"House of God" Author Samuel Shem Speaking at the University of Maryland School of Medicine


Uploaded by schoolofmedicine on 09.05.2012

Transcript:
Good afternoon, and thank you all very much for coming. My name is Hamil Safad [phonetic];
Iím a fourth year in the School of Medicine and on behalf of the Gold Humanist Honor Society,
I want to welcome all of you. Before I introduce this afternoonís speaker I want to just take
a moment to thank our sponsors for this lecture. This lecture was sponsored by a grant from
the Arnold P. Gold Foundation. In addition, we received generous contributions; the Medical
Schoolís Chapter of the American Medical Association, medical students section, from
the Medical Alumni Association, and from Dr. Richard Colgan of the Department of Family
and Community Medicine, our thanks to all of them for making this lecture possible.
In the fall of 1988, Dr. Arnold P. Gold, a pediatric neurologist at Columbia University
created the foundation that bears his name because he felt that the phenomenal advances
in medicine in the 20th century had dwarfed the essential humanistic elements resulting
in new physicians who are academically brilliant but who often lack caring and compassion.
The Arnold P. Gold Foundation and the Gold Humanism Honor Society were established to
restore that message. At the University of Maryland members of the Gold Humanism Honor
Society are selected through a peer voting process and faculty review during the third
year of medical school where the goal is selecting rising seniors that most demonstrate the ideal
traits that Dr. Gold saw in the compassionate physician. Earning membership in the Gold
Humanism Honor Society is one of two honors that is noted on the medical student performance
evaluation that goes out with every fourth year medical studentís residency application.
The other honor of membership is being on the Alpha Omega Alpha Medical School Honor
Society. At Medical Schools across the country the Gold Humanism Honor Society sponsored
the annual white coat ceremony, in which members of the freshman class of medical students
received their white coats and take the Hippocratic Oath as they formally become practitioners
of medicine. In addition, at the University of Maryland our chapter sponsors an annual
service project. This year on April 11th we partnered with Habitat for Humanity to build
safe homes in our community. Our goal is to promote the ideals of compassionate patient
care and to raise awareness as to the issues that hinder physiciansí abilities to engage
in such care. And there is perhaps nobody more keenly aware of these issues than our
speaker this afternoon. Dr. Stephen Bergman did his undergraduate training at Harvard
University, which included doing neurosurgical research right here in Baltimore as part of
his senior honorís thesis. He also attended Oxford University in the United Kingdom under
a Rhodes scholarship before enrolling at Harvard Medical School where he earned his MD. It
was Dr. Bergmanís experiences during his internship at Israel Hospital in Boston that
inspired him to write his first and most famous novel the ìHouse of Godî. Written under
the pen-name of Samuel Shem, the House of God has been described as a novel that, through
its biting satire and vivid imagery it does for medicine what Joseph Hellerís novel,
Catch 22, did for the military. Although condemned by the medical community when it was first
published in 1978, over the past three decades the House of God has become one of the most
widely read and most widely respected books in the medical field, and has been named by
the prestigious medical journal Lancet as one of two most important medical novels of
the 20th century. The Harvard Club of New York writes that, ëSamuel Shem is easily
the finest and most important writer to ever focus on the lives of doctors and the world
of medicineí. Dr. Bergman is the author of four novels; his most recent being the ëSpirit
of the Placeí, which won two national best novel of the year awards, as well as numerous
essays, several non-fiction works, and an Off Broadway play entitled ëBill W. and Dr.
Bobí about the founders of Alcoholics Anonymous, which won the Performing Arts Award of the
National Council on Alcohol. Dr. Bergman is a psychiatrist and served on the faculty of
Harvard Medical School as a clinical instructor of psychiatry for 35 years. He is the winner
of numerous awards, has given the commencement address at over 50 medical schools across
the country and had the honor of giving the Arnold P. Gold Humanism and Medicine Lecture
at the 2008 annual meeting of the Association of American Medical Colleges. Ladies and Gentlemen,
please join me in welcoming Dr. Stephen Bergman. [Applause] Yes, yes, amazing. One of the thingsóthank
you, itís a great honor to be here. One of the things that I also wanted to mention asóthis
is the writer partóis that I will be doing a book signing after the talk, is that right?
Theyíll be books here or there or where? Yeah, you can buy the book and you can have
my autograph, which will decrease the value of it. As you heard, the Universityóthis
is the first time Iíve been back to the University of Maryland Medical School since the summer
of 1965 when I was going into my senior year at Harvard College. And I had wandered into
deciding that I would solve the mystery of the neurobiological basis of learning and
memory. And that somehow involved spending the summer here working with a scientist named
Robert Grenell [phonetic] and learning this neurosurgical technique that you could profuse
a little section of cortex. And I went back to Harvard and they gave me a lab at the mass
general and I worked diligently on this; I was really enthusiastic about this. And it
really was because of that, I think, that I then got lucky and got a Rhodes scholarship
to go to Oxford. Usually they donít include scientists really but they did in this case
and my three years at Oxford really changed my life, changed my life to get out of the
country from 1966 to 1969. When I came back thenówell, I started writing at Oxford when
I got over there and I decided I wanted to be a writer and there was a little thing called
the Vietnam War going on at that time. So after the scholarship was upóyou didnít
get drafted if you were in a graduate program so after the scholarship was up I faced a
not too difficult choice between Vietnam or Harvard Med. So I chose Harvard Med and I
always wanted to be a writer and I decided, okay, medicine will be my meal ticket. And
then I finally decided to become a psychiatrist, partly because I would have my mornings free
to write and that worked out well for a number of years and now Iím just a writer so Iím
finally being a little more productive. So I call this ëstaying human in medicineí;
itís a topic Iíve been talking about for a long time and Iíll tell the story through
my journey as a writer, basically, and Iíll use some of my works as examples, of course,
especially, the House of God. And the theme of this to keep in mind is a very simple one
that Iíve come to embrace in various different ways and that is the danger of isolation and
the healing power of good connections. The danger of isolation and the healing power
of good connections. As you heard, when the House of God came out in 1978, I wasnít the
most favorite person at places like the Harvard Medical School and the Beth Israel Hospital.
In fact, I was roundly condemned as you heard. And over the years, as youíve heard, itís
kind of gotten kosher, however, I found outóI recently found out I have to be on my guard
about the book. This was a potluck supper for our daughter, Katieís class one time,
a few years ago, and I didnít know what to do. Iím sort of wandering around looking
for someone to talk to, and I hear these two women talking and I get closer, and theyíre
both doctors. Great. So I get closer, doctors at the Beth Israel Hospital, my Alma Mater,
something in common. I go over, sit down, wait for an opportunity; I said, you know,
I may not be the most favorite doctor at the Beth Israel Hospital, and one of them looked
at me with venom and said, well, you canít be as bad as that guy that wrote that book.
