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A Matter of Life and Death
In early October of 1980, Sherwin Nuland had just arrived at New Haven’s Hospital of Saint Raphael to begin his evening rounds. But no sooner had he stepped through the doors than Nuland, a 1955 graduate of the Medical School and a clinical professor of surgery and gastroenterology at Yale, heard a frantic appeal over the hospital’s public address system. “Any general surgeon! Any general surgeon!” the announcer cried. “Go immediately to the operating room—immediately—any general surgeon!”
Of course, Nuland could have just gone about his business in the expectation that someone else would answer the page, but surgeons are not like that. As he recalled in his 1997 best-seller, The Wisdom of the Body, “the clamorous message, at once supplicating and commanding, part outcry for help and part call to arms, spoke to me like some suddenly recalled ancestral imperative. Feeling as though I had been set off by a self-starting high-speed internal dynamo over which I had no authority, I raced off toward the nearest staircase and bounded up the steps.”
Readers familiar with Nuland’s dispatches from the front lines of medicine—How We Die: Reflections on Life’s Final Chapter (1994), The Wisdom of the Body (1997), and The Mysteries Within: A Surgeon Reflects on Medical Myths (published in March of this year)—know what’s about to come: an account of a surgical procedure told in a you-are-there manner that is at least as gripping as anyof the dramas found on television. After more than 30 years as a practicing surgeon in New Haven, Nuland had hundreds of such tales to tell, and in 1992 when he was 61, he traded his scalpel for a Number 2 Eberhard pencil and took a year’s leave from his profession. He never returned.
Past and potential patients were no doubt the poorer for this decision. But a wider audience would soon benefit, for Nuland has not only become a graceful teacher about what he calls “the wonder that is us,” he is also a forceful spokesman for changes in the way medicine is practiced, particularly at the end of life.
Although Nuland did not publish his first book for a general audience until he was nearing retirement age, the writing impulse had emerged long before. “I’ve always had a 'gee-whiz' sense of the world, and I started writing about it when I was very young,” he explained. “As an 8-year-old, I remember going to a carnival in the Bronx, where I grew up, and being so excited that I had to rush home and write about the experience. But the only thing I had for paper was the blank front and back pages of this cheap cardboard book on the wonders of the planet. I filled them with my first bit of nonfiction.”
In 1988, Nuland, who by then had become a distinguished physician, a teaching surgeon, and a scholar of medical history at Yale, wrote Doctors: The Biography of Medicine. The book, “warmly recommended” by New York Times reviewer John Gross, offered in-depth portraits of some of the most important figures in medicine over the past 2,500 years. The author “succeeds in bringing his subjects to life,” said Gross, “and he leaves you with a much better understanding of what they achieved.”
Nuland loved surgery. In a presentation he once made to first-year medical students, he emphasized how much fun the profession could be. And yet, the notion of being a full-time storyteller, of getting down on paper tales he'd accumulated over a lifetime in operating rooms and in the musty archives of historical libraries, was growing more and more compelling.
As he passed his 60th birthday, the physician did not feel that his surgical skills were in any way eroding, but in the early 1990s, the upheaval in the way medicine was being practiced made it “easy to step away. The joy of being a surgeon began to disappear,” Nuland recalls, adding that the advent of managed care was “eroding our relationships with patients.”
Worse still, the pressures the Medical School and the Yale–New Haven Hospital were under to make every operation a teaching case-study changed the relationship between the clinical staff, which is composed largely of private-practice physicians, and the medical faculty. “I enjoyed operating,” Nuland said. “I didn’t enjoy being a teaching first-assistant.”
When the surgeon took his sabbatical in 1992, he quickly discovered that he missed the “easy companionship” that came with membership in the medical community. “It’s more than just being part of a surgical team,” he said. “You can be in x-ray or pathology and wind up in a complicated clinical conversation in which everyone is contributing and learning something, or you might run into a colleague who asks, ‘How’s Mary?' and wind up discussing the state of the universe. This place is jam-packed with bright, interesting, articulate people, and conversation—as I wrote on my application to medical school—is my hobby.”
