How the Book Began

Richard C. Reynolds

Being a doctor has always been a romance for me. It was a must for me to spend some years in the private practice of medicine, so after completing my training, I opened an office in a town of 20,000 in western Maryland. Here my education truly began. Patients came with their illnesses and in doing so told me the stories of their lives. After nine years in that practice, I spent the next two decades in academic medicine, the second as dean of the Robert Wood Johnson Medical School, a unit of the University of Medicine and Dentistry of New Jersey. In 1987, I joined The Robert Wood Johnson Foundation as executive vice-president, and remained there until 1997. Since that time I have been courtesy professor at the University of Florida. It was while I was at the Foundation that this book project began.

As it happens, there was a kind of personal literary precursor to On Doctoring. From 1932 to 1953, every graduating American medical student received a copy of Aequanimitas: With Other Addresses to Medical Students, Nurses and Practitioners of Medicine by the distinguished physician-educator Sir William Osler (who taught at the University of Pennsylvania and Johns Hopkins University, and was Regius Professor at Oxford University). Osler's book was a collection of essays about medicine-the practice, the teaching, the science, the history, and the human relationships that characterize the profession. The book was a gift from Eli Lilly and Company given to mark graduation from medical school. Pasted to the inside front cover of the book was this letter from the president of the company:

While in private practice, I was visited often by pharmaceutical representatives who promoted the products of their companies. Usually, they left brochures attesting to the effectiveness of their company's drugs. They would also give out pencils, pads, mugs, drug samples-anything to remind us of their products. I suggested to some of these representatives that their companies would be better served by providing physicians with reprints of classic medical articles, such as Peabody's "The Care of the Patient" and Beaumont's observations on gastric physiology. Some representatives were taken by this idea, but nothing came of it.

In the summer of 1987, just after I joined The Robert Wood Johnson Foundation, I wrote to 50 physician-educators across the country, asking them whether the time might be right for an anthology of literature and medicine; whether such a book would be useful to medical students; and, finally, what kinds of readings such an anthology might contain. The fundamental aim was both simple and complex: to remind medical students of the human dimensions of the distinguished profession they have chosen.

The responses were compellingly positive. There was little consensus about what readings should be included, but there was plenty of spirit behind the suggestions. Moreover, my new position at the Foundation brought me an additional opportunity: to present to its trustees the idea of an anthology for medical students. I was encouraged in this quest by Leighton Cluff, a physician who was then the president of The Robert Wood Johnson Foundation, and on December 8, 1988, I made a presentation to the Program Review Committee of the Foundation's trustees in which I described the project in the following terms:

After the presentation, the chairman of the Trustee committee, Foster Whitlock, said, "Let's do it." Now an anthology had to be compiled. I would need help. Whom to ask?

Whatever success the book has had results in large part from one phone call. I had never met John Stone, but I had read some of his poems and his occasional essays that appeared in The New York Times. In replying to my initial letter to 50 medical educators, he had said, "Good luck on the project and do let me know if I can help further." I called and asked for his help in compiling the anthology, and he agreed.

John and I subsequently asked Lois Nixon and Delese Wear to join us in the project; they are now associate editors of On Doctoring. Both of these medical educators hold doctorates in areas crucial to the overall effort-literature and education-and both have long been involved in the uses of literature in medical education at their own schools. Their contributions have helped give shape and substance to the book.

In selecting work to appear in On Doctoring, we had, of course, a wealth of material to choose from. At editorial meetings and through correspondence, the editors discussed and debated, nominated and supported their favorite authors and literary selections. We have been unable to include some pieces of great merit because they are too long, are not close enough to the theme of doctoring, or have too much overlap with a contribution already selected. There is a conscious effort to make sure the anthology includes a diverse group of authors, with a blend of physicians and non-physicians, men and women, a mixture of poems, stories, and essays, and representative writings across historical time periods.