And there was this delicious pause, right, and I said, well I am the guy that wrote that
book, and she blushed beet red and that was the last play date our daughter had with her
daughter. The House of God had a terrible start. I never had written a novel before;
I had written other things, plays and poems and stuff. But when we entered our internship
we were idealists when we went to medical school and we entered the internship it was
such a bad experience in some ways. And I figured somebody had to write it. itís what
I callówhat drives me as a writer is something I call, hey, wait a second moments, and these
are moments--you probably already had some todayówhere you find yourself thinking something
or doing something or not doing something you think you should have done, you saidólater
you say, hey wait a second, why did I just do that? Why did I think that? Why didnít
I help that person or why did I do this? And in the internship there are nothing but these
hey wait a second moments that I figured somebody had to tell about them, and that somebody
was me. So I started writing the House of God as a catharsis, really, after what was
and probably still is the worst year of my life. The story of how it got published is
kind of interesting and ridiculous. I was looking for a play agent; I was in my psychiatry
residency and someone said there was this agent in New York who was a play agent. So
I wrote her, I said Iím looking for a play agent; p.s., I have a little bit of a doctor
novel Iíve kind of been working on. And she wrote back and she said well Iím not a play
agent but why donít you send me what youíve got. Well what I hadóI didnít even know
you were supposed to double space things, you know, and this was in the days of a typewriter.
Remember, a typewriter is kind of a box, big box like thing with keys like a piano, you
know. So I sent it off. It had coffee rings on it, it was single spaced, scrawls in the
margin, you know, cigar ash, pipe ash, God knows what else on it. You know, I sent it
off; forgot about it, went on with my first year of psych training. So there I am one
day, several weeks later, Iím standing in the secretaryís office of McLean hospital
where I was doing my trainingóthatís a Harvard Hospitalóand the phone rings and the secretary
says itís so and so for you. I didnít even recognize her name. she said, oh, she says
sheís an agent, you sent her something. So I get on the phone and this is my first feedback,
right, of this mess. And her first words to me were, well I donít know if youíre a mad
man or a genius but I really love what you sent me. And I had the presence of mind, actually,
to say well I canít help you there but you should know Iím speaking to you from within
a mental institution, at this time. So, you know, gradually, you know, nobody wanted to
publish it. Eventually, I double spaced and got a contract, you know, and I remember it
was rewritten seven times. I seem to have to rewrite my novels seven times for some
reason. And it was just about to be published and I met with the publisher and he said,
well, you know, weíve got to look at this legally. Are there any people in this novel
that are identifiable? I said, oh God, you know, who isnít, you know. so I thought Iíd
kind of fudge it and I said, well, yeah, actually thereís one whoís really identifiable; heís
the chief of medicine. So he asked me, yeah, he looks like him, he acts like him, he talks
like him, you know, all of his mannerisms are like him. And, meanwhile, the guy says,
oh, oh, thatís bad. And Iím thinking this book isnít going to get published, you know.
And so he looks at me and he says, well does he have a big red birthmark on his cheek?
And I said, no, he doesnít. he said, well now he has. And if you open your copy the
first, and I think only time itís mentioned is that the chief of medicine has a birthmark
on hisóitís called the libel prevention birthmark. The small miracle department about
the House of God, all these years later, the places that hated me the most were the Harvard
Medical School and the Beth Israel Hospital. And, low and behold, a couple of years ago
guess who was the commencement speaker at Harvard Medical School? And even more amazing,
guess who was invited to speak at the Beth Israel Hospital about a month ago? So the
message there for you young people is if you live long enough the people who hate you are
either dead or retired. When I told my buddies at Harvard Medical School that I had been
invited to give the commencement speech, my House of God buddies, I immediately got three
emails. One of them said they must really be hard-up, we must really be in a depression,
right. The second one said there must be some mistake. Are you sure itís not the commencement
address at the Harvard Liquor Store on Mass Ave. And the third said this is the end of
civilization as we know it. Okay, what about the House of God? This is all in retrospect,
you know, I was just trying to, as I said, it was a cathartic effort and I was meeting
with my friends who had been interns and weíd talk, etc. but years later what I realized
is we, often at times, think weíre making a decision based on some rational data or
practical advice or whatever and it turns out, looking back later, you find out you
hadnít the slightest idea of what historical and cultural forces that were driving you
along, carrying you along, at the time that you made that decision. And that became true
years later as I look back on the House of God because our generation was the ones who
at collegeóweíre in the brief, wonderful period of American History. We had this bizarre
notion if you saw an injustice or an inequality like the 1 percent and the 99 percent now,
if you got together and took action you could change things. What a bizarre idea, right.
Well, we helped to put the civil rights laws on the books and we ended the Vietnam War,
okay. So when we went into our internships, when I went into my internship at the Beth
Israel we just naturally were of aówe just naturally thought that if we saw things we
didnít think were right in medicine we could resist them. And, in fact, you can read the
House of God as a kind of a novel of non-violent resistance; the different ways the different
interns resisted what they saw was an unjust system. And that was what happened. We walked
into the system as idealists and we immediately felt ourselves in a conflict between the received
wisdom of this big medical system and the call of the human heart. Simply put, we were,
as in the book, we felt we were not being understood and we were being forced to treat
patients in ways that we didnít think were humane. And so naturally we kind of took action.
Let me read you a short, true piece. This actually happened in the House of God early
in the year. Itís about an intern called the runt. The runt was having a hard time;
he sat down to lunch, he took out a pill box, put a pill on his hamburger and munched it
down. When I asked what it was he said Valium, Vitamin V. Iíve never been so nervous in
my life. Does the Valium help? It makes me feel sleepy but I feel pretty unflappable.
Iím writing orders for it for all my patients. What? Youíre putting all of them on Valium,
too? Why not, he said, theyíre all very nervous having me as their doctor. After the others
had left the runt said he had a confession to make. Itís about my third admission last
night; in the middle of all this trouble with the yellow man this guy comes into emergency
and I couldnít handle it. I offered him $5 if heíd go home; he took it and left. True
story. Try it next year for those of you who are graduating. This other short piece Iím
going to read from the book is one of the joys of writing actually. One of the things
you can do as a fiction writer is if youíve been in a situation and youíre writing about
it and you realize you didnít do the right thing and you wanted to kind of correct it
you can kind of do it in writing and youíll see what I mean in this. The true part of
this story is there was a woman who was a patient of mine, middle aged woman, with metastatic
breast cancer who had gone down to surgery that morning. The surgeons had opened her
up, it was too widespread. They did nothing, and they just sent her back up to the ward.
And she was there on the ward, conscious again, and nobody had come up and told what they
had found. And so the nurse came up to me and said, you know, youíre an intern, youíve
got to tell her. And I said, look, Iím notóI was scared stiff and we hadnít had any instruction
on how you give a patient bad news. I mean, we wereóthis was the dark ages you know.
And I said itís her private doctorís responsibility or maybe a nurses or something. And thatís
as far as it went in reality and I just walked away. I donít know who told her. But in the
House of God youíll see this passage if youíre interested. This is what I wrote when I came
to write this. I said, well letísóthis is whatóI donít know it wasnít conscious,
this is what I wrote. The fat man comes upóover here itís the fat man who is the hero in
the House of God laws such as in cardiac arrest the first procedure is to take your own pulse,
right. And the fat man says heíll do it, right. And then this is the way it goes on.
