades, she sees how “the rise of the behemoths of ‘Big Tech’” has transformed them “from intermediaries of social power to its primary executors.” (p. 175)  

All this to Vallor “is a calamity—a betrayal of life and its possibilities,” (p. 36) but she does not go so far as to say we’re doomed. She allows how huge benefits could accrue to societies and individuals if the AI mirrors become more reliable and objective sources of information, that is, amidst a pile of bullshit, the optimist in her is saying there must be a calf in it somewhere. She offers suggestions on how we unearth the calf. 

How to be the Fairest of them All 

Vallor’s suggestions for managing AI applications call upon the wherewithal of users for now—DIY quality control required. Many of her suggestions center on comprehending how AI output is constructed and accounting for the implications of that construction. 

When we do catch sight of our past in the AI mirror, it is essential that we do not mistake those patterns for destiny or allow them to become self-fulfilling prophecy…If we mindlessly replicate what we see in the mirror of history, we will never build upon that knowledge, never be free to try new and better approaches. (p. 101) 

She speaks of knowing “data provenance,” and of knowing when “algorithmic predictions and profiles are scientifically credible, ethically justifiable and politically accountable, and when they are not.” (p. 52) Although that may seem like asking a lot from even advanced AI users, we need to go through the same processes for our own analyses. And from these analyses, we also at times produce hallucinations, distortions, and slanted results. In this way to a degree, the AI mirror metaphor applies to humans. But we can incorporate aspirations, imagination, wisdom, and morals into our analyses. That differentiation is key to seeing how Vallor’s AI mirror metaphor situates AI as a “powerful amplifier of human ability,” not as a substitute for it. (p. 28) 

Vallor S. The AI Mirror. Oxford: Oxford University Press, 2024. 
Frankfurt H. On Bullshit. Princeton: Princeton University Press, 2005. 

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Five years into writing about her mother’s slow decline from a respiratory illness, Joanne Jacobson was diagnosed with a rare, life-threatening blood disease. That discovery dissolved the illusion that she and her mother had separate fates. “How could I continue writing about my mother as though I were observing her from outside the circle of Illness?” Jacobson asks (27). She can’t. And Every Last Breath becomes, as its subtitle discloses, “A Memoir of Two Illnesses.” Doubling its concern, Jacobson’s memoir in essays becomes a richer, more urgent, and ironic revision of her original project.  

With writerly attentiveness, perceptive intelligence, and some impatience, the four opening essays witness the negotiations that Florence Jacobson makes with her body, her environment, and her psyche. From a distanced perspective, Jacobson wonders at her mother’s courage and stubborn animal will to go on. Her mother’s slow pace and reluctance to let go—of her possessions, her habits, her life—initially frustrate and puzzle Jacobson. She even expresses impatience with the constant sound of her mother’s oxygen pump filling the apartment, the inconvenient bulk of the oxygen canister, the tangles of tubing connecting the machine with her mother’s nostrils.  

As Jacobson’s diagnosis closes the distance she perceived between herself and her mother, it ignites the memoir’s transformative insight. It’s first articulated at the end of the essay titled “Mirror Writing” and it sustains the rest of the memoir. Realizing that her mother might outlive her, Jacobson writes: “. . . I can no longer pretend that the ragged approach of death is likely to be smoothed by nature’s grace, or by the natural order. So long as I believed I was writing about my mother, I was able to hold mortality at a distance . . . Now in the mirror of my mother’s aging face I see myself” (29). In “Dead Reckoning,” when Jacobson learns that her blood is starved for oxygen, she hears her “own lungs fall into the thrumming motor’s pulse” of her mother’s respirator. Revising her response to the technology, she writes that it is “the sound of death being pushed mechanically away that is audible to me now—steadily asserting its nearness . . .” (63-4). Jacobson’s descriptions of her hospitalizations and treatments (“Written in Blood,” “If My Disease Were an Animal”) sharply observe her new understanding of herself and the “call to the imagination” that her experience issues (59). Jacobson’s elegant and vulnerable rendering of her efforts to survive pain, uncertainty, and terrifying treatments register her courage and will to go on.  

The final essays bring together the shared destinies of mother and daughter. Jacobson thinks of their relationship as “invisibly entwined, cellular,” as she recalls that mothers’ bodies can absorb the fetuses’ cells (88). In “Book of Names,” Jacobson’s closing essay, she and her mother recite the names in Florence’s heavily edited address book, tracking the alterations in the lives she’s shared. The recitation invokes the lists in Genesis. Begotten. Gone.  

Every Last Breath should be read. Its profound and startling reflections on mortality are lyrical, fierce, and deeply felt. At times readers take extravagantly metaphorical flights of the imagination. At times we’re immersed in revelatory scientific facts about the natural world and our human biology. This slender book melts other boundaries as well: between caregiver and patient, mother and daughter, self and other, personal and universal. It simultaneously challenges literary classifications, blending poetry, essay, and memoir. Read separately or together—either way can be satisfying—Jacobson’s brilliant essays refuse to let us ignore our shared vulnerability or the unpredictability of living in a body, as Jacobson once naively thought she could. 

Every Last Breath–A Memoir of Two Illnesses
Joanne Jacobson 
The University of Utah Press, 2020; 114 pages 
https://uofupress.com/books/every-last-breath/

A previous version of this review was published in the NYU Literature, Arts, and Medicine Database. 
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