As we entered the final phases of the first edition of the book, we were still calling it Readings In Medicine, for want of a better name. We had selected the texts to be included, were making plans with the publisher, Simon & Schuster, and enjoying our work with one of that company's best editors, Frederic W. Hills. But we were still referring to the book using this clumsy name-or worse. The advertising copy that was being written used the temporary title Untitled On Medicine. The names we considered were just as unwieldy, and some, in retrospect, were even embarrassing.

Fred Hills was urging us to make a choice among ten or so titles "in the next few days"-time was short because jacket design was imminent. Early one morning, I had a phone call from John Stone. As he was driving to work, a possible title had occurred to him. I liked his suggestion at once and we made phone calls to all involved. There was quick and universal agreement; the title would be On Doctoring: Stories, Poems, Essays.

About On Doctoring

John Stone

In the late 1980s, the editors came to grips with one of the first editorial problems of the first edition of On Doctoring: how the book was to be arranged. There was easy and quick agreement among the four of us: put the selections in chronological order by date of birth of the author. After all, life must be lived "forward," as Kierkegaard said. But we were also in agreement that we needed an opening piece to set the tone for the book, something contemporary. We found what we believed was the perfect first piece, one that appeared originally in The New England Journal of Medicine. Written by Dr. Carola Eisenberg, dean of student affairs (now emeritus) for many years at Harvard Medical School, the title was "It Is Still a Privilege to Be a Doctor."

In our planning for the third edition, Eisenberg's piece still seemed fresh and compelling, and remained as the opening piece. In it, she first summarizes the opposing point of view: "Indeed, some in the role of tutors for premedical students have begun to dissuade the college students they advise from choosing medicine, because they consider the prospects to be so bleak."

Eisenberg is firmly on the other side: "How absurd! It stands the world on its head to suggest that the liabilities of a career in medicine outweigh the assets. . . . The satisfaction of being able to relieve pain and restore function, the intellectual challenge of solving clinical problems, and the variety of human issues we confront in daily clinical practice will remain the essence of doctoring, whatever the changes in the organizational and economic structure of medicine." She adds, "Our students need to know about the problems facing medicine. But those problems need to be seen in perspective." She ends by saying, "What we do as doctors, most of the time, is deeply gratifying, whatever the mix of patient care, research, and teaching in our individual careers. I cannot imagine a more satisfying calling. Let us make sure our students hear that message from us."

At an editorial meeting, we decided that it would be nice to have a bookend effect in the new edition. The second edition began with Eisenberg's piece. The rest of the edition was chronologically arranged, from John Donne to Ethan Canin. What we needed to find was a companion selection to complement that written by Eisenberg-a short poem or paragraph that would be placed at the end of the book and would assert some of the same ideas her piece does. Each of us agreed, via e-mail and with some urgency, to think on this matter. That evening, while drifting off to sleep, I remembered a paragraph at the end of As I Remember Him, an autobiographical book by Dr. Hans Zinsser. I thought, "It just might work."

Zinsser lived from 1878 to 1940. He was born in New York City and received both his B.A. and M.D. degrees from Columbia University. He served as professor of bacteriology at Stanford, Columbia, and, finally, Harvard. His most famous work was on typhus. He isolated the bacterium that causes the disease, and, with his colleagues at Harvard, developed a way to mass-produce the vaccine. He served with the American Red Cross sanitary commission during the 1915 typhus epidemic in Serbia. His best known book is titled Rats, Lice, and History, a chronicling of the impact on civilization of epidemics from typhus to the black plague.

The next morning, it didn't take me long to find the selection from Zinsser's writings. As I reread the paragraph, I understood why it had stuck in my head for so many decades. Zinsser's writing was memorable both for the scene it evoked and the language he used to make his case:

I remember one dark, rainy day when we buried a Russian doctor. A ragged band of Serbian reservists stood in the mud and played the Russian and Serbian anthems out of tune. The horses on the truck slipped as it was being loaded, and the coffin fell off. When the chanting procession finally disappeared over the hill, I was glad that the rain on my face obscured the tears that I could not hold back. I felt in my heart, then, that I never could or would be an observer, and that, whatever Fate had in store for me, I would always wish to be in the ranks, however humbly or obscurely; and it came upon me suddenly that I was profoundly happy in my profession, in which I would never aspire to administrative power or prominence so long as I could remain close, heart and hands, to the problems of disease.

