What does a report on cancer survival rates in the United States have in common with civil unrest in Syria? The withering of fear.

Fear of cancer in the national psyche began to wither in July of 1985, with an essay entitled “Seasons of Survival: Reflections of a Physician with Cancer.” [Mullan, Fitzhugh, M.D. New England Journal of Medicine 313, No. 4 (July 25, 1985): 270-273.] Fear of tyranny in the Middle East—in Syria no less than in occupied Iraq—began to wither on April 9, 2003, when a U. S. Marine armored vehicle toppled the imposing statue of Saddam Hussein in Baghdad’s Firdos Square.

From each of these seemingly unrelated historical inflection points have come a flowering of human potential.

The CDC reported in the March 11 issue of the Morbidity and Mortality Weekly Reporthttp://www.cdc.gov/mmwr/preview/mmwrhtml/mm6009a1.htm?s_cid=mm6009a1_w—that the five year cancer survival rate in America is now up to 66%, the highest in the world, confirming empirically what Dr. Mullan passionately asserted two decades before: that it was time to begin speaking of cancer survivors rather than cancer victims. By believing it could be so, the tenacious striving of medical science eventually made it so.

The eidetic image of Saddam Hussein’s massive totem falling in central Baghdad is an equally powerful symbol of the dynamism of human belief, indelibly burning into the brains of millions of oppressed people throughout the Middle East the notion that if Iraq could be free of Saddam, they could all be free. In Tunisia and Egypt and maybe Libya and even in the police state of Syria—and yes, one day Iran, too. Like cancer survival rates—climbing slowly but inexorably, decade by decade—so will the number of countries in the Middle East no longer under the yoke of authoritarian regimes rise too, painfully but relentlessly.

Yet neither of these vital struggles—the quest to overcome cancer and the quest to overcome tyranny—would ever have been joined without the necessary withering of fear. For fear suffocates hope, and it is hope that gives rise to noble deed. Only when fear withers can hope and nobility of deed germinate and take root, to finally grow into the stout trees of human health and liberty.

Remarkably, a single work of literature anticipated—as great art often does anticipate—each of these still-chrysalid human triumphs, the (partial) cure of cancer and the incipient bloom of liberty amongst the darkest of tyrannies: The Cancer Ward, by Aleksandr Solzhenitsyn. First published in 1967, the book was banned in the former Soviet Union for its symbolic contumely of Soviet totalitarianism. Though famous as a metaphor for the ravages of tyranny, it is also—all 616 pages of it—a poignant and courageous narrative on the ravages of cancer in the mid-twentieth century.

The action occurs in a hospital ward—Ward 13— dedicated to the care of cancer victims in Central Asia in 1955. The patients, who come from all strata of Soviet society, have one thing in common: cancer.

The main character is Oleg Kostoglotov, a political exile who is transferred to Ward 13 from a gulag for treatment of a nebulous tumor. (The author had a similar real-life experience: Solzhenitsyn was transferred to a hospital in Tashkent for treatment of testicular cancer after having spent eight years in exile as a political prisoner.) Kostoglotov’s foil in the story is Pavel Rusanov, a Communist Party minion who has an enlarging neck mass and boundless contempt for the other patients—whom Solzhenitsyn democratically introduces chapter-by-chapter—of Ward 13.

But Pavel Nikolayevich was tormented, no less than by the disease itself, by having to enter the clinic as an ordinary patient, just like everyone else.

Rusanov is as much in denial of his neck cancer as he is of the “cancer” of Soviet tyranny.

“We mustn’t talk about death! We mustn’t even remind anyone of it.”

To which Kostoglotov responds, “If we can’t talk about death HERE, where on earth can we?”

Prominent in the story, too, are Zoya, a nurse/medical student to whom Kostoglotov is attracted—“The strongest memory he had…was of her neatly supported breasts which formed, as it were, a little shelf, almost horizontal”—and Vera Gangart, a female physician (all the physicians at Ward 13 are female) whose romance with Kostoglotov is never consummated.

…he began thinking about Vera Gangart…Her smile was kind, not so much her smile as the lips themselves. They were vital, separate lips…made, as all lips are, for kissing, yet they had other more important work to do: to sing of brightness and beauty.

But mostly the patients of Ward 13 think about their cancers. It is everywhere, all around them, in plain sight day after day, week after week, moment after excruciating moment.

There was a stabbing pain under his neck—his tumor, deaf and indifferent, had moved in to shut off the whole world.

But the real cancer in the novel is tyranny. Again, it is Kostoglotov who frames the matter.

“A man dies from a tumor, so how can a country survive with growths like labor camps and exiles?”

The corrosive effect of totalitarianism oozes from the pores of every patient of Ward 13 like the shameful ichor it is. The librarian Shulubin (afflicted with rectal cancer), one of the “good Russians” who cooperated with Stalin’s purges, gives voice to it while speaking to Kostoglotov.