Roy describes a scene. I watched him enter her room and sit on the bed. The woman was
40, thin and pale, she blended with the sheets. I pictured her spine x-rays riddled with cancer,
a honeycomb of bone. If she moved too suddenly sheíd crack a vertebrae, sever her spinal
cord, paralyze herself. Her neck brace made her look more stoic than she was. In the midst
of her waxy face her eyes seemed immense. From the corridor I watched her ask fats her
questions and then search him for his answer. When he spoke his eyes pooled with tears.
I saw the fat manís hand reach out and, motherly, envelop hers. I couldnít watch. Despairing,
I went to bed, and then later that night, after seeing a patient he returns. Roy glances
into the room again; fats was still there playing cards, chatting. As I passed something
surprising happened in the game, a shout bubbled up and both the players burst out laughing.
So you see what I mean about being able to re-do reality and fiction and actually Iíve
been told if you think about it that is really a good lesson for, you know, you who are about
to go on to wards about how you deliver bad news to patients, right. He comes in, sits
at eye level, letís her ask her question, answers it truthfully and he doesnít run
out the door. He sits there and he doesnít say anything, and then we donít exactly know
what happens but he stays, you know, he stays for awhile and, you know, there is some healing
that takes place as I described, hopefully. It doesnít always happen like that. So, in
looking back, what are the lessons Iíve learned that I usually tell to medical students especially
about staying human in medicine. Well itís very simple and, you know, there are essays
on the website that go into it in more detail. Itís SamuelShem.com, the website. The first
and most important is, as Iíve already mentioned, is connection, connection comes first. Once
again, isolation is deadly and connection heals. And itís interesting as we get more
and more savvy about the difference between a patient, say whoís isolated in the hospital
and one who has a whole family involved or friends, those people tend to do better in
all kinds of things, things you might think of like, you know, infections or recovery
from surgery but even in much more what we think permeable or drastic things like really
serious illnesses, cancer, and stuff. So I think thereísówithout going into it too
muchóthereís a lot of hints now after all these years that whatever the qualities are
of a good connection with someone they can affect the body, probably, through the immune
system, right. There are some studies that show immune response goes up and immune response
can go downóI remember one studyóif a doctor delivers bad news in not a very empathic way
versus really delivering it in a good way. So I think weíre sort of getting a hint that
connection in the physical world is as important as in the emotional and psychological world.
Part of that is saying, you know, connection not just in medicine. Medicine is part of
life, not vice versa. You know, one of the things thatís really hard when you become
a doctor is to keep your family going, your family connections going, your relationships
going. The one thing that a teacher of mine once said is that happiness is not an individual
matter. That is, you know, in America weíre taught that, you know, itís a self actualizing,
one might say self centered culture compared to some others. And thereís a lot about how
to make yourself happy but the fact is, is that happiness is not an individual matter;
itís a matter of your connections with other people, your good connections with other people,
which Iíll get to later. People, over the years have kind of called the House of God
a cynical book but in response to that I went through it and I didnít see it as that so
much when I wrote it and it turns out there is one consistent ëmessageí in the House
of God that is pointed toward doing good in terms of connection and that is the phrase,
being with the patient. Now Iíll read you a couple of passages from the bookóa couple
of sentences. This is the fat man. I make my patients feel like theyíre part of life,
part of some grand, nutty scheme instead of alone with their disease. With me they still
feel part of the human race. Letís see, yeah. And this is a patient of Roy, the narrator,
Dr. Sanders. What sustains us is when we find a way to be compassionate, to love, and what
mostóand the most loving thing we do is be with a patient, like youíre being with me.
And then Roy, at the end of the book, says, what these patients wanted was what anyone
wanted, the hand in their hand, the sense that their doctor could care. So even then
when I wasnít very wise about these things I made a kind of aówhat do they call it on
the screen where you put a marker on the screen or something of your computer, you know, you
mark it as, being with, was important. The other three things I mention when I talk about
how to stay human, staying human in medicine, are speaking up is the second one, speaking
up or speaking out. Itís important when you see something thatís not right in the medical
system, thatís unjust or unethical that you speak out not only to call attention to it
but because speaking out is essential for your survival as a human being. If you witness
some of these things and you keep it to yourself, you donít say anything, guaranteed youíre
going to suffer and youíre going to spread more suffering around. The third thing is
empathy; learn empathy, and thatís obvious. I said this to a second year Harvard class
I was teaching, seminar group, and a guys hand shot up, oh, we already learned empathy.
Wow, you know, pretty impressive. Harvard, you know. So I said, well, you know, what
did you learn? And he said, oh, it was easy. It was last year in patient interviewing.
I said, yeah. He said all you do is you repeat the three last words the patient said and
you nod your head. Our daughter picked this up, I think, from Janet and me at one point,
and she hadówhen she started doing emails she had a tag on her emails and sheóit was
about empathyóand she saidóyou know, because empathy is basically putting yourself in another
personís shoes and feeling likeóso the tag she had was, itís important to walk a mile
in another personís shoes. That way youíre a mile away and you have their shoes. How
do you learn empathy? In another personís shoes, obviously, but for doctors itís really
interesting. I mean, I heard it again today, you know, we doctors learn empathy often if
weíre treated very well by a doctor when we were young or we have a family member who
is in trouble in a hospital and we see that person being treated badly. You know, Iíve
had the experience sitting in the corner of a room and I think my mother was sick in a
bed, and the hospital team came in not knowing I was a doctor, and howís our gal today,
you know, and treating her like we sometimes treat people, and I was kind of appalled.