But in his quiet, book-lined study in Hamden, and in an office at the Historical Library at the School of Medicine, Nuland realized that he also “loved the writing life.” In the Bronx tenement on 2314 Morris Avenue where he grew up, he was “enchanted by the conversations I heard every Friday night when my grandmother would hold court. For me, writing is simply another form of conversation.”
It would soon become apparent that Nuland was exceedingly good at his alternate craft. In 1994, the results of his efforts were published by Alfred A. Knopf, Inc. How We Die examines in uncompromising detail the biology of infections, cancer, heart disease, AIDS, Alzheimer’s disease, and other fatal afflictions. It is not a book for the faint-hearted, but it amazed the publishing world, staying on the New York Times bestsellers’ list for 17 weeks. It has been translated into 17 languages, and in 1994 it received the National Book Award for nonfiction.
One reviewer spoke for many in calling the book, which features a mixture of memoir, operating room high drama, mea culpas, and a heartfelt cry for a more humane kind of medicine, “brilliant, touching, and oddly uplifting”—no easy accomplishment in what is fundamentally a ceaseless litany of systems failures. But other readers complained that Nuland went too far and was “almost sadistic in his candor.” Indeed, in a chapter called “Murder and Serenity,” his account of precisely what happened when a 9-year-old girl was attacked and killed by a knife-wielding paranoid schizophrenic is more than most people could be expected to bear.
“A specific sequence of events takes place in people who bleed to death,” the author notes in the course of the description, and then calmly proceeds to delineate the physiology of what is technically called exsanguination. The words, cold and clinical, are made all the harder to read because the subject under scrutiny is a child, not a nameless cadaver.
And yet read on we do, for the writing is compelling, and when Nuland is on a roll, his prose is nearly impossible to put down. Consider his description of cancer: “The disease pursues a continuous, uninhibited, circumferential, barn-burning expedition of destructiveness, in which it heeds no rules, follows no commands, and explodes all resistance in a homicidal riot of devastation,” he writes. “Its cells behave like the members of a barbarian horde run amokleaderless and undirected, but with a single-minded purpose: to plunder everything within reach.”
The writing evokes at once Shakespeare and the Bible in its combination of richness and resonance, and that, it turns out, is entirely deliberate. “I grew up the son of poorly assimilated, old-style shtetl Jews, and the stultifying aspects of Old World orthodoxy were always in conflict with the richness of my background,” he explains. “I wanted to be an American, and to me, the ultimate freedom was the English language. It was my liberator and my oxygen.”
Nuland fondly remembers the first book he ever took out of the Fordham branch of the New York Public Library near his home in the Bronx—it was Ab the Caveman; he was 7 years old—but it wasn’t until he enrolled at New York University that he embarked on a serious exploration of literature. Shakespeare’s plays found a receptive student, but oddly enough, the King James version of the Bible—that most Protestant of books—reached deepest into Nuland’s literary consciousness. “There’s an exalting beauty to the sound of the words, and the King James version has this amazing combination of simplicity and grandness to it,” Nuland says. “I tend to write out loud, and the Bible’s cadences and flow, particularly in the Old Testament books of Ecclesiastes and Psalms, have had a profound influence on my writing style.”
But however enamored Nuland was with literature, his upbringing would lead him in a very different career direction. In the close-knit world of his Bronx tenement community, disease and death were always present. A brother had died before Nuland was born, and his mother lost a painful battle with colon cancer when he was 11. And then there was his grandmother, with whom he was forced by the family’s meager circumstances to share a bedroom for eight years, a period during which he would watch the health of his beloved “Bubbeh,” as she was known in Yiddish, fail. (The story of her gradual and steady decline is told in “Three Score and Ten,” a chapter of How We Die.)