“At least you haven’t had to stoop so low…You people were arrested, but we were herded into meetings to ‘expose’ you. They executed people like you, but they made us stand up and applaud the verdicts…they made us demand the firing squad, demand it!”

A 1968 New York Times book review of The Cancer Ward, entitled “A Diseased Body Politic,” correctly identified the true subject matter of Solzhenitsyn’s story.

http://www.nytimes.com/books/98/03/01/home/solz-cancer.html

But the review couldn’t have been more mistaken in its opinion of the impact the novel would have.

“Clearly Solzhenitsyn believes in the power of literature to exorcise Stalinism. Vain as this hope may be, it has inextricably bound a great writer to his great, and perhaps his only subject.”

Pace New York Times, it was precisely the power of Aleksandr Solzhenitsyn’s literature—One Day in the Life of Ivan Denisovich; The First Circle; The Gulag Archipelago; and The Cancer Ward—that began the decades-long exorcism of Leninism and Stalinism from Russia. The Cancer Ward challenged tyranny in the same way Dr. Fitzhugh Mullan challenged cancer and in the same way that America challenged the brutal authoritarianism of Saddam Hussein’s Iraq: by replacing fear with hope.

May hope thrive, and may health and liberty follow.

What makes a young man or woman want to become a doctor? Ego? Intellectual challenge? The prospect of financial success? Scientific fascination?

The answer for most of us—none of the above—can be found in the 2009 debut novel Cutting for Stone, by fellow physician Abraham Verghese.

It is a novel that is widely loved by readers, if not all critics. The New York Times Sunday Book Review, for instance, concluded its critique of Cutting for Stone on a decided downer: “In Verghese’s second profession, a great surgeon is called an editor. Here’s hoping that in the future the author finds stronger medicine in that line.”http://www.nytimes.com/2009/02/08/books/review/Wagner-t.html?_r=1And the Boston Globe’s traducing review was no kinder: “…not a great work of fiction but an interesting one…Despite its somewhat labored plot and alternately flat and overwrought characterizations, Cutting for Stone is worth  reading…”

http://www.boston.com/ae/books/articles/2009/03/19/a_familys_odyssey_of_love_and_healing/

Most other reviews, however, were glowing, and readers have decisively overruled the above outliers. Many reasons for the book’s appeal have been suggested: Verghese’s engrossing description of Ethiopia, where much of the action occurs; the detailed descriptions of all things medical and of the taxing life of a surgeon (which Verghese is not, by the way—he is an infectious disease expert and professor of medicine at Stanford); the obvious love the author has for medicine; the compassion he holds for his characters.

There is no denying, though, that Verghese qua author found it difficult to detach from being a doctor, and consequently let the physician in him rule the novelist. The price paid is that the book is laden with long, jargon-filled passages that bring its narrative flow to a screeching halt. Yet despite this, it is clear that both Abraham Verghese and his physician-characters in Cutting for Stone became doctors to help people. Which is why the public continues to hold physicians in such high esteem, repeatedly naming “doctor” as the most respected career choice, reserving their deepest contumely for lawyers and politicians. In my opinion, it is on account of its manifestation of human altruism that Cutting for Stone has enjoyed such stunning commercial, if not always critical, success.

Altruism has fascinated mankind for centuries. Altruistic behavior is at first blush inconsistent with Darwinian natural selection, in that it is behavior by an organism that benefits another at its own expense. The great religions of the world use the fact of human altruism as evidence of God’s existence, by equating love of others with love of God: “…thou shalt love thy neighbor as thyself: I am the LORD.” (Leviticus 19:18.)

For unbelievers, the existence of altruistic behavior is a glaring contradiction, an inconvenient conundrum that challenges the very foundation of secular rationalism: evolution. For how could behavior benefitting another to one’s own detriment possibly be explained by evolution theory? But recently, the scientific community—mostly, though not exclusively, atheist—has produced a multitude of studies purporting to show that altruism is purely a neurobiological phenomenon. One of the earliest came out of Duke, and showed that sophisticated MRI scans of the brain revealed relatively greater activation of the brain’s posterior superior temporal sulcus when experimental subjects were watching as compared to playing a computer game. This heightened activity strongly predicted a given subject’s propensity for altruistic behavior. (Nat Neurosci. 2007 Feb;10(2):150-1. Epub 2007 Jan 21.Altruism is associated with an increased neural response to agency. Tankersley D, Stowe CJ, Huettel SA.
Brain Imaging and Analysis Center, Box 3918, Duke University Medical Center, Durham, North Carolina 27710, USA.)

Other researchers found that areas of the brain stimulated by food or sex—fronto-mesolimbic networks—became relatively more active when subjects were asked to think about donating a large sum of money as compared to keeping it for their own use. That is, it made them feel good to be altruistic, thereby explaining Saint Francis of Assisi’s famous observation: “For it is in giving that we receive.”

http://www.pnas.org/content/103/42/15623.full

Predictably, it was only a matter of time before a study appeared to advance the notion that altruism was selected out over the course of human evolution in order to confer a survival advantage. Last October, Dr. Tim Phillips and colleagues studied the responses of identical and non-identical female twin pairs to questions about their own altruism and how desirable they found altruism to be in potential husbands. Results showed a link between human altruism and sexual selection, supporting the theory that altruistic behavior evolved as it became necessary for the earliest human beings to choose mates who would be willing to make the sacrifices required for successful child-rearing. (Tim Phillips, Eamonn Ferguson and Fruhling Rijsdijk. A link between altruism and sexual selection: Genetic influence on altruistic behaviour and mate preference towards it. British Journal of Psychology, 2010; DOI: 10.1348/000712610X493494)

So, is altruism a conscious, moral act of free will, or is it a complex neuronal circuit? I have covered this ground before in a discussion on Cartesian dualism and the mind-body problem: Does human consciousness—the mind—exist separately from the human body? This is the larger issue under which any debate about the origins of altruism must be subsumed.

http://richardbarager.com/near-death-experiences/watching-yourself-die/

Whatever the answer, the attraction of medicine as a calling is born in large part from the altruistic urge to help other human beings. What the proximate cause of this desire is depends on where one believes consciousness resides: in the soul or in the neurochemistry of the brain. It is my personal belief that the mind and soul are not discoverable by scientific method, as they are infinitely intangible and not part of the observable, accessible universe. Serious works of fiction like Cutting for Stone, however—with complex meanings embedded in narrative in a manner beyond the capacity of ratiocination to convey—are capable of accessing the infinitely intangible.

And of revealing why doctors become doctors.

How would you like to lower your blood pressure by listening to a story? As improbable as it may sound, that is exactly what happened in a study reported in the January 18, 2011 issue of Annals of Internal Medicine (Houston TK, et al. Culturally appropriate storytelling to improve blood pressure. A randomized trial. Ann Intern Med. 2011; 154:77-84).

I have previously written of a category of medical instruction known as narrative medicine. Integral to the field of narrative medicine is the idea that while a disease can be understood through the process of empiric research and publication (left brain activity), illness—defined as the fully expressed human response to disease, as manifested by its emotional, spiritual, financial, and physical aspects—is best understood in story form, i.e. the narrative (a right brain activity).

Stories have a multi-layered, intuitive meaning that purely rational expression does not. Literary fiction, for instance, has the capacity to present characters so completely rendered we begin to understand ourselves—and others—more profoundly simply by identifying with such characters. Fully drawn fictional characters have much in common with patients. Identifying deeply with a fictional character—shivering when a character is cold, feeling sorrow when a character is sad, or becoming angry when a character is wronged—stimulates the same neuronal connections that allow physicians to feel empathy for patients#mce_temp_url#. Experiencing the world from a fictional character’s point of view is not so very different than experiencing the world from a patient’s point of view—a critical skill for doctors to have.

But what about our patients? Might they benefit from the unique virtues of storytelling too?

The authors of the Annals article sought the answer to this question by performing a randomized, controlled study to determine if viewing culturally appropriate videos had a beneficial effect on blood pressure control. 147 patients watched a series of 3 hypertension DVDs given at baseline, three months, and six months; a control group of 152 patients witnessed DVDs unrelated to hypertension control. The hypertension DVDs involved personal stories of blood pressure control as related by patients drawn from the same African American population in Birmingham, Alabama as the control patients.

Results of the trial showed that patients with uncontrolled blood pressure who viewed hypertension-treatment stories of cultural peers experienced an 11-point greater fall in systolic blood pressure than did similar patients in the control group. The authors speculate that such video storytelling changes behavior—in this case compliance with diet and medication—by breaking down cognitive resistance, perhaps by identifying with and mimicking the behavior of a particular story character.

This study is unique in that it applied left brain scientific method in an effort to document benefits of a right brain, intuitive form of treatment. The authors’ conclusion?

Storytelling not only changes lives, it can help save them, too.

The title of Everyman, the mordant yet immensely moving 2006 novel by Philip Roth, comes from a medieval play of the same name, and is intended to remind us that aging and death await us all, every man and every woman. In 2009, Roth became the third living American writer to have his work published by the Library of Congress. As I have said before in these pages, Philip Roth is the greatest living writer never to have won the Nobel Prize in Literature.

Roth sets the tone for this 192-page novella with an epigraph quoting Keats.

Here where men sit and hear each other groan; / Where palsy shakes a few, sad, last gray hairs, / Where youth grows pale, and spectre-thin, and dies; / Where but to think is to be full of sorrow.

The novel begins with Everyman’s funeral, then skips backward in time to an unvarnished accounting of his life. The protagonist, who remains unnamed throughout, is a 71-year-old retired—and materially successful—advertising executive who has walked away from two marriages, three children, and his once-revered older brother, leaving him ill-equipped to cope later in life with his decaying body and a series of medical events—appendicitis, two heart surgeries, and various other procedures—that force him to confront his own mortality. His death-and-dying tocsin, though, rings well before his body fails him, at his father’s funeral.

All at once he saw his father’s mouth as if there were no coffin, as if the dirt they were throwing into the grave was being deposited straight down onto him, filling up his mouth, blinding his eyes, clogging his nostrils and closing off his ears. He could taste the dirt coating the inside of his mouth well after they had left the cemetery and returned to New York.

Everyman reaches old age and Starfish Beach, the retirement community his infirmities consign him to, cynical and resentful, unshriven (by two adult sons) for cheating on his first wife, unforgiving of the body that betrays him and robs him of his prodigious sexual vigor. Only his daughter from his second marriage remains loyal—as only daughters can. She sees to it that he is buried in a Jewish cemetery alongside his parents, even though he is an atheist, because she …didn’t want him to be somewhere alone.

The last to pay respects at his funeral is Maureen, a home health nurse who cared for him after his first heart surgery.

…a battler from the look of her and no stranger to either life or death. When, with a smile, she let the dirt slip slowly across her curled palm and out the side of her hand onto the coffin, the gesture looked like a prelude to a carnal act. Clearly this was a man to whom she’d once given much thought.

And that was that.

…In a matter of minutes, everybody had walked away—wearily and tearfully walked away from our species’ least favorite activity—and he was left behind. Of course, as when anyone dies, though many were grief-stricken, others remained unperturbed, or found themselves relieved, or, for reasons good or bad, were genuinely pleased.

I once recommended—prescribed—this book to a patient, now deceased, who in addition to being on dialysis with kidney failure, had heart disease so severe it was clear to all, my patient included, that he would not survive another year. A fiercely intelligent man, he understood his predicament intellectually, but refused emotionally to accept it. When he grew angry and then despondent, I suggested Everyman, which he agreed to read. He found the protagonist’s cynicism and bitterness and lack of grace so contemptible he vowed to die a better way. For the remainder of his life, a few months only, he was notably happier and at peace. Sometimes, only great fiction can tell the truth in a way that is transformative; we humble doctors lack the words.

Everyman is a profound adumbration that settles nothing, but fearlessly illuminates everything, leading the reader to a place where confronting death is at least possible.

Why do we fear death so? Do the atheists among us fear they are right? And the faithful that they are wrong? And this notion of bodily decay, how to deal with that, our unwanted senescence? Is there no limit to what we are willing to do to forestall it?

Perhaps it is the loss of those we love that we most fear. A different way of saying we fear losing our humanity. But what I have learned from my patients, I think, is that it is the sweetness of life, the intensity, the vividness we fear losing. And that the balm for this fear is to have savored fully all the heavenly ambrosia this mortal world holds.

Before youth grows pale.

Middlemarch is the magnum opus of George Eliot, the masculine nom de plume of Mary Ann Evans, one of the foremost English novelists of all time. She was born in 1819 at Arbury Farm, England, to an Evangelical Protestant father whose religious beliefs she soundly rejected. Like Tolstoy and Flaubert, George Eliot was part of the nineteenth century realist movement in literature, taking great pains to create life-like characters representing ordinary people in stories of remarkable verisimilitude. Eliot believed female novelists were held in low regard by the English literati, thus the pen name.

At 838 pages and 86 chapters, Middlemarch is no light read; entire semesters have been consumed by it. Suffice it to say that a broad cast of characters—none dominant, all astonishingly real—drive three wide-ranging but interwoven story lines revolving around a number of themes: love and marriage; the station of women in Victorian society; class and social mobility; and the clash between idealism and self-interest, all set in the (fictitious) rural English town of Middlemarch. The book’s complete title— Middlemarch: A Study of Provincial Life—suggests as much.

Among the principal characters is Tertius Lydgate, an ambitious young doctor who comes to Middlemarch intent on starting a new fever hospital for the poor. Lydgate vows to establish new ways of practicing medicine, based on observation and the recording of data and scientific method, in place of the rampant charlatanism of the day.

“A fine fever hospital in addition to the old infirmary might be the nucleus of a medical school here, when once we get our medical reforms; and what would do more for medical education than the spread of such schools over the country?”

…there was a general impression that Lydgate was something rather more uncommon than any general practitioner in Middlemarch.

But Lydgate, like many visionaries, is arrogant, to colleagues and patients alike.

“I have not yet been pained by finding any excessive talent in Middlemarch,” said Lydgate bluntly.

Lydgate’s conceit was…never simpering, never impertinent, but massive in its claims and benevolently contemptuous.

He winds up marrying the town beauty, Rosamond Vincy, but it is an unhappy match. Rosamond is shallow and materialistic, and her pretentious spending quickly plunges Lydgate into severe indebtedness. His financial desperation leads him to accept a loan under dubious circumstances, and the ensuing public humiliation he suffers causes him to surrender his dream of revolutionizing the way medicine is practiced. To appease his wife, he becomes the kind of doctor he once held in contempt, catering to the wealthy until he becomes wealthy himself. Lydgate dies at fifty, disillusioned and unfulfilled, arrogant no more.