So in medicine you canít really powerpoint empathy; the way you learn empathy in medicine
is you watch people who are good at it and when you find people who are good at it, and
I guarantee there are some in the room, you sort of follow them around. You do rotations
with them, you know, you try to get them as a mentor, things like that. And then the final
thing about staying human is learn your trade in the world. And what that means is the patient
is never only the patient. The patient is the family, the friends, the where the water
comes from, where the garbage goes, the toxins, the climate, the whole thing. Now when I went
to medical school out of 100 people in my class I donít think more than 10 had ever
been out of the country, you know, the good news is that this class, your generation of
doctors, young doctors, medical students have been everywhere. Theyíve done everything,
you know, youíve been all over the world by now and you really donít feel that strangers
are strange or foreigners are foreign, you know. itís a remarkable thing and the diversity
in medical school now is absolutely astonishing so thatís the good news. The bad news is
that youíre about to enter a healthcare system, those of you who are just going into it, thatís
a total disaster. Itís a disaster. Itís worse for the patients, itís worse for the
doctors, itís only better for the insurance company, insurance industry. And I have a
lot to say about that. Maybe Iíll hold that for questions at the end or I can talk a little
bit more at the end about it. Simply, you know, simply put, myóI mean, Iím for a national
healthcare system like every other industrialized company. The question really is why should
a healthcare system be for profit? Why should a healthcare system be for profit? And under
the SHEM plan, of course, weíd have a national healthcare system, we would have tort reform
because so much of the cost is in cover your ass medicine, right. No question. And this
is for the medical students and those still struggling with their $200,000 debts in medical
school. Medical school will be free, loans will be cancelled retroactively from today
in returnóyou see why Iím not in politicsóin return for two years of service after you
graduate somewhere in America. How many medical students would take that deal? Yeah, everybody
would. Itíd be exciting; itíd be fun, youíd learn medicine, you know. the hint about how
this should happen, this could happen because weíre not going to get it from Obama care
or the otheróany other politicians is, you know, somebody said to me once, when youíre
in a theater and somebody falls down in trouble, you know, does the cry ever go out, is there
an insurance executive in the house. I meanóthis is the last thing Iíll say and then Iím
going to move onówe are doctors. We and other healthcare workers do the work. Without us
thereís no healthcare so we can get back to that. But youíre the ones, your generation
is the one thatís going to have to deal with this. I wanted to say one more thing I learned
about the House of God before leaving it, and that is the House of God was one of these
big hierarchal systems. Itís called power over systems where somebody has power over
you and you have power over somebody else. And in these big systems what happens is the
pressure comes down on the lowest down people and in the medical system, the interns, we
the interns were the lowest down, right. And what happens in the book and what happens
in real life, too, is when the pressure comes down the interns got isolated. Not only did
they get isolated from each otheróitís in the book, one goes crazy, one commits suicideóeach
of us got isolated from our authentic experience of the system itself, right. Each of us got
isolated from our authentic experience of the system itself. You start to think Iím
crazy for thinking this is crazy and thatís, you know, that immobilizes us. Itís like
what Chuck, the African American intern, said, how can we care for patients if nobody cares
for us? Now given these power over systems, thereís only oneóthese power over systems
are based on a hierarchy that can be of race, gender, sexual preference, ethnicity, etc.
And the only threat to a dominant group is the quality of connections among the subordinate
group. The only threat to the dominant group is the quality of connections among the subordinate
group. Thatís why the first thing I say stick together, connection comes first. And connection
in your internship; donít get isolated in your internship, thatís really death. So,
once again, the issue is connection versus isolation and somehow sticking together. Okay,
Iím going to move on toóI wrote a sequel to the House of God. The publisher has tried
to hide it for all these years. Itís called Mount Misery; itís about the same main character
going into his psychiatry residency in a big mental hospital called Mount Misery. I went
into psychiatry from the Beth Israel and McLean Hospital thinking that psychiatrists were
really the ones who knew how to be most human to patients and with patients. And guess what,
maybe it was just my experience again but they were worse. It was really very, you know,
people during my residency were brought up for child molestation, for drinking with patients
in the office, sexual abuse of many patients, all this stuff. You can read about it in Mount
Misery. Also there were some funny things that happened. My work rides on two things,
humor and love or sex, love and sex, at best. This is a true story, a little true story
from Mount Misery where Roy is admitting a psychiatric patient, a middle-aged Italian
brick-layer who thinks heís God. How do you know your God, I asked? Because I was in hell;
you want proof. He unbuttoned his shirt, on his belly was a magnificent tattoo of the
last supper. Clearly it had been done many years before, when what was now his belly
had been his chest and when he had been thinner. For now it had expanded so that Christ and
all the Apostles were all wearing broad grins. What did you think, doc, asked the security
guard after weíd locked him up. 298.80, brief reactive psychosis. You donít think heís
God? He may be but itís not reimbursable. And then, as I did before, this is a one of
these things I wish had happened that I wrote in a way that I wanted to make it better.
I had a patient that year that was really a lot of trouble. She was alwaysóa young
woman who was always challenging me thinking I didnít know anything, which was sort of
right at that time. So this is the last session that I imagined with her. Terrific, she said
to me sarcastically, putting me down. She looked sullenly into her lap. In the past
I might have gotten angry at her but suddenly I understood. The issue wasnít me or her
but us. The we in the room which seemed so solid right then that you could shape it,
yet so femoral that it was the unseen historical forces shaping you. My job right then was
to hold this we, this connection with her, hold it for both of us; that was my job as
a doctor. To use my experience with others who had suffered and my vision born of that
experience to bring someone who is out on the edge, the so-called sick, to current the
human, to take what seems foreign in a person and see it as native. This is healing; this
process is what the healing process is. This is what I signed up for years ago. This is
what good doctors do. Weíre with people, at crucial moments in their lives, healing.
That was a little bit of an advance for me and it leads me to the next thing Iíll mention.
My wife and I then started working with men and women trying to bring them together across
differences at Wellesley College, the womenís center. And to be very brief, what we developed
and worked on was kind of a new way of looking at psychological development and at psychological
health. And to be very simple, the notion of psychological health in western civilization
has been that based on the house of this thing, this person, a person is healthy, right, and
the development of a healthy self is the goal of normal development. Well thatís a male
model. If you talk to women itís a little different. And what Janet basically came up
with was that a measure of psychological health of a person, any one of you, can be looked
at as the quality of the connections with other people. Now that doesnít take away
from being a strong self, right. In fact, think about it, a good relationship makes
you feel better about yourself, right. And so thatísóyou can read about that. We wrote
a book called, We Have to Talk, Healing Dialogs Between Women and Men, which if any of you
are in relationships, which I hope you are, you might, you know, this may be of use to
you. Itís on the website. But the application to medicine is pretty simple in a way. Iíll
give youófor instance, in psychiatry, rather than asking a patient, tell me about your
mother or tell me about your father, I started asking tell me about the connection with your
mother or the connection with your father, the relationship with your mother, and all
of a sudden youíre talking about the relationship. As a doctor using the we rather than the I
is very helpful. For instance, the old surgeons, the patriarchal surgeons, you know, the good
ole surgeons, used to say, well Iíve done all the tests and we have the results and
Iím going to operate on you. All right, thatís an I, you, and itísóthe patient would often
say, okay. The newer iteration is the surgeon will say, well Iíve done all the tests and
I think I should operate on you but youíre welcome to get a second opinion. Not bad.
But what if the surgeon said, you know, weíve done all the tests and now letís talk about
what weíre going to do. Now that seems like a little thing. But what you find out is if
you, as the doctor, use the we, what does the patient say? She says, yeah, okay, letís
talk about what weíre going to do. So the use of the word concretizes the fact thereís
a relationship here and comes back to the person whoís using the word we. So try it
with your patients, try using the we. And, certainly, in surgery, studies have shown
whatís the main factor in whether surgeons get sued or not? The quality of the relationship.
If people have a good relationship with a surgeon theyíre much less likely to sue.