“I’d had devastating contacts with disease, but I was always interested in what made people tick,” said Nuland. “It seemed like a natural thing to study biology.”
He did so at the Bronx High School of Science and at NYU, but when he entered the Yale School of Medicine in 1951, the intellectual environment there triggered a latent interest. “Several of my professors had a passion for medical history and referred to the subject on rounds,” Nuland explained, adding that it was easy for him to get hooked. “I’m a Jew after all—we’re made of the memories we’ve inherited from thousands of generations. My sense of history is a sense of continuity.”
That fascination produced Nuland’s first books, and medical history is woven into the fabric of his human body trilogy, as well as into his latest effort, Leonardo da Vinci, which is being published this month as part of the “Penguin Lives” series of brief biographies. This intellectual bent, said Nuland, had him leaning in medical school towards specializing in either psychiatry or internal medicine. Ironically enough, he had no interest in surgery.
“In the early 1950s, surgeons were all big men who drove fin-tailed Cadillacs, smoked cigars, and talked about women—a bunch of gregarious guys who were into only the pragmatic things of life. People who considered themselves sophisticates didn’t go into surgery, which was regarded pretty much as a coarse craft,” Nuland explained.
But one day as he was working in the old Tompkins Pavilion of Yale–New Haven Hospital, chief surgical resident Bob Chase called him over and said that another intern had had to leave suddenly. “I’ve had my eye on you—you’re just terrific,” said Chase, who asked Nuland to fill in.
The physician’s praise, Nuland would learn decades later, had been a complete fabrication. “They needed somebody then and there, and I was a warm body,” he said.
But as a result, he would work closely with a surgeon named Jose Patino, who later became Colombia’s minister of health and founded a medical school there. “Jose had an aesthetic approach to surgery, a certain romance,” said Nuland. “I was captivated by him and by the inside of a living body, which was so different from that of a cadaver.”
Nuland was hooked, and as a result of what he calls this “fortuitous and transforming experience,” he decided to become a surgeon, eventually specializing in gastroenterology. “We have had a rewarding relationship, the belly and I,” he says.
In part, Nuland’s books are a celebration of that relationship—an intimate, fascinating, and often hair-raising look at how medical battles have been fought, and won or lost, both in Nuland’s experience and over the past 2,500 years. Surprisingly, his tales from the operating room do not come from notes penned immediately after the surgery was over. “I’ve never kept journals, and I didn’t deliberately set out to collect these stories,” he said. “When I write, I sit down with a pencil and a pad and let things happen. I first try to capture the feeling and the emotion of the time, and then the words just flow. The most basic thing in the human mind is emotion, and from it comes formed thought, then the language of the intellect, and finally the language of the mouth and tongue. So a single word can set off a train of memories, and I’ll remember an entire sequence of events: how things felt, who was there with me, where they were standing.”
The process results in powerful chronicles of cutting, curettage, cardiac arrest, and, in the case of the emergency call over the P.A. system that Nuland was impelled to answer, the successful stanching of a burst aneurysm and the dramatic rescue of a young mother from certain death. There is a tender account of the birth of one of his children, with a detailed description of the precursors: the physiology of sex, conception, and gestation. And there are solutions to medical mysteries, such as Nuland’s discovery of just what kind of bizarre growth was blocking an infant’s digestive system.
But what lingers after the anatomy and medical history lessons dispensed in his books is the feeling that Nuland is precisely the kind of doctor you'd want on and by your side when things go very badly.
“A surgical training program bleaches out the sense that you have in front of you a fellow human being in travail, and all the rituals of surgery are designed to distance you from the humanity of your patient,” says Nuland.
He is quick to add that this separation is usually both good and necessary, because it helps a surgeon remain calm and clear-headed when blood is gushing out of some unseen artery or a heart valve has to be “cracked” open with a finger, an exquisitely delicate procedure, described in a harrowing chapter of The Mysteries Within, that can either kill or cure a person. But he explains that the distancing process also has its negative side.
With managed care and its single-minded stress on cost-cutting has come an emphasis on so-called evidence-based medicine. “We’ve created algorithms that dictate treatment, and every person has to fit in a standardized pigeonhole,” says Nuland.
Such a medical model may make a certain amount of economic sense, but it violates an ancient tenet of caregiving: that every patient is unique. “This is the old Hippocratic tradition, and we’re in danger of losing it,” says the surgeon.
Losing the idea that there’s a person, not just a piece of ruptured intestine or diseased pancreas, under the surgical drapes may be temporarily fine, Nuland continues, but this mindset has made it difficult for today’s doctors to recover a sense of their patients’ humanity once people in their care are in recovery, or, as also happens, beyond it. “Surgeons are activists, and when they feel they can no longer do anything, many of them turn away, first emotionally, then physically,” he notes, adding, with no small amount of regret, that he was also guilty of this collective sin of his craft. “Many times, I’d be making rounds with students and when we'd come upon a dying patient, I’d say, ‘let’s go on to the next room.' I didn’t know what I should do. I felt impotent.”
But surgeons have more at their disposal than just the physical tools of their trade. “A surgeon is a healer, and sometimes you may be able to help best simply by sitting there and holding someone’s hand,” says Nuland, whose book on the biology of death came out when pathologist Jack Kevorkian was publicly providing the means for assisted suicide. Nuland quickly became caught up in the national debate over how doctors should respond to patients whose lives had nearly run their natural course. He was an uneasy spokesman, for Nuland and his wife, Sarah, director of humanities and education at Long Wharf, had two teenaged children, Will, now 18, and Molly, 16, still at home (Nuland has two other children from an earlier marriage: Victoria, 38, deputy ambassador to NATO; and Andrew, 35, a business executive in China), and the sudden demands on his time that came along with fame “took a toll” on his family life. But on paper—he writes a regular column for the American Scholar and is in constant demand as an essayist for publications ranging from the New Yorker to Surgical Oncology Clinics of North America—as well as on-line and in personal appearances, Nuland has offered a compassionate counterpoint to Dr. Kevorkian’s suicide machines.
Modern medicine, which until recently has emphasized an intervention-at-all-costs strategy, has no doubt helped make life harder than ever to leave. But the ideal, suggests Nuland, is not simply to abandon the dying or work actively to hasten their end. “By and large, death is a messy business,” he acknowledges, pointing out that physicians can certainly help minimize the messiness by curbing the tendency to always try to do something, even if it would be futile, and by taking the hospice approach to minimize pain.
However, this by itself is not enough, says Nuland. “The skill with your hands, the skill with a diagnosis—these are a kind of magic—but the ideal doctor, the true caregiver, also needs the skills of the heart: the ability to create the aura that a patient is important to the physician and They’re both enmeshed in a journey they’re taking together.”
In How We Die, Nuland advocates a return to one facet of an almost Norman Rockwell-esque notion of medicine: “the resurrection of the family doctor. Each of us needs a guide who knows us as well as he knows the pathways by which we can approach death.” This is not, he hastens to point out, a call to abandon high-tech medicine. Rather, it is a prescription that would temper today’s medical wizardry with a dose of humanity and help patients achieve that much sought-after prize: “death with dignity.”
For all too often, ars moriendi—the art of dying—proves artless. “The dignity we seek in dying must be found in the dignity with which we have lived our lives,” Nuland explains. “Ars moriendi is ars vivendi: the art of dying is the art of living.”
As Nuland sees it, the journey is made easier if patients, dying or otherwise, know that they can count on traveling in the company of someone who understands the values with and for which they’ve lived. To be sure, there are times when physicians with superspecialized skills are required, but at the end, “it is not the kindness of strangers we need,” says Nuland. Rather, it is “the understanding of a longtime medical friend.”
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