But arrogance is not the brilliant and perceptive Lydgate’s worst flaw; a lack of empathy is. He seeks to understand human behavior in a cold, dispassionate way, without emotionally connecting to the human beings he studies. Both his métier and marriage suffer for it.

“I was early bitten with an interest in structure, and it is what lies most directly in my profession. I have no hobby besides.”

The tragedy of Lydgate is the tragedy of any doctor who fails to become proficient in the art of medicine as well as the science. The science of medicine involves knowing what treatment to apply; the art of medicine requires the persuasion of other human beings to suffer it.

All medical schools produce their share of Lydgates, brilliant classroom students who excel at mastering the basic sciences, but founder at the bedside. It just isn’t there, that natural camaraderie that causes a patient to turn to his wife and say, within minutes of meeting a surgeon, “I like her. I’m going to let her do whatever she needs to.”

Consent to undergo the often invasive and sometimes hazardous treatments we ask patients to endure depends upon an irrational trust—irrational in that an emotional connection forged between doctor and patient gives rise to it. Such trust is the coin of the medical realm, and the path to gaining it begins with authentic recognition of—and genuine sympathy for—the plight of the afflicted. These skills are not acquired in cellular biology class, but rather are developed with the aid of paintings and plays and poems and novels.

Like Middlemarch.

One of the most challenging aspects of medical school is to drink from the torrent—the fire hose—of scientific knowledge pumped down your throat while still remaining a sentient human being. And to remember that it was a desire to help other human beings that attracted you to medicine in the first place. The amount of information medical students are asked to assimilate is so enormous—so pantagruelian, to steal from the French doctor-turned-humanist Francois Rabelais—that it almost unavoidably turns idealistic young men and women into cold-purposed cyborgs, whose entire reason for being becomes the digestion of data.

Medical educators have for decades struggled to produce physicians who can not only process this ever-growing fund of knowledge, but who are also capable of evincing genuine compassion and empathy for the patients they apply it to. Many approaches have been tried to achieve this delicate balance. As readers of this blog are aware, courses in the field of narrative medicine help medical students maintain a humanistic perspective by requiring close reading of specific works of literature that stimulate the brain’s empathy centers, putatively located in the anterior cingulate cortex and amygdala.

Another possible way of assuring that medical trainees leave medical school with an ability to forge empathic connections with their patients is to select a limited number of students who already have this quality, in hopes that their humanistic impulses will be less prone to withering than those of hard-core science types. One medical school that has gone all in on this theory is the Mount Sinai School of Medicine in New York, with their Humanities and Medicine Early Acceptance Program, which “provides a path to medical school that offers maximum flexibility in the undergraduate years for students to explore their interests in humanities and social sciences at top liberal arts colleges and research universities.”

Thirty to thirty-five college sophomores are accepted annually into the program. To qualify, they are required to major in a humanities subject in exchange for not having to take physics or calculus, and for taking a reduced course load of organic chemistry. One year of undergraduate general chemistry and biology and one semester of organic chemistry remain mandatory for matriculation. Students admitted through this program are not permitted to take the Medical College Admission Test (MCAT). In 2009, there were 300 or so applicants to the program, with 34 students accepted.

Medical students entering Mount Sinai via the Humanities and Medicine Program performed in line with students accepted in traditional fashion, as assessed by class ranking, medical clerkship grades, standardized test scores, and the quality of residency positions obtained for post-graduate training. As described in a letter in the British medical journal The Lancet this month (Medoff, S. Correspondence. Lancet. 2010; 376: 1542), “Students in the programme this year have worked as professional actors, lived with shaman healers in Peru, taught English in Indonesia as Fulbright scholars, and pursued advanced degrees in classical music performance.” Mount Sinai’s web site states that they seek candidates who “have personal attributes that show promise for becoming a compassionate and humanistic physician.”

In other words, despite the explosion in basic science knowledge all medical students are expected to master, educators have become gun-shy about taking too many science nerds. The message of programs such as Mount Sinai’s is clear: Be first a human, then a doctor.

Pity me as I wish to be pitied. That is the plea of the tortured protagonist in Leo Tolstoy’s brilliant 1886 novella, The Death of Ivan Ilyich.

Tolstoy was born in 1828 into Czarist Russia’s landed gentry. Though orphaned at a young age, he enjoyed the typical privileges wealth and title afforded—passive income, summers in the country, and enrollment at Kazan University. But it was later, after dropping out of school and joining the army, that Count Tolstoy would launch his career as a writer from the Crimean front.

There is perhaps no other literary character who gives voice to the agony of the afflicted more profoundly than Ivan Ilyich, a forty-five-year-old parvenu who assiduously wends his way through Czarist Russia’s bureaucracy to become a respected judge, only to develop an insidious illness that announces its presence while he is hanging curtains in a stylish home beyond his means to afford.

…he made a false step and slipped…but only knocked his side against the knob of the window frame. The bruised place was painful but the pain soon passed…

But not for long.

…Ivan Ilyich…had a queer taste in his mouth and felt some discomfort in his left side.

His symptoms begin to disrupt his carefully ordered and superficially fulfilling life. He grows irritable from discomfort and more quarrelsome with his wife, with whom his relationship is abysmal to begin with, a thing to be endured to keep up appearances. Her patience with him is soon exhausted.

She began to wish he would die; yet she did not want him to die because then his salary would cease.

Tolstoy passes judgment on the spiritual emptiness of social striving with one of the most famous and devastating sentences in Russian literature.

Ivan Ilyich’s life had been most simple and most ordinary and therefore most terrible.

Ivan’s symptoms intensify, mystifying a bevy of doctors who attribute it one day to a “floating kidney,” and the next to appendicitis.

The pain in his side oppressed him and seemed to grow worse and more incessant, while the taste in his mouth grew stranger and stranger…It seemed to him that his breath had a disgusting smell, and he was conscious of a loss of appetite and strength.

The nephrologist in me cannot resist pointing out that with the exception of his pain, all of Ivan Ilyich’s symptoms can be explained by uremia, an advanced stage of kidney failure. But whatever the cause, he becomes angry and bitter over his doctors’ failure to cure him. He realizes he is dying.

And he had to live thus all alone on the brink of an abyss, with no one who understood or pitied him…

He becomes resentful, especially of his still-healthy wife.

While she was kissing him he hated her from the bottom of his soul and with difficulty refrained from pushing her away.

Why is he so resentful? Because no one gives him what he wants. We come, now, to the heart of things, to what patients want and need and crave with all their being.

…what most tormented Ivan Ilyich was that no one pitied him as he wished to be pitied. At certain moments after prolonged suffering he wished most of all (though he would have been ashamed to confess it) for someone to pity him as a sick child is pitied. He longed to be petted and comforted.

He finally gets the succor he seeks from the peasant Gerasim, who holds him the way he wants to be held—and talks to him about death openly and honestly. The authenticity of Gerasim, in contrast to the hypocrisy of the aristocrats Ivan Ilyich has lived his life to please, has a powerful effect on him.

“Maybe I did not live as I ought to have done,” it suddenly occurred to him…“What if my whole life has been wrong?”

He softens and allows a priest to hear his confession, then endures an agonizing three days, during which…he struggled in that black sack into which he was being thrust by an invisible, resistless force.

In the end, Ivan Ilyich rejects the lie of his life and embraces the truth of his death; in so doing, he is at peace.

He sought his former accustomed fear of death and did not find it. “Where is it? What death?” There was no fear because there was no death.

In place of death there was light.

“So that’s what it is!” he suddenly exclaimed aloud. “What joy!”

Ivan Ilyich wanted nothing more than to be stroked like a child. Tolstoy’s insight into the enormous frustration patients feel at the end of life, the agony they endure, at not being touched in a compassionate way is a call to physicians—to all caregivers—to lay hands on our patients not only in a clinical way, as part of an examination, but also in an emotionally meaningful, loving way. Embrace them. Pity them. And patients: express your need. No pathos, no pity. Let people know you want to be held like a baby.

For from this will come a relief no surgery or medication can bring.

I evoke a variety of expressions—ranging from quizzical to dubious to why-are-you- wasting-my-time?—from my colleagues when I tell them I have started a literature and medicine blog. Their eyes become filmy if I mention the phrase “narrative medicine”—a sure sign I have thirty seconds tops to win them over.

I usually succeed in under twenty. How? By pointing out to them that storytelling is integral to what we do.

Every time we gather a medical history from a patient, we listen to a story; every time we dictate a consultation and formulate a treatment plan, we tell a story. But the manner in which we elicit our patients’ stories is critical. We will have a hard time arriving at a correct diagnosis if we are not skillful enough in extracting a complete and accurate narrative from a patient. Similarly, if we fail to construct a persuasive enough narrative to explain to a patient what we think she has, she will be less inclined to think our diagnosis credible, and less willing to comply with our treatment plan. And since we spend so much time listening to, analyzing, constructing, and telling stories, it can only be helpful to develop and hone this type of critical thinking. What better way to achieve this than by reading and reflecting upon the fiction of master storytellers?

After making these arguments, my skeptical colleagues’ eyes spark with comprehension, as if to say, “Yes, that is what we do.” (Except the dermatologists among us, who do not do any of these things, and who are not awakened at night to come to the ER, and who make more money than…Sorry. I know. I could have done a Derm residency. I’ll behave. I promise.)

Stories—narratives—are no less critical in the legal world, where the plaintiff goes head-to-head with a defendant’s competing version of the dispute in question. More often than not, the attorney that tells the most persuasive, credible story—that weaves the best narrative for the jury—is the attorney that wins the case.

But perhaps nowhere is the power of a compelling narrative more evident than on the hustings during a political campaign. I would even suggest that nearly all the heat and noise of American politics is generated by a single pair of competing narratives: those in support of the values of equality and liberty.

What matters most to Democrats is equality—even, sometimes, at the expense of liberty. Case in point? Healthcare for all, even if their fellow citizens, under penalty of law, have to be forced to buy something—health insurance—they may not want. And what matters most to Republicans is liberty—even, sometimes, at the expense of equality. Case in point? The same issue, healthcare: by their willingness to tolerate unequal access to healthcare in favor of protecting each individual citizen’s freedom—liberty—to decide for themselves whether or not to purchase health insurance. The tension inherent between the values of liberty and equality has given rise to two overarching national narratives that define the two political parties organized around these values. Depending on which narrative resonates most with voters at a particular time, that of equality or liberty, one party or the other carries the day. In our current mid-term elections, for example, the narrative of liberty prevailed; but in the Democrat landslide year of 1964, at the height of the Civil Rights Movement, a narrative of equality triumphed. In two years there will be a presidential election, and I am quite confident that the dueling narratives of equality and liberty will again shape the conflict. And to the side that tells the best story—the best narrative—go the spoils.

At all levels of interaction between human beings, stories matter: whether in our personal lives, in forming the national debate over equality and liberty, or when it comes to doctors caring for their patients. It is in our best interest as a nation and, more narrowly, as physicians to be proficient in evaluating the various narratives in our lives. Many medical schools agree with this and now require courses within the field of narrative medicine (the study of literature applied to medicine).

But the benefits of narrative medicine should not be limited to medical students. We can all read and reflect upon great works of literature, even in the absence of specialized instruction. By reading literary fiction, we naturally and unconsciously examine narrative structure, become more familiar with narrative process, and hone our skills of narrative criticism. The critical thinking and sifting of ideas we do while reading and reflecting on a novel is the same type of critical thinking and consideration we do in caring for patients—and in deciding elections.

In all of us, there lies a voice within that utters but one command: Tell me a story. Wise are those who heed it.

“I don’t mind dying, I just don’t want to be there when it happens.” — Woody Allen

Near-death experiences, as first reported by Raymond Moody in Life After Life, typically consist of patients leaving their bodies and floating above their own Code Blues—essentially watching themselves die—before passing through a dark tunnel toward a brilliant light while in a state of serene ecstasy. Such accounts, which now number in the millions, have been uniformly consistent across different age groups, cultures, races, and religions.

An article by Melinda Beck in the October 25 edition of The Wall Street Journal describes a multi-hospital study in which investigators suspend specific images—face up—from the ceilings of emergency rooms and intensive care units in an attempt to verify claims of patients who report out-of-body experiences after being successfully resuscitated. The study, which has yet to report even preliminary results, seeks not only to authenticate such experiences, but to use its findings to help settle a question that has fascinated philosophers since the days of Aristotle: Does human consciousness—the mind—exist separately from the human body?

The seventeenth century French philosopher René Descartes believed it did. His theory of Cartesian dualism asserts that mind is not matter, but rather a nonphysical, immaterial substance capable of interacting, in a causal way, with the material body. The so-called mind-body problem, then, arises from the implausibility of this assertion: How can existential vapors of an immaterial nature cause the material body of a human being to get up out of a chair and stretch? How can the mind cause the body to do anything if the mind is not itself part of the body?

In the nineteenth century, Arthur Schopenhauer termed the conundrum of consciousness “the world knot,” and was pessimistic an explanation for the mind would ever be discovered. But much has changed since then. Contemporary neuroscientists and philosophers regard consciousness—the mind, that thing apart that registers thought, memory, awareness—not as the immaterial stuff of Descartes, but as the result of processes of the physical brain, a neurobiological event that can be explained entirely by the sequential firing of specific neuronal circuits. A previous post of this blog discussed a paper on the biology of empathy that even named the amygdala and anterior cingulate cortex as the brain’s empathy centers, capable of creating feelings of sympathy for other human beings.

So what about near-death experiences? Did patients who have had them briefly straddle a spiritual DMZ between Heaven and Earth? Or can these incidents be explained on a neurobiological basis, the firing of spent brain cells in a specific way as the brain begins to die, a final common pathway of neuronal death that results in a reproducible perception of out-of-body floating and tunnels of tranquility leading to white light?

As the mission statement of this blog maintains, scientific method is not the only way to learn. Stories can instruct us, too. Stories that are textured, layered, with complex meanings embedded in their narratives in a manner beyond the capacity of empiric reasoning to convey. So what does the world of contemporary fiction have to say about the nature of consciousness?

I’m glad you asked.

A pair of novels by Barnard philosophy professor Rebecca Goldstein—The Mind-Body Problem and 36 Arguments for the Existence of God—explore this very question. I refer you to the 1983 New York Times review of The Mind-Body Problem and to this year’s Washington Post review of 36 Arguments for the Existence of God for full-length book reviews of each, but suffice it to say that Goldstein is a witty, intelligent, and mostly accessible writer—though she does succumb at times, as you might expect of a philosophy professor, to fits of academic indulgence and narrative wandering before finding her way back to the main thread of her engaging stories.