So try using the we; itís a shift to the we. It seems like a little thing but you willóit
defines that there is a relationship here. It strengthens the relationship. The next
step for me, aside from the we and the idea of the relationship came from what you heard
about before. Itís a play we wrote, my wife and I, called Bill W. and Dr. Bob about the
relationship between the two men that lead to the founding of Alcoholics Anonymous, 1935,
in Akron, Ohio. Has anybody hear heard of Alcoholics Anonymous, yeah, okay. Do students
have to go to meetings and stuff now? Great, excellent. Thereís a current epidemic in
colleges now; 2000 college students per year die just of alcohol poisoning, not getting
into cars and stuff. Five a day die, and weíre trying to use the play to do that. Okay, whatís
so interesting about Bill W. and Dr. Bob? Bill was a stockbroker from New York, some
kind of genius. The only flaw he had was he was a drunk; couldnít get over it. Dr. Bob
was a surgeon in Akron, Ohio, wonderful man except for one thing, he tooótheyíre both
dying of alcoholism. They happen to meet by a series of really karmic or fate events in
Akron. And Bill had the realizationóhe was alone in Akronóhe had the realization he
wanted to take a drink. The only thing that could keep him sober was telling his story
to another drunk, which is kind of bizarre, right. Telling his story to another drunk
would keep him sober; he didnít know if it would help the other guy. And they met, and
when Bill told this to Dr. Bob, Bob wanted nothing to do with this, but when he told
him in that meeting that he realized this was the only thing that could keep him sober
and that his doctor in New York, Billís doctor, had said, you know, he believed alcoholism
was an allergic disease of some kind. And Bob stopped him and he said, a disease with
signs and symptoms, a course, a progression, implying what, a treatment? And so from that
moment Bob the doctor put it in medical terms and he said, weíve got to see if this treatment
works, this treatment of yours works. Weíve come to think that it had to be a doctor Bill
met because that was the crucial step. Thereís one point in the playóthey do stupid things
trying to get other drunks. They chase them down in bars, they go to their houses, itís
ridiculous. And finally Bob says, you know, Bill, I figured out where weíre going wrong.
We need to find ourselves a steady supply of more reliable alcoholics, and then he says,
those already in the hospital. And so he takes it into the hospital, takes it into the hospital
and that was the major step. Now why am I telling you about AA today aside from the
fact that youíre all going to see alcoholics and drug addicts. Theyíre all going to fool
you; youíre not going to recognize them, youíre not going to treat them right. I hope
youíll send them to 12-step programs as part of the treatment. Well because these guys
discovered two things that were new in the world. One, they started this whole thing
we take for granted of same disease support groups, right. You have a patient with abuse,
you send him or her to abuse group, etc. The other thing they discovered, they said alcoholism
is a disease that has physical, psychological and spiritual elements and has to be treated
in all three ways. The start of the holistic movement, right, in medicine, 1935. So what
did I learn? Whatís the point of AA? How does AA work? AA works because it shows the
healing power of mutual connection, right. Itís not an I program, itís a we program.
The healing power of mutual connection. Thatís been a big step in my understanding. Okay,
thatís as far as Iíd gotten, and the next step, the final step so far, is this new novel.
Itís called the Spirit of the Place; it came out a couple of years ago. In the back, you
canít see, but thisóthe cover is an original Shegal painting. So if you buy the book you
can cut it out and put it on your refrigerator, frame it, whatever. this book isóonce again,
one of the joys of being a fiction writer, a novelist, I always had theówhen I grew
up I had this wonderful old doctor, general, you know, one of these old time general practitionersóIíll
read you a little about himówho was very important to me in my growing up years. He
was like a counselor, I went to him for advice, which he never gave. But he started to take
me around with him, you know, and thatís what got me into medicine. And I always dreamed
of going back to that little town, Hudson, New York, up on the Hudson River, to join
him in practice, you know. But it didnít work out so I did the next best thing, I did
it in fiction. Itís about this 40-year old guy, divorced, running around with Doctors
Without Borders, and heís finally fallen in love with a dynamite, wonderful, Italian,
beautiful, sexy, yoga teacher. So I get to write about that; itís another joy. And heís
finally kind of happy after this miserable divorce and all, but his mother back home
has died. Heís missed the funeral because they didnít know where he was and he goes
back and heís broke, he needs money. It turns out the terms of her will are such that he
doesnít get anything unless he lives in her house in the middle of this town for a year
and thirteen days. He hates this town; itís been anti-semantic, heís Jewish, itís this
broken down, horrible wreck of a town. And he thinks well heíll just go home and the
hell with it, heíll go back to his Italian lover, but, of course, he stays, otherwise
there would be no book. I want to read a couple passages once again. So this is really a more
general story about a doctor. Let me just see, what am I lookingóokay, here we go.
It has humor in it, as usual. This is in the winter, the town is called Columbia. Two Columbian
ice fishers and their dog had a bright idea. It was the end of January, the Hudson River
was ice blocked. Even though they never caught anything much in the polluted river when it
was free of ice, many Columbians imagined that when ice, a foot thick, covered it the
fish would reappear. Their greatest difficulty in ice fishing was not keeping warm; after
all they would drink enough beer so it would act like anti-freeze and they would drag portable
gas stoves out to their huts on the river. The difficulty was cutting through the ice.
Many Columbian males had a love affair with internal combustion, and their favorite was
when their manly hands were caressing a chainsaw. Yet in the dead heart of winter a chainsaw
required just that little bit extra presence of mind from inebriated Columbians to cut
through the ice without shearing off a toe or a foot or a leg. At dawn on this viciously
cold day, the two Columbian ice fishermen and their dog had the bright idea of using
dynamite to blast their hole in the frozen river. True story now. They drove their pickup
out on the ice toward the neglected old lighthouse. They got out, all three. They managed to identify
the fuse end of a stick of dynamite, congratulating themselves on their creative intelligence
and hardly able to contain their excitement. One held the stick of dynamite, from his cigar
the other lit it. It sizzled a fuzzy phosphorescence. The Columbian threw the lit stick a long way
away, it sailed in a high sputtering ark out toward the decaying lighthouse. They watched,
first in drunken puzzlement mixed with a hint of satisfaction at the order of the world,
then in drunken horror as their dogódog ownersóran after the stick of dynamite, fetched it and
started barreling back toward them. See the dog run, see the Columbians run, see how fast
the dog runs, see how slow the men run. So our hero is called to patch that up. Now this
is a little love portrait of this old doc that had such an important effect on me. His
name is Bill Starbuck, and Orville goes to see him the first time heís back in his office.
Ushering Orville in, Billís hand was on his shoulder. As always, Bill was a toucher, a
great toucher. You might forget what he told you was wrong with you or what he was going
to do about it but you remembered that touch. Hours later the place he touched still felt
special, warm in winter, cool in summer. Good to see you, son, Bill said, settling in behind
the big cluttered desk and another, yes, smoking sign. His words came out in a calm, deliberate
way with significant torsion of his lips as if each word was being molded as delicately
as an egg and required care to survive. His greeting blew the scent of fresh scallions
of Orville. Billís other addiction besides nicotine was fresh scallions. When in season
his real patients kept him supplied. Bill, the scallion, Starbuck. Bill shook a Camel
free and lit up blowing out two dragons of smoke. As a teenager embarked on a course
of rank failure, when he refused to talk with his parents or sister about anything close
to his heart he was sent to Bill for advice. Bill never gave any advice; he sat and smoked
and told stories of the 14 point buck and the gun slinging doctor and what was in the
office safe. The summer after a desolate sophomore year when Orville was bored half out of his
mind and depressed out of the other half, Bill began to take him around with him, let
him help out in the office, go on house calls out in the county, learn about medicine. What
a time that had been, deliveries, deaths, and everything in between. The shy boy opened
up to the kindly man. Orville had been enthralled by the realness of doctoring. The intense
contact with people at the crucial times of their lives had often helped them heal. It
was incredible for the boy to see that things actually happened in life, actually got done.
