A COUPLE of years later, I was accepted into medical school at the University of North Carolina at Chapel Hill. We spent the first two years in classrooms and laboratories. In anatomy lab, we huddled around cadavers in groups of four. As a nursing assistant, I had helped wash the newly dead and wrap them in clean sheets before zipping them into thick, translucent bags. We would then heft the ungainly bundles onto special carts, and I would push them to the morgue. Since I had already handled corpses, I didn’t expect the cadaver to bother me. But the first few times I lifted the damp cloth we kept draped over the leathery contours of his face, I avoided looking at the dried-out eyes that had shriveled back into their sockets.
Using saws, scalpels, and our fingers, we tried to create precise and elegant dissections from the dead bodies lying on stainless steel tables. In the color plates of Clemente’s Atlas of Human Anatomy, the muscles were shown in striated reds and pinks, and the arteries were plump and full and a deep rich red. I imagined them pulsating with life and purpose. I loved the way the blue veins and yellow nerves ran gracefully and discretely alongside the arteries, beautiful in form and function.
But the tissue of our preserved corpse was brownish-gray and stringy, and the empty veins and arteries all looked the same. Somebody compared it to deboning the dried-out carcass of a Christmas turkey after it had been left on the counter overnight, and then taking an exam on what we’d seen.
In our dissecting group, two of us wanted to preserve the cadaver, and two of us were eager to cut it open and look inside. The preservationists moved with excruciating caution. They’d look at the pictures in the atlas, tug on a strand of tissue, look back at the book, scrape some of the crud off the nerve or artery or vein, then look back at the book. The other cutter or I would say, “Go ahead. Cut it.” The guy was already dead, what difference could it make?
There was only room for two of our group to dissect at a time, so a couple of us would work with the scalpels, and the others would watch, make notes, and flip back and forth between several anatomy texts, looking for information that would help us decide if the stringy gray strand of tissue running beside the medial epicondyle of the elbow was the superior ulnar collateral artery, the ulnar nerve, the basilic vein, or just a strand of connective tissue we should’ve cut out of the way. Finally, I said, “Cut it and see if it’s hollow inside.”
A preservationist covered the desiccated bit of meat with a gloved hand, and said, “No. Wait.” If they had their way, the anatomy session would be over before they’d cut through the first layer of skin. But if they hadn’t insisted that the cutters exercise some caution, our cadaver would’ve looked like we had pushed it through a wood chipper. After the first few sessions, we paired up a preservationist and a cutter—giving each team someone to keep things moving, as well as someone to keep us from slashing off in the wrong direction.
The smell of formaldehyde leached through our gloves and into our skin. After anatomy lab we’d wash our hands over and over, trying to get the smell out. Someone brought in a can of “Beard Buster” shaving cream which upperclassmen had said cut the smell. But it didn’t really. Just made our hands smell like a freshly shaved cadaver.
There was a crushing amount of detail to memorize in gross anatomy, but at least it was concrete and finite. Other classes—physiology, pathophysiology, histology—required massive amounts of detail, but you also had to understand it. One of my classmates said, “It’s like trying to drink from a fire hydrant. You feel like you’re going to explode from all the information you’re taking in.” I didn’t tell her that as a firefighter I had drunk from a fire hydrant, and it wasn’t that hard—you just had to turn it down until it was manageable. Of course, in medical school, there was no valve to turn down the flow.
You’d think that after being flooded with the Latin names in anatomy, the changing morphology of embryology, and the endless feedback loops of endocrinology, we would welcome some of the “softer” subjects. Instead, the lectures on medical ethics and seminars in medical humanities merely underscored our need for relief from the volume of work required. Many of us felt as if the professors were like the string quartet who played as the Titanic sank—“Thanks for the background music, fellas, but what I really want is a lifeboat.”
One of our professors started his lecture with a question: “Who do you think was the most empathetic to the survivors of car wrecks that had involved fatalities?” The professor stood at the front of the classroom, his hands behind his back. “Was it the cop at the scene, the nurse in the ER, or the physician in the ER?” He raised his eyebrows and waited.
I knew it had to be the nurses.
“The cops.” The professor chuckled and shook his head. “The cops were more caring than the nurses, who were more caring than the doctors.”
So? I felt my face flush hot, as if I were already accused of callousness. Maybe the cops could seem more “caring” because it hadn’t been their job to keep someone alive. Maybe the cops didn’t have anything to do other than watch the firefighters hose down the spilled gasoline.
“The doctors had all slipped down the caring curve,” the professor said. He then turned toward the blackboard and in a brisk, sweeping motion drew a curve in white chalk. He added in the vertical and horizontal lines representing the X and Y axes of a graph, and turned to face us again.
We were accustomed to seeing graphs, equations, and molecular structures chalked out in front of us, and most of us dutifully copied the diagram into our notebooks. The curve looked like a ski slope, which started at a level just above the professor’s head and ran steeply downward to a level just below his waist, before scooping back up to the level of his chest. “Researchers took a cohort of premed students and gave them a test that would measure empathy and altruism, which they graphed on the Y axis.” He scribbled the word “empathy” sideways, running up the Y axis. “The X axis represents time.” He made a small mark at the top of the slope. “This point represents the premed responses.” He then made a mark where the slope began to gradually trend downward. “The descent begins during the preclinical years, and accelerates as the medical students go through clinical rotations in the hospital. You can see that during residency, it plummets.” He took his chalk and made a short slash across the graph at each transition. “Empathy bottoms out a few years after residency.” He pointed at the upswing. “Empathy improves as clinicians get out in practice, but it never gets back to its initial value.” He put the chalk down in the tray that ran the length of the blackboard, and dusted his fingers against his thumb.
The “caring curve” was interesting, but it seemed to me that compassion was something you should have learned before applying to medical school. And I was much more confident of my ability to remain compassionate than I was of mastering enough anatomy, biochemistry, pathophysiology—it went on and on—to keep from hurting someone out of ignorance. If a neurosurgeon seems brusque, a patient will tell his friends and family that his doc was uncaring. If a neurosurgeon isn’t certain of the vascular supply to the cerebral cortex, the patient may not complain about anything.
Of course, you can become technically proficient and still care about people. But when your grasp of neuroanatomy is tenuous, and you’re a little fuzzy on just how the circumflex branch of the left coronary artery wraps around the heart, you’re scrambling too fast to fill the knowledge deficit to worry about your future bedside manner.
At the end of the second year, we all bought white coats. Forty percent polyester, they were stiff, and smelled of sizing. Each had a breast pocket, and two large patch pockets sewn to the front. We picked them up from the medical bookstore, a crowded little room packed floor-to-ceiling with textbooks, percussion hammers, stethoscopes—all the knickknackery of doctoring. My coat was baggy, and the sleeves seemed an inch too long. A classmate assured me that after I washed it, the fit would be perfect. We stuffed our pockets with the small spiral-ring reference booklets we hoped would bail us out if we forgot something, and draped our stethoscopes around our necks. The stethoscope was new and stiff and didn’t drape comfortably or securely. I kept touching the head of the scope where it rested just above my right collarbone, afraid it would slip off in front of a patient, nurse, or doctor.
The bookstore opened up to a brick courtyard. If you turned right, you went back to the medical school; if you turned left, you walked into the hospital.
We were nervous, but excited. For two years we’d wanted to escape from the lecture halls and labs, and get to the hospital wards where we’d learn to take care of real patients with real problems: people who needed our help. Solving medical problems while at the same time showing compassion was no longer a lecture topic—it was for real. We would get on-the-job training.
“Never, ever,” a professor would tell us, “let me hear you refer to a patient as ‘The pneumonia in room four-one-five-five.’” Our small group of medical students and interns standing in the hallway outside a patient’s room leaned closer to hear better. “You may have a patient with pneumonia, but she is much, much more than a disease process.” The professor looked down at the floor, his chin spreading against his perfectly knotted tie, then looked up, making eye contact with each of us in turn. “Each patient is a person. While you are on my service, you’ll treat them as such.” Of course, he’d been right: People are individuals, with our own stories and relationships. His message resonated with my upbringing.
But in some emergencies, the last thing you want the doctor to do is consider you as a person. Years after I’d finished my internship and residency, I was the attending physician in an ER—the doctor in charge—when the paramedics brought in a drowned seven-year-old. The boy’s wet blond hair fanned across his forehead as if he’d just climbed out of a pool. His lips were blue and his unmoving eyes stared up past long, wet lashes. His teeth rested against the plastic tube the paramedics had slipped down his windpipe. He looked like my son, John, and he was dead.
I was frozen by the enormity of what I faced.
“Paul,” one of the nurses called.
“Continue CPR,” I said reflexively to the nurse poised over the child’s chest. I told myself to just do the drill. This small thing on my stretcher wasn’t a child: he represented a series of decisions I had to make; an exercise the team and I had to go through. And any redemption we could pull from that room would be a function of how well we did our jobs. On some level, it didn’t matter whether the small wet thing would become a child again or would be taken to the morgue: our only hope for solace would hinge on working quickly and efficiently. I packed my emotions down into a place where they wouldn’t interfere.
After fifteen minutes of pumping on his chest, squeezing air into his lungs, and pushing medications into his bloodstream, we finally got a pulse back. No one cheered, or even smiled. We were just doing a drill, and knew we could lose the pulse at any time. A paramedic came into the room and said that the boy’s dad had shown up. The paramedic gestured to the child on the stretcher and lowered his voice. “We found him in his dad’s girlfriend’s backyard swimming pool. The mom’s on the way.”
“His dad’s girlfriend’s pool?” Of all the places a kid could drown. I shook my head. I took a deep breath and exhaled through pursed lips. With the immediate crisis stabilized, my emotions began to stir. I had to clamp them down again. It was time to talk with the boy’s father, a man I’d never met and would never see again.
He was pale. His lips trembled. He kept his eyes focused on the floor. I told him, in a clear and calm voice, that we’d gotten the boy’s heart beating again and that a machine was breathing for him. I told him we’d transfer him to the university medical center across town, where they had a pediatric intensive care unit. The man looked up to my eyes, then back to the floor. I told him I didn’t know when, or if, the boy would start breathing on his own. I didn’t know if he’d regain consciousness. The man wiped his cheek with the back of his hand.
What I didn’t tell him was that I, too, had a son, with blond hair and long eyelashes. I didn’t tell him I’d been terrified of failing, or that I, too, felt like crying. My feelings were small and unimportant in the presence of a man standing at the edge of such vast loss and guilt. And I didn’t have time for feelings; the ER was filled with other patients, and I had six more hours to work. The best I could do for the boy’s father was to give him room, and offer a gentle and steady presence. Emotional distance may not always indicate a failure of empathy—giving the boy’s father a respectful space may have been the most compassionate thing I could’ve done.