I e-mailed the selection to Dick Reynolds that evening, and he answered the next morning. "Perfect. Great find. No need to look anymore." So the third edition ends with Hans Zinsser.

All of the stories, poems, and essays in On Doctoring are there for a reason. The first and most important requirement is that they be well-written. Beyond that, we have chosen some selections because they have proven useful in the classroom or because they can trigger specific discussions, often ethical in nature. The short play "Fortitude," by Kurt Vonnegut, was included in the second edition and remains in the third. It is a provocative piece, with the biting dark humor one expects of this author. The machinations of its characters asks the reader to consider the ever-changing world of biotechnology as it seeks to provide "life support" for failing organs.

The selection, "Misery" by Anton Chekhov, illustrates the power of On Doctoring to direct the attention of medical students beyond the scientific to the personal and emotional. The story begins with an epigraph: "To whom shall I tell my grief?"

Only a few pages long, "Misery" concerns one Iona Potapov, driver of a horse-drawn carriage on a blustery and snowy night. As Iona ferries three different groups of passengers, he tries to tell each of them about a great loss he has suffered: his son has died this week, in a hospital, victim of a fever. The passengers, though, are oblivious, some drunkenly oblivious, to Iona's plight. Listen to Chekhov's description:

"But the crowds flit by heedless of him and his misery. His misery is immense, beyond all bounds . . . His son will soon have been dead a week, and he has not really talked to anybody yet . . . He wants to talk of it properly, with deliberation . . . He wants to tell how his son was taken ill, how he suffered, what he said before he died, how he died. . . ."

Distraught, Iona ends work early and leads his little mare to the stable, saying, "'Since we have not earned enough for oats, we will eat hay.' Iona is silent for a while, and then he goes on:

'That's how it is, old girl. . . . Kuzma Ionitch is gone. . . . He said goodbye to me. . . . He went and died for no reason. . . . Now, suppose you had a little colt, and you were mother to that little colt. . . . And all at once that same little colt went and died. . . . You'd be sorry, wouldn't you? . . .' The little mare munches, listens, and breathes on her master's hands. Iona is carried away and tells her all about it."

For the most part, we have preferred that selections in On Doctoring be complete in themselves. When this is not possible, we have chosen compelling chapters from longer works. One good example is the excerpt from Dr. Abraham Verghese's book My Own Country. The book chronicles the effects of AIDS on a town in Tennessee, where Verghese served as a specialist in infectious diseases. The excerpt points up the human dramas that surround AIDS and leads to discussions of its attendant problems: complex ethical issues; the cost of sophisticated health care; the disruptions of family units; the ways in which society cares for (or doesn't care for) the terminally ill.

The writers gathered in On Doctoring deal with the medical profession, of course, but their other, inseparable theme is that of humanity. Anatole Broyard, the late editor and essayist, who wrote a New York Times Magazine piece called "Doctor, Talk To Me" about his own illness, prostate cancer, and his difficulties in finding a physician to treat it, puts the matter this way:

Diabetes

I

Sugar One night I thirsted like a prince
Then like a king
Then like an empire like a world
On fire. I rose and flowed away and fell
Once more to sleep. In an hour I was back
In the kingdomstaggering, my belly going round with self- Made night-water, wondering what
The hell. Months of having a tongue
Of flame convinced me: I had better not go
On this way. The doctor was young
And nice. . . .

Because poems are short and evocative and can communicate a complete experience in a few words, they recommend themselves for the anthology. Poems can be squirreled away in the crevices of time between a medical student's readings in biochemistry and physiology. Listen as the American poet, James Dickey, describes a patient's encounter with diabetes:

And who has given better counsel to surgeons than Emily Dickinson?

Surgeons must be very careful When they take the knife! Underneath their fine incisions Stirs the Culprit-Life!

In the third edition of On Doctoring, after considerable debate, we selected authors, agