Anatomy Class Observing Corpse

The standard statements about what medical humanists "do" evoke cultural, ethical, political, and personal dimensions of health, illness, and the practitioner-patient relationship.

Such statements often mention reasoning skills and professional stances that allow for—even celebrate—uncertainty, contingency, and context. I want to talk here about aspects of medical humanities that go deeper, to places where a language of autonomy and beneficence, an examination of Ivan Ilych's journey to death, or a recognition of the biases that shaped past and current medical research won't suffice. New reasoning or interviewing skills can address some of this, but patterns of thinking and protocols can still address only surfaces. For example, I attended an ethics consultation in which all parties agreed to withdraw life support from a woman, but the medical team could not—would not—address the grief of the third-year medical student who was facing a patient's death for the first time. In another conference participants could accept a straightforward edict that it was wrong to abandon a patient but could not talk about the obvious and largely justified anger they felt toward that patient.

Although courses in medical humanities and ethics profess the importance of the social, cultural, and personal dimensions of human action and interaction, they often shy away from the even more basic emotional and psychological elements that shape those interactions. These feelings are timeless. Two poems, written more than ten years apart by medical students at my institution, demonstrate the persistence and pervasiveness of such feelings. These ten years have seen the advent of required and elective courses in medical ethics and the humanities, problem- and evidence-based teaching, and primary care and longitudinal ambulatory medicine, beginning in the first weeks of school. Still, my students grapple, often alone, with conflicting feelings of transgression, awe, horror, pride, and shame.

The first poem, "Our Lady of the Tank," was written in 1988 by Peter Draper. Its topic, Gross Anatomy class, is a familiar one:

Our Lady of the Tank

Draper's language, deliberately ironic, quickly pulls readers into the poem's complexity. The sacred allusion in his address of the cadaver immediately creates a tension between holiness and transgression. The mysteries of life are presented with a scatology of anatomic terminology and irregular, almost frivolous rhyme, alliteration, and pun. Yet the tensions persist: "The sickle swings, the scalpel scrapes, / As through your greasy gift we sift." The sickle of death and the scalpel of the lab are both wielded against this once living person, and her "greasy gift" conveys both the physical unavoidability and the incredible opportunity the cadaver provides them. Even when reduced to "pickled" parts lying in "a chemical puddle," the body somehow remains superior to the "ungracious exploration of fools." Draper breaks from his irony when he bluntly asks two questions of his cadaver, in which he contrasts "the hand of some paternity" with the earthbound students who now disassemble the body on the table before them.

The "semester of eternity" that the students spend in Gross Anatomy, eternal in part because of its seeming interminableness, also involves a usurpation of a divine role that leads the speaker to fear "our lady's" judgment of him. The last line of Draper's poem always raises questions whenever I teach this poem. Are the thanks "empty" because they are insincere or because they can never be sufficient? Both answers seem to apply. The last line asks both the speaker and the readers to contemplate what has become of the student who has engaged in this last danse macabre in "the ballroom of the living and the dead." By engaging in such a dance, he realizes that he has been forever changed, although he still has more questions about the nature of that change than he has answers.

These questions do not end with Gross Anatomy. The following untitled poem from 2000, written by Heather Hill in a literature-and-medicine elective at the start of her fourth year, sounds the same themes but in a different setting:

When Hill read this poem to the other students, one immediately piped, "Where did you do surgery?" His question was followed by a unanimous bark of laughter, then silence. This exchange demonstrated perfectly the tensions the poem captures: the necessity—even, moreover, perhaps, the drive or desire—for medical students to learn procedures, coupled with the horror of what they're learning to do and what, in turn, that knowledge and those skills might be doing to them.

Hill, like Draper, begins with a deceptively light tone that turns deadly serious. She mocks her excitement at the same time that she insists on the importance of this unnamed event to her. She turns to the people who have always shared her joys, but no one in her family understands the thrill she feels. Even more, they are made uncomfortable by it. So is she, as she acknowledges a need "to explain, trying to justify really." It is, however, only a brief pause, she admits. In class, students discussed the ethics and legality of the double amputation, and Hill's careful selection of details indicates that she has learned the basics of autonomy, consent, and competence, but they talk most about the undeniable excitement of getting to do dramatic, wonderfully horrible procedures and the moral and spiritual costs that come with learning those skills. Hill captures that awful power in her one use of "I"—"I cut off her legs today, both of them,"—after which she returns to "i" and to the circumlocutious, effervescent syntax of youth, whose lightheartedness now rings hollow, even desperate.

These poems speak of the emotional, psychological, and spiritual development of medical students. Medical humanities courses may have created venues where important moments in that development become more apparent, but this development touches on a more profound process than any course one can teach. The most that a medical humanist—who can as easily be a surgeon as a historian or theologian—can do is to witness these moments, create a space for them to be acknowledged, and promote respectful discussion of them. These moments are permitted, even planned in some courses, but for many teachers—of literature and ethics as well as pediatrics or psychiatry—this is a perilous, mysterious step to take. It calls for an openness, creativity, and tact—elements that have been as absent in the education of the humanist as they have been in the education of the physician. Together, we still have a lot to learn.