More importantly, though, she does what a good novelist should do: considers all sides of the argument and in the end leaves the reader to decide. Though a credible case for atheism and the mind-as-extension-of-the-brain is made in these two novels, one could just as easily conclude from them that the mind and soul may not ever be discoverable by scientific method, because they are infinitely intangible and not part of the observable universe. Rebecca Goldstein loosens Schopenhauer’s world knot, perhaps, but she does not untie it.

What about you? Where do you think consciousness resides?

Much is required of physicians: an unstinting devotion to others, a mountain of psychic energy. The punishing effect of these demands on doctors’ personal lives has long been recognized. Medicine is indeed a jealous mistress.

But what of the women and men who are married to doctors? What of the impact this grueling profession has on them, the non-physician spouses of doctors? (Two-physician marriages are another matter; doctors who are married to other doctors enjoy a considerably lower divorce rate than marriages where one spouse is a physician and the other not.) The phone rings all night long, emergencies constantly disrupt family functions, and their physician-mates, immersed from dawn to dusk in the drama of human illness, are often emotionally unavailable. Yet how to compete with matters of life and death?

One of the unhappiest medical marriages of all time is the subject of Gustave Flaubert’s Madame Bovary, a literary masterpiece about the dreamy wife of a kind, but inferior small-town doctor. Flaubert’s father was the resident physician of a hospital in Rouen, France, but Flaubert the younger chose to study law in Paris before turning to writing. He published Madame Bovary in 1857, following the acquittal of charges of immorality brought against him because of the book’s frank treatment of adultery.

The doctor in the story is Charles Bovary, an amiable dullard smitten by young Emma Rouault, the beautiful and—compared to Charles—refined daughter of a patient of his. After the death of his first wife, Charles pursues Emma and convinces her to marry him. But their torpid, ordinary marriage leaves Emma yearning for the excitement, opulence, and romance she has read about in certain novels of the day.

…it was at meal-times that life seemed especially unbearable, down there in that little ground-floor dining-room with its smoking stove, its creaking door, its sweating walls, and its damp floors. It seemed as though all the bitterness of life was served up to her on her plate…

Was this hopeless existence going to last forever? Was there to be no escape?

…She would lean her head against the wall and weep, longing for a life of excitement, masked balls and tumultuous pleasures…

She enters into a lengthy affair—which her adoring husband Charles remains oblivious to—with a local rake, who seduces her and then casts her aside, plunging her into a state of depression made worse by the financial burden of her many impulsive purchases.

Emma’s opinion of Charles during this time suffers even more on account of his disastrous attempt to repair the clubfoot of a villager named Hippolyte. An under-qualified, second-rate doctor with an appealing bedside manner and gentle disposition, Charles’s motivation for trying such (then) experimental surgery is professional vanity. Unfortunately, he is nowhere near skilled enough to perform the procedure, which he bungles horribly, resulting in the amputation of poor Hippolyte’s leg.

…Bovary kept indoors, not daring to stir from the house…If Hippolyte were to die, everyone would say he had killed him. And then what was he to answer when he went his rounds and people asked him about it? Perhaps he had made a mistake somewhere…Of course the best surgeons make mistakes. But that’s just what people will never understand. They would laugh at him. Everyone would be talking…There would be controversy in the papers and he would have to reply. Hippolyte might bring an action against him. He saw dishonor, ruin, irretrievable disaster staring him in the face…

Emma emerges from her grief no more satisfied with Charles than before; she takes another lover, and is even more indiscreet than the first time.

It little mattered that she felt herself humiliated by such degrading pleasures. Habit, or vice, demoralization, compelled her to cling to them; and every day saw her calling ‘for madder music and for stronger wine’, drying up pleasure at the source by asking too much of it.

Her contempt for Charles and her ruinous spending intensify, even as she grows tired of her new lover. When a creditor calls in her debt, which has been secured by her husband’s modest estate, she turns in desperation to her first lover, offering herself in prostitution to secure the money she needs. His refusal drives her to suicide; she poisons herself with arsenic, a torturous, anguished death.

A minute or two later she was bringing up blood. Her lips were drawn, her limbs contracted, her body covered all over with brown patches, and her pulse flickered away beneath the fingers like a taut wire, or like a harp-string, stretched to breaking point. Then she began to scream.

Only after Emma’s death, upon finding her love letters, does the loyal but fatuous Charles learn of his wife’s adulteries. He dies penniless and alone, leaving their daughter Berthe an orphan who is forced to work in a cotton mill.

This remarkable piece of writing is best known for its explicit treatment of adultery and for Flaubert’s complex rendering of Emma Bovary. His brilliant characterization of her is so vivid and original it even gave name to a new kind of psychological malady: bovarism, from the French bovaryisme, romantic fantasy run amok, until the dreamer becomes detached from reality and pursues her dreams with wanton self-destruction.

So, the question is, was this new malady of bovarism cause or effect? That is, did Emma Bovary destroy herself? Or did the peculiar oppression of being a doctor’s wife drive her crazy?

Tell us your thoughts about medicine, marriage, and Madame Bovary.