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

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

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

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

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

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

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

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

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

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

“At once it struck me what quality went to form a Man of Achievement, especially in Literature, and which Shakespeare possessed so enormously — I mean Negative Capability, that is, when a man is capable of being in uncertainties, mysteries, doubts, without any irritable searching after fact and reason.”¹ 

The young physician then went on to cite Samuel Taylor Coleridge as a poet whom he considered deficient in negative capability because he was “incapable of remaining content with half-knowledge.”¹ What exactly did Keats mean? That Coleridge was too curious or too intellectual to be a great poet? We’ll never know because Keats, who died of tuberculosis less than four years later, never referred to negative capability again, either in his letters or other writings.  

A single mention in a private letter is not much of a pedigree. Nonetheless, Keats’ casual turn of phrase has generated plenty of writings by others in the centuries that followed. Literary critics generally interpret negative capability to mean being open to the world without having preconceived theories, a willingness to suspend judgment, and/or the ability to function imaginatively in the face of incomplete knowledge (e.g. uncertainties, mysteries). In recent decades notable psychoanalysts and philosophers have championed the importance of negative capability in their own fields. In fact, with the enthusiasm of a dilettante who knows little about literary criticism, I’ve gone so far as to argue that negative capability is an important quality for clinicians to develop.²  

Wait a second! There’s something wrong with this picture. Physicians not “searching after fact and reason”? Doctors “remaining content with half-knowledge”? How can negative capability be a positive quality in scientific medicine? It sounds negative for sure, but not very capable.  

What did John Keats have in mind when he invented the term? In 1816 he had successfully passed his examination for a medical license and joined the Worshipful Society of Apothecaries, yet had also become increasingly ambivalent about a career in medicine. By late 1817 he and his brothers had rented a house in Hampstead, where John devoted himself to writing poetry, as well as taking care of Tom, who was dying of tuberculosis. Keats had given up the idea of practicing medicine. Yet could medical training have had any influence on his concept of negative capability?  

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, medical knowledge, or even logical deduction—with all due respect to Sir Arthur Conan Doyle and his teacher, Dr. Joseph Bell, who served as the model for Sherlock Holmes. When I was a medical student, my teachers referred to this quality as clinical intuition or clinical judgment. Yet the word “intuition” was always suspect because it smacked of mysticism, and “judgment” was co-opted in the 1970s by clinical epidemiologists, like Alvan Feinstein, who characterized it in mathematical terms of probability and utility, which sounded good but didn’t capture the experiential quality of medical thinking.³  

In an episode of “Star Trek,” when Spock questions Captain Kirk about an apparently foolhardy decision that has endangered the entire crew of the USS Enterprise, Kirk replies, “It’s not logical. It doesn’t make sense. It’s my gut feeling!” Kirk, as usual, had chosen the right course of action and by the end of the episode saves the day. However, even if clinical judgment can’t be reduced to an algorithm, surely it must have more going for it than gut feelings. I recently found an interesting, and I think plausible, definition in the nursing literature: “a judgment in which visual and verbal cues are so rapidly and subliminally observed that their contributions to the final decision are virtually forgotten.”⁴ 

Yet visual and verbal cues can’t stand alone. They require something to integrate them, a process, a creative spin. Some years ago Edward de Bono coined the term “lateral thinking” for an indirect approach to problem solving, involving ideas that might not be obtainable by using traditional step-by-step logic. (Parenthetically, I imagine that for de Bono the more traditional approach to problem solving must logically be entitled “medial thinking, i.e. closer to the center, whatever that means.) De Bono’s lateral thinking seems roughly equivalent to today’s favorite metaphor for creativity, “thinking outside the box.” Alternatively, those of us who slavishly adhere to reason are doomed to remain trapped inside the box, like Schrödinger’s cat, neither dead nor alive.  

Whatever you call it, I find something attractive about attributing a special openness and curiosity to the art of medicine, an openness that permits a greater variety of information to enter the box, rather than kicking the logical brain out of it. In his famous turn of phrase, Keats obviously chose to give “negative” a beneficial meaning. Negative in this context implies passivity, receptivity, and humility , yet it seems these qualities are precisely what made the difference between a competent poet like Coleridge and a truly creative one. Does this sense of negativity have a place in the art of medicine? Does it tell us anything about the difference between merely competent and master clinicians?  

One aspect of the comparison fails immediately. Unlike Keats, whose primary goal was beauty, physicians are heavily invested in truth. So “searching after fact and reason” is the name of the game in medicine, not the road to mediocrity. But other aspects of negative capability seem more promising. What if you view negative capability as intellectual and emotional openness, a willingness to be reflective and mindful about one’s practice? While “reaching after fact and reason” may be a defining feature of scientific medicine, clinicians confront a human reality that remains opaque, even after machines and lab tests have yielded their results. If we as clinicians predicate our care entirely on “irritable reaching,” or abandon patients because of “uncertainties, mysteries, doubts,” we lose much of our effectiveness as healers.  

Of course, poetry is only one of many tools that can assist us in developing the habit of reflectiveness, but for me it offers a glimpse into the paradox of the art of medicine: the ability to function at the interface between detachment and engagement, steadiness and tenderness, resilience and vulnerability, science and art. In pursuing the steadiness and detachment required to master clinical practice, it is tempting to neglect the more difficult project of nourishing engagement and tenderness in our relationships with patients—and with ourselves. In an address to medical students at McGill University, William Osler claimed,  

“Nothing will sustain you more potently in your humdrum routine… than the power to recognize the true poetry of life—the poetry of the commonplace, of the ordinary man, of the plain, toil-worn woman, with their loves and their joys, their sorrows and their griefs.”⁵  

That “power to recognize the true poetry of life” is a function of negative capability. Notice that Osler speaks of sustaining the physician through the “humdrum routine” of professional life, not specifically of patient benefit. Could it be that physicians who develop negative capability are happier, more productive, less likely to burn-out? 

I’ll end with an example close to home. In my narrative medicine elective at Stony Brook, I used to ask students to keep a clinical journal. In one of her final entries, one fourth year student, reflecting on her experience in medical school, wrote, “The practice of medicine is simply poetry in motion. The art of medicine is the validation of everything that makes the human experience. I learned more about myself than I ever imagined….”  

Simply poetry in motion.  

I wonder what John Keats, who rejected medicine for poetry, would have to say about that?  

References

1. Keats J. The Complete Poetical Works and Letters of John Keats, Cambridge Edition. Houghton, Mifflin and Company, 1899, p. 277. 
2. Coulehan J, Clary P. Healing the healer: Poetry in Palliative Care, J Palliative Medicine, 2005; 8: 382-389. 
3. Feinstein A. Clinical Judgment. Baltimore, Williams & Wilkins, 1967. 
4. Cioffi J. Heuristics, servants to intuition, in clinical decision-making. J Adv Nurs 1997; 26: 203-8. 
5. Osler W. The student life. In Osler’s ‘A Way of Life’ & Other Addresses With Commentary & Annotations, eds. S Hinohara and H Niki, Durham, Duke University Press, 2001, pp. 305-330.  
   

Web image from Keats Letter Project.

For nearly two decades after the fatwa was issued, his literary career flourished, and he became a visible spokesperson for freedom of artistic expression. As president of PEN, Rushdie promoted initiatives to protect and promote the careers of writers living in fear under repressive political regimes. In August 2022, he was invited to speak on this topic at the Chatauqua Institution, an adult education and social movement. On a sunny summer morning, as he sat on the stage of the amphitheater to begin a public conversation with his interlocutor at Chatauqua, he noticed a man dressed in black suddenly rise up from the middle of the audience and charge the platform. There was no security at Chatauqua that day or any other day because the violent world had never intruded into the bucolic space of the institution during its entire 148 year history. Rushdie found himself rooted to the spot, frozen and unprepared to defend himself as the attacker stabbed him seventeen times – in his eye, his face, his neck, his chest, his abdomen, his hand. Heroic people charged the stage and subdued the assailant. Miraculously, Rushdie survived and he was helicoptered to the nearest trauma center for emergency treatment. Knife is a meditation on the event, the ordeal of rehabilitation that Rushdie had to endure, and his reaction now that he is healed, and his life is restored.

Knife is a visceral book that is grounded in the harsh reality of crazed, religious zealots and painful, tedious rehabilitation. It is different from the magical prose that characterizes much of Rushdie’s writing. The events are described in excruciating detail. One can feel the hurt and sense the worry etched into the pages. It is testament to the many doctors and nurses and therapists who took part in his bodily reconstruction and long convalescence. Most of all it is an inspiring testament to his wife who had the fortitude to be at his bedside throughout the entire ordeal . Rushdie gives her most of the credit for his stamina, the tenacity and resilience that he displayed during the long months after the attack. He substitutes an imaginary dialogue with his attacker in lieu of a face-to-face encounter in prison to express his contempt for his religious intolerance. Rushdie and his wife summon the courage to revisit the Chautauqua stage one year after the attack and achieve some degree of closure on the event.

There is much humanity and wisdom in these pages, lessons on how to confront and overcome adversity. One might question what we, mere mortals, can learn from a singular person like Rushdie who was blessed with such an abundance of human and professional resources to draw on as he recuperated from his injuries. However, differences in fame and access to expertise do not ultimately carry the day. Instead, it is how we as individuals, regardless of our wealth or social status, are able to tap our inner strength and utilize the help and support of our loved ones. The task for us all is to draw on our cognitive and psychological reserves and convert life-threatening tragedies into surmountable setbacks. If, like Rushdie, we succeed, then we will have reached a more mature and meaningful embrace of life in all its beauty and complexity. Rushdie’s story played out in the international limelight. The narrative also unfolds every day on countless hospital floors and rehabilitation units the world over as people strive to overcome injury and illness in their own private world. Rushdie’s template is universal.

But for readers of the Medhum website, I suggest that there is an unspoken but instructive message lurking in Rushdie’s story, specifically for health care providers, doctors and nurses both. There were unexpected turns of events during Rushdie’s recovery. It was not an uninterrupted march from near death to healing. He experienced disabling complications from medications that were prescribed for rational clinical reasons, iatrogenic problems. In one case, severe urinary retention requiring repeated painful bladder catheterization, it was only through the astute observation of one of the clinicians that the causative medication was stopped and the problem spontaneously resolved. In another, he experienced symptomatic hypotension, a disabling side effect of one of the drugs prescribed for him. There was a cancer scare when an imaging study performed to assess his urological problems. suggested he might have a lesion in his prostate. He experienced excruciating pain when his eyelids needed to be sutured together to protect his injured eye. In each case, Rushdie was reassured that things were proceedings according to plan and that things should improve with time. Follow up tests were done to monitor the prostate anomaly and confirm improvement in his symptoms but the discomfort and unease lingered in his body and his mind. The anxiety that the problems might not resolve was ever present in Rushdie’s consciousness. 

Doctors know that recovery from injury or illness is a time consuming process that rarely occurs overnight. They are right to encourage their patients to take the long view of their health problems, to reassure them the treatment is usually a continuing proposition. But even for a highly intelligent patient like Rushdie, the doctor’s confidence in how things were going could never completely allay the fear that his broken body would not heal, and his health would not be restored to what it had been pre-knife attack. Daniel Kahneman and Amos Tversky won the Nobel Prize in Economics in 2002 for groundbreaking studies that explored how people assess loss and gain and make financial decisions. Kahneman expanded on their studies in behavioral economics and proposed that rational thought utilizes two operational modes. System 1 is rapid and instinctive in contrast to system 2 which is slower, more deliberative, and more reasonable. Channeling this work by Kahneman, there may be two systems operating during recovery from bodily injury. Doctors may be employing an analog System 2 method of thought as the disease is steadily halted, reversed, and repaired. Patients, however, live through illness in a binary System 1 approach of thought: sick or back to normal. We physicians would do well to remember that the only words our patients really want to hear from us when they come to us for care are, “You are now fine. We can stop the medications and stop the follow up. You are back to normal.”

Knife
Salman Rushdie
Knopf 2024, 209 pages

“Should we worry about the reliability of medical knowledge?” asks philosopher John Huss (University of Akron). We consider this question from the perspective of Thomas Kuhn’s classic, 1962 book, The Structure of Scientific Revolutions. Kuhn explains how science does not evolve incrementally, one step following another, but rather undergoes wholesale revolutions disconnected from all that came before. He called these revolutions, “paradigm shifts” (to his everlasting regret). While Kuhn draws mostly from astronomy to make his case, we draw from recent and past medical examples to show how his concept applies to medicine as well. We talk about how various groups dependent on reliable medical knowledge (e.g., patients, health care professionals, educators) can be affected by the possibility of major shifts in established approaches to health care at any time. There’s no escape from reality, as the song goes.

Primary Source Citation
Kuhn T. The Structure of Scientific Revolutions, 3rd ed, Chicago: The University of Chicago Press; 1996.

Links
Russell Teagarden’s related blog posts on According to the Arts:
-Kuhn’s book, The Structure of Scientific Revolution
-Michel Foucault’s book, The Birth of the Clinic

Dr. Barry Marshall’s story of how he and Dr. Robin Warren engineered the change in peptic ulcer disease from acid based to infection based.
The Clinic & The Person Episode 12 (September, 2023), featuring the paradigm shift from lobotomies and other forms of psychosurgery to psychopharmacology.
Sir Brian May’s bio (guitarist for Queen and PhD-level astrophysicist).

The Clinic & The Person is a podcast developed by our editor Russell Teagarden to summon or quicken the attention of health care professionals, their educators, researchers and others to the interests and plights of people with specific health problems aided through knowledge and perspectives the humanities provide.

Feature photo by National Cancer Institute