And thatís one of the great things about medicine. Now starting across the desk at
the old doctor, Orville realized that for Bill to, given his suffering with his handicapped
only child who had died young, their friendship had not only been an opening but a rejuvenation.
Bill got in the habit of calling Orville when there was a particularly interesting house
call or emergency. Have I ever felt more at peace Orville wondered, then in the dawn light,
alongside Bill in his black caddy on the drive home from delivering a baby somewhere out
in a godforsaken shack in the middle of nowhere. This man had grown him up. And then Bill says
at the end of their meeting, yeah, there are a lot of rumors in this town. The only person
who really knows whatís going on around here is me. People tell the truth in here. A fellow
like me gets to lift up the lid, peak in under the edge and see past the bullshit. And thatís
another reason I wanted to write this book is because I realized that if youíre any
good as a doctor, if you listen, if you really listen, empathically, you will hear the truth.
Youíll hear the truth from your patients. It may take awhile, a couple of visits, but
youíll hear the truth and the truth is usually the best clue to diagnosis, even now. And
also in our societyóoh, the other thing about being a doctor in a small town is you hear
the truth in your office and then you hear the lies, socially, when youíre mixing with
people, you know, which is kind of interesting. And in the era when truth is less and less
a cherished commodity in our society, you know, given all the advertising and political
stuff. As a doctor itís very rewarding to be in that reality, right. The last thingóas
I said every book I write is a love story, and this has oneóis one. Heís finally stayed
in the town for awhile, part of that year. Itís still the winter and heís fallen in
love with a historian named Miranda, and this is after theyíve had their first intimate
contact. But heís on call. His beeper roused him at 2:00 in the morning, the delivery ward,
something urgent. The nurse had paged him for a delivery of twins. Heíd been tending
the couple through pregnancy, her first. They were poor and black, a man and woman heíd
known vaguely as a girl and boy. Thereís something wrong, the night nurse was saying,
come quick. Wrong, big time, he realized. The tap of death on a babyís shoulder. He
explained heíd have to do an emergency c-section; the couple agreed. He scrubbed in fast and
did the section. Twin boys, one was well formed, robust, squalling. The other microcephalic,
his head the size of a dolls but with lips and nose and eyes crammed together with no
forehead giving it a frog like look. Trunken legs normal but for a remnant of tail; it
was horrible to see yet transfixing like something you see in a bottle of formaldehyde in a medical
museum. The nurse took the healthy baby to the father, leaving Orville to wait for the
other to die. Luckily, and quietly by the time he had gotten done with closing the groggy
new motherís abdomen it did. Orville went out to the father; he was still holding the
healthy baby in that awkward way that new fathers do. The nurse had told him the other
had died. What happened, the man asked, in shock? The other baby lived only a few minutes,
it was deformed. Can I see him, doc? Orville hesitated. The older doctor in him, the good
ole Doc Starbuck would have patted him on the shoulder, no son, better you donít. The
younger doctor applauded his wish, though knowing that once seen, it would be indelible.
Orville said, you can, sure. I just want you to know youíll never forget it. Him, the
man said, I want to see him. The nurse took the healthy baby; Orville and the father went
into see the other son. Heíd been cleaned up so he looked better, less frightening.
The father reached out a hand and touched a perfect shoulder and then the squashed head.
He bowed his own head and then crossed himself, in the name of the Father, the Son and the
Holy Ghost, Amen. He looked up at Orville, his eyes were wet, sorrowful. He said, thank
you. And you, Orville said, feeling in this man the power of facing into in a world that
as a rule turns away. I think sheíll want to see him, too. Fine. The father picked up
the dead baby to take him to his mother. Orville got beeped away to tend to a drug overdose
from the Bliss Towers Housing Project and a stabbing victim from a happy household,
and a car crash and several Christmas specials, including a Sheppard from Austria that was
sure he was picking up radio free Europe through a metal plate recently placed in his skull.
A normal night. Later during a break in the action he walked out into the parking lot
and searched in his pockets for the half smoked Progie cigar and matches. The night was crisp,
the little town was iced up and the air tasted like cold quarters and seemed stretched tight
as an eardrum so it was like you could hear everything. He thought of the dead twin who
would always be almost there floating there like all the dead, and the live twin. He thought
of Miranda, of their histories, of their love making and he whispered out loud, this is
the one that will survive. So when you write a novel you really donít know what itís about, you know. Youíre not interested
in what itís about because youíre so involved in the characters, in the story and itís
kind of writing itself, etc., and youíre using all of my 40 years of skill at this,
until somebody tells you what itís about. So a friend of ours, a woman, said, hey, you
know what this is about? And I said, what? She said, well, itís like itís about this
youngish doctor who comes back to heal the town and the town heals him. Heal is an interesting
word; heal goes both ways, you know, to heal, right. And thatís right. One of their viewers
said about this book that itís a perfect bookend to the House of God because the House
of God is on the wards and it shows you how to kind of get through that experience. This
is about how you be a doctor in a town, in your life. This is how to be a doctor in your
life, kind of, right. What happens is this guy comes back to this broken down, horrible
town and heís forced to be in relationship, be in connection with a whole slew of these
towns people and he canít leave. And through that process something else happens. So this
book is really about something more basic than the others. Itís a story not just for
doctors but for everybody. And itís about suffering; we all suffer, everybody is going
to suffer. You canít get around that; thatís the first noble truth of the Buddha, right,
there is suffering. The issue is not the suffering; the issue is how you walk through it. If,
as, you know, one model of this is if you decideóand this is more of the male modelóIím
going to gut it out, Iím going to stick it out, Iím going to, you know, get through
this no matter what, myself, youíre going to suffer more and youíre going to spread
more suffering around. And one of the things this hero here is at a crucial point in this
book, itís like he hears a voice in his head when he has to make a decision and it says,
donít spread more suffering around. Whatever you do donít spread more suffering around,
which is not a bad thing for doctors to know, too, right. Donít spread more suffering around.
If you walk through it alone youíre going to spread more suffering around. If, on the
other hand, you walk through the crucible of suffering with others, with caring others,
and thatís where we come in, rightóas I said these crucial moments where weíre thereóif
you walk through this crucible of suffering with caring others you will suffer less and
you will not spread more suffering around, and you might even come out of it with more
understanding and even redemption. Thank you. Yeah, obviously this book is written and it
sounds like youíre training in the 70s, and thereís been a lot of changes trying to make
the practice of residency and internship [inaudible] with our limitations and different bureaucratic
as well as, you know, sort of mentoring type of person. How different do you think it is
now compared to as far as formulating physicians who have been [inaudible] or better suited
to care for these things. Well, thatís a good question. Itís better and itís worse.
