• Mending Walls and the Dynamics of Patient Care

    By Ralph Didlake, MD
    Director, Center for Bioethics and Medical Humanities

    It was a great experience to witness three Stanford actors as they participated in the Millsaps College conference that followed UMMC’s 2013 Medical Humanities lecture by Dr. Suzanne Marrs, Eudora Welty and the Art of Diagnosis. Each visiting actor read and interpreted one Eudora Welty story: Rush Rehm, professor of Classics and Drama, Where is the Voice Coming From?; Angela Farr Schiller, doctoral student in Theater and Performance Studies, The Worn Path; and Courtney Walsh, actor and lawyer, Why I Live at the P.O.

    Only one of the three, Ms. Walsh, had a direct experience with Mississippi: her mother had roomed with Ms. Welty in college. Ms. Schiller had become interested in the Welty opus through a critical race studies examination of segregationist literature. Professor Rehm had come to Welty’s work from – classics and drama!

    Now I do know something about classics and drama. My sister, Pam Didlake Brewer, studied classics, eventually writing a thesis on Roman military vernacular language, with work as well on English romanticism. What this scholarship would ever contribute across the closing years of the 20th century in the US South and the opening ones of the 21st was for almost two decades a mystery to me. No Roman soldiers, Lucy gone to reruns – what actual purpose could literature serve in a world of broken bones and ruptured spleens?

    From secondary school forward, math and science provided answers in which I could place a high level of confidence. Whether the force of a tornado, the function of a bird’s wing in flight, or the limitations of an engine, quantitative and inductive reasoning unlocked how the world worked – mathematics answered, and science explained. Their information was tangible. It could be put to explicit use.

    Having been raised on an Air Force base, I expected to study engineering and physics. However, as coursework increasingly showed that biology and physiology followed similar principles, an interest in and ultimately a love of medicine grew. All considered, it is not surprising that I specialized in Surgery.

    Nor is it random that nearly two decades later, when my children encountered literature in middle school, the recognition of a mirrored world caught me completely off guard. I had begun reading in parallel with them, considering it an interesting exercise and important to understanding their academic development. To my great surprise, The Bell Jar, a novel written by a young Sylvia Plath and published in England shortly before her untimely death, contained descriptions of illness and hospitalization that were astoundingly accurate – I had encountered ‘this patient’ before.

    My sister, the literary scholar and teacher, pointed me toward Plath’s poetry, and in particular to The Surgeon at 2 a.m. How on earth – and by what skills – had this poet captured so completely the point of view of the other side of the medical encounter?

    In health care we are constantly reminded to observe our patients – from Plath I learned how closely we are ourselves observed. Plath had experienced the death of a parent, worked in hospitals and herself been hospitalized at length, but she had no training in science or medicine writ large, much less differential diagnosis and a honed sequence of responses to much that can go wrong. How did she so fully grasp and portray what that surgeon was doing?

    A seasoned clinician stumped by a discovery interrogates minutiae with the potential to reveal. Plath’s writing had demonstrated her findings; its elements would yield her technique.

    There was then no turning back. After two years of further literary exploration, working particularly with texts representing health, its loss or decline, and responses to that alterity, I told my sister, “You were right. I apologize for saying all these years that your education equipped you for life in the 12th century.” I realize now that in this admission there might seem to have lingered a whiff of “Why I Live at the P.O.” – a great sibling story if ever one was written – but it was sincere.

    Literature provides models of human perspective. Of importance in health care, where the subtleties of differential access have become increasingly recognized as key in both providing and seeking care, literature provides an important exposure to the dynamics of human engagement. It prepares us to listen, to reflect on what we heard, to keep hearing cadence, tonality, context, what is omitted as well as stated, in exploring the not yet explained.

    My experience tells me that our training both prepares us for this and delays it. To become the diagnostician, we must focus entirely on evidence-based paradigms. To develop acuity as a diagnostician, we must situate those paradigms within a context that requires increasing facility in discerning their limitations, in hearing a wealth of information, concisely presented, as well as in speaking one.

    Mathematics and science teach us; poetry and prose literature teach us. Our patients teach us the most, and give meaning in the full sense of the human to our work. As a mid-level surgical resident in the Sonny Montgomery Veteran’s Administration hospital, I was on call and checking on all my patients. Now this checking was not perhaps motivated entirely by the same inspiration that had led me to medicine. Perhaps it was to make sure that nothing on the list had been left unchecked that could get me into trouble the following day.

    A patient began to talk as I went through my list. He had been on deck of a ship anchored at Pearl Harbor on Dec. 7, 1941. Coming off an all-night watch, he had twenty dollars in his pocket and a two day leave to spend in Honolulu. Suddenly he saw a low-flying airplane. “These crazy Navy flyers will do anything,” he thought. The bombs sent him flying into a search light. He raised his arm and showed me a jagged scar. “One of the first wounds of WWII, right here.”

    The outcomes of health care rely on a profound understanding of sheer matter, the spirit of function, the dynamics at play upon, within, and surrounding the body. Patients tell you, in honed precision, the world they know. Use every means at your disposal to be able to hear it.