I mean, I know thereís a lot of controversy about limiting hours and there are good arguments
on both sides actually. Iím not exactly sure where I come down. But I do know from my experience,
and itís written in the House of God, and anybody whoís been on call every other night
for awhile know the worse thing for you and a patient is if youíre exhausted. You canít
think straight, you know, and so I applaud limiting hours. Although, as I say, I know
there are other sides to that argument especially surgeons. What do they say in the House of
God, the only problem with admitting every other patient is you only get to do half the
operations or something like that. The things that are better are, number one, women in
medicine. You know, when I wasómy class of 100 had 10 women and now itís 50 or 60 percent
in every medical school Iíve been at. And the good thing about that is that women are
valued more in the culture for the qualities of empathy, care, concern, maintaining relationships,
those kinds of things. And those things do translate into the hospital environment. I
think we have seen that in some ways. The problem in terms of really getting those kinds
of ways of being with patients, more embedded in the culture of the hospitals and the academic
institutions is that there are many, many feweróas you know, women that stay in the
system to become professors or administrators than there are men so that kind of gets lost,
and there are certain reasons for that. But women is one big thing; I think thatís helped.
Another thing is the thing that we used to call the new age movement, which is now taken
for granted. All these other ways of helping patients, you know, I mean, acupuncture, we
didnítóI didnít know what acupuncture was when I was in, you know. You name it, thereís
all theseómeditation, you know, John Cabotís work on using meditation may help reduce stress,
all that stuff. Anyway, thatís another thing thatís better now. The whole, I mean, I worked
for awhile in a biotech investment company and so we saw all of the last ten years of,
you know, the greatest inventions all over the world. The things that we can do now,
you know, Iím the proud possessor of a really good hip and, you know, both things. You know,
the things we can do now are amazing; theyíre absolutely amazing. The technology for how
we can deal withóthe other thing that I think is a great thing is the hospice movement.
That never existed back then either. We didnít know what to do with these aging people and
thereís a whole new field for ontology. So there are a lot of very good things that have
happened. There are a lot of things that are not good. One is just the direction of society
where families are fragmented, you donít have contact with patients for an extended
period of time, the patients donít usually live where their supports live, that whole
thing. You know, I already mentioned, I think, theóweíve got it backwards in terms of what
good healthcare is, really. I mean, you know, there are starting to be some movements but
preventive care is so much more important in some ways, you know. I mean, where do we
start. Talk about what people eat, you know, talk about what people eat. At the Inter Quality
meeting I heard just one statement on the radio yesterday driving in the car; in the
50s the poor segment of the population ate the best and the upper classes ate the worst,
you know, and now itís absolutely different. As you know, I mean, if there are any divertologists
[phonetic] here, there is going to be this tsunami, right, this tsunami of obesity associated
with diseases. So on a lot of different fronts I really am worried. You know, we have the
capacity to really save people and do better but in the bigger world, you know, weíre
going to have a hard time delivering that, we really are. And one other just quick thing
about healthcare, you know, we have a house in Costa Rica, my wife and I, and, you know,
we chose it partly because itís a country that in 1948, by Constitution, said they could
not have an army. Now you have to understand I was born in 1944. From the day I was born
until what looks like an extension past 2014, that Obama announced last night in Afghanistan,
right, what is that? Thatísóhow many years is from 19444 to 2014ófrom a lot of yearsómy
whole life this country has been at war, mostly declared, sometimes not. And Costa Rica uses
all the money that they would have had for the Department of Defense and maintaining
an army, they have an incredible healthcare system, free, totally free. They have a good
educational system thatís free. I mean, in this little village down in the mountains,
somebody who was with us hurt their head, brought them down there. You know, it was
a bit of a severe laceration, walked into this little tiny clinic, immaculate, just
like the best youíd see around here, fully trained doctor, fully trained nurse, fully
trained pharmacist, saw him, did everything right. Pharmacist handed him antibiotics and
boom, that was it. I mean, you canít have it both ways. I think the biggest problem
for healthcare in this country is, you know, over half of my tax money going for the Department
of Defense. And, of course, the other big tsunami thatís going to hit are the vets,
you know, the vets from these two wars now. As everybody knows, horrible, lasting intensive
care diseases. I donít know where that money is going to come from. The VA is one of the
best systems. Anyway, better and worse. The best of times and the worst of times. Yeah?
Hi, thank you for your talk. I have a two-part question. The first part is about the inner
world and the second part is about the outer world. Good. So the first part, it sounds
like most of your career youíve been juggling being a writer and being a doctor and I was
wondering if you ever experienced the tension of wanting to be a good doctor and wanting to be a good writer
and if those were competing with each other? I mean, it sounds like one informed the other
in both ways. So how did you deal with that tension if you had it because time to spend
on one thing is time away from the other? And my second partóletís do the first part.
Okay. Iíll forget it thatís why. Thatís a very good question for any of you who want
to be writers as doctors. You know, you find out what your passion is and mine wasóIím
happiest when Iím writing so that was going to survive. And I think you have to be practicalóif
you want to write things from your heart then you have to have another job, you know, I
faced that choice. If I wanted to be a writer and support myself I would go to Hollywood
or, you know, TV or movies. Thatís where the money is. But I didnít want to do that;
it was too important to me, you know. So then itís a question of, okay, what job can you
choose, and for me, as I said, it was, you know, Iíd already been accepted at Harvard
Medical and I loved medicine. I didnít like the pre-clinic years but once I got into the
clinic I loved it. My heroes were doctors as writers, you know, Chekhov, he was the
greatest doctor writer. I have a letter from him up over my desk, you know, and many others.
You have to find something that will allow youówell if you want to write what I write,
which are novels, which are long things, they take a lot of years or plays, which also if
you do it right take time. You need something that will allow you time every day. If you
notice, to my knowledge, maybe Iím wrong, there are no surgeons who have written really
good, long, I mean, quality long novels or just novels. You know, you donít see surgeons
very often writing novelsóyou know, they write thrillers and stuff, but I mean, things
that really, you know, might be around for awhile. Like my friend is a wonderful writer
[inaudible] you know, he does what most surgeons do, he writes short pieces, you know, essays,
a book of essays, non-fiction. I think also one thing you might want to learn if youíre
thinking about becoming a writer or a doctor, I thoroughly convinced that you either have
a non-fiction brain or you have a fiction brain. I do not have a non-fiction brain;
it kills me to write non-fiction. I like, you know, going places. So, you know, if you
want to write non-fiction things then it doesnít matter what you choose in medicine because
you can write essays, short stories, etc, that will work. If you want to write longer
things I think you have to choose something that will allow you time every day. And I
was delighted to find that with psychiatry I could have the mornings free. Now the problem
with thatóthat sounds easy but itís very difficult. I had to learn toóitís like when
you do physical exercise. I had to do emotional exercise to, you know, write fully in the
morning and stop around 11:00 or so and then switch to, you know, listening to people fully
in the afternoon. And it didnít work sometimes; Iíd be sitting there with a patient and Iíd
think aboutóone of the novels I had been working on, it was in China, set in China.
Iím thinking Iím still in China. So itís a skill to learn. I think you could be good
at both but itís wearing. Itís much easier now. For about five years I have just been
a writer. But Iím afraid, in this day and age especially, if you write crap you need
another job. You know, itís amazing whatís happened in publishing now. The thing that
publishers are looking for now, mostly, frankly, sounds like kind of like sophisticated blogs.
You know, theyíre lookingóthey literally are looking foróthey go and search blogs
of people to turn into, even fiction. Anyway, whatís the second question? Well you lead
into my second question, which was the practicalóhow you write dailyóthe question was, do you
wake up in the morning and what kind of practice you had in the afternoon that allowed you
to take the mornings off. Just the practical andójust likeóI appreciate the discipline
youíre saying then. Well I can tell you a little more detail. I mean, I think if youíre
planning the business for thoseóif you want to be a writeróif youíre planning to try
writing you have to find for yourself what is the best time for you to work and how many
hours and, you know, do you use your typewriteróI know you donít. Actually, you know, I have
been part of thisóIíve been part of the revolution because I certainly worked on the
typewriter and then I was one of the first to getóanybody here remember a Wang word
processor? They had this great word-processing program back in 1982 or something so I made
the shift. I said this is going to be a lot easier, you know. And actually my friend John
Updike, he was so impressed by this, you know. He thought, hey, I could be more productive,
tooóproductive, right. So he got one, and guess what? It made it harder for me to write.
It took longer. Guess why? Because in the past when you when you were on the typewriter
and you had youróif you had a bigger correction and you had to re-type the whole damn page,
you were pretty damn ready by the time you got to type you knew what you were going to
do. Not everything, but you knew pretty much your intention before you hit the screen.
You know, now as our daughter isóboom, everything is up on the screen. You think you can fix
it later and in non-fiction you canít but in fiction itís a lot more difficult. But
anyway you find the way that you write. I happenómost people do it in the morning.
And then you have to find out, you know, once you get your whatever media, whatever youíre
doing and what kind of writing, fiction, non-fiction, etc, how do you rewrite because, as I said,
I have to do these things seven times. I take comfort from the fact that Tolstoy rewrote
War and Peace seven times. Actually, thatís not quite true. His wife rewrote, he dictated
to her. It finally got to the point where his editoróhe wanted to revise it and his
editor said, will you stop your infernal scribbling. Itís a great book. So, you know, how much
you have to rewrite and, you know, the emotional how you do it, how you get that critic out
of your head, you know. Maybe one more and then weíllóyeah, sureóand then weíll stop.
Thank you; Iím a big fan of you Dr. Bergman. Thank you. I have a question, a recent survey;
it just came out this weekend, so it said that 54 percent of doctors, if they had to
do it again, wouldnít. So I guess this is a two part question for you. One, reading
the House of God made it seem likeóI was actually shocked at how low that number was.
It seemed to me that most of the characters in the House of God seemed like they would
do it again if they could. It wasnít a very difficult process to go through. Do you think
itís gotten better in that sense is the first question. The second questionóokay, repeat
theóI didnít quite get it. Whatís gotten better? Do you think medical education, in
general, or the process of becoming a doctor has gotten better? Do you see the process
getting better or worse? And the second question is if you, personally, had to do medicine
again, would you? Yeah, those are good questions. Medical education has, I think, gotten better
and worse. I think the pre-clinical years, you know, all the different ways theyíre
being taught now with more of an awareness of actual patient, I think thatís all better,
I really do. You know thereís so much that you really donít have toówell, Iíll go
back. Someone once said to me you forget information but you never forget when you understand.
And, you know, I still remember my first interview patient in medical school. You know, like
where Kennedy was shotówhere were you when Kennedy was shot or the World Trade Towers.
Youóitís an interesting thing in the brain. You never forget something thatís linked
to an emotion so I think thatís a key thing to medical education now and I think itís
a much kinder, gentler way and all the new age stuff and meditation for stress and all
comes in. I donít think that the clinical yearsóI mean, Iím not in it so much right
now but I have been up untilóI donít think the clinical years are much better, I really
donít because these systems, as I said, wellóshift that a little bit. I think the smaller medical
schools itís better because they focus more on the kinder, gentler specialties like maybe
family medicine or things like that, pediatrics. Harvard, you know with Harvard, itís probably
the mostóyou know, in a culture as [inaudible] noticed, itís very self-centered. Itís the
most self centered of the self centered so I notice in Mount Misery these people are
sitting there interviewing their patients with an eye on what paper they can publish,
you know, theyíre half with the patient and thatísóthat wonít work. So in the big medical
academic centers, I think itís worse because thereís this tremendous competition for grants,
promotions, etc., and the other factors I said. But I have come across really wonderful
training programs that go right through residency and theyíre usuallyówell, Iíll just think
of one. Like in North Dakota, you know, I spoke there and the wholeóthere are several
states, actually, where they really put an emphasis on if you go to this school we expect
you to go back and practice in this state, Southern Illinois and North Dakota Medical
School. In the last year, both of those things, I think they absolutely find a doctor to work
with them for a year, you know, and thatís a wonderful experience. Theyíre ready to
go. I mean, one of the real good changes, I think, in my lifetime, in medicine is that
it used to be that doctors would make the most money and have the most prestige in their
communities, right. Every survey, I mean, rich people in my town were doctors and they
had the most prestige. That ainít so anymore, and thatís kind of good because people are
coming into, you know, 60 percent from Harvard go into finance every year. But the people
who go into medicine now theyíre doing it because they want to be doctors, you know,
most of them, and they bring those skills there. Would I do it again? Well thatís aóas
I said, Iím not sure that my choice was very relevant here. You know, Iíll tell you one
last piece of that. When I graduated from medical school and was thinking of doing an
internship I knew I wanted to be a psychiatrist at that time. And I could have gone directly
into my psychiatric training without ever having done any medicine in a hospital, right.
I could have skipped a whole year. But I said, lookófor some reason I said, look, I want
to know how to do this. Iíve spent all my lifeóI was still afraid of writing an order
to give aspirins to a patient, you know, they werenít trained in some internships in those
days, you know, we knew nothing. At Harvard, we knew so little at Harvard Medical from
our clinical rotations that the most attended course was just before we graduated somebody,
I forget his name, ran a two day course of all the things you really had to know to go
into your internship. Everybody is writing, you know. But I didnít have to do an internship
atóa medical internship. But I wanted to complete, I wanted to be able to say Iím
a doctor, I know how to treat patients. And actually I moonlit that after the internship.
Well guess what, if I hadnít made that choice there would be no novel. I probably would
never be hereóI know I would never be here; I would have been writing plays, you know,
and not doing very well. So itís hard to say; Iím thrilled at the way itís worked
out. Those are good questions; thank you. Thank you. Now everybody can go and buy a
book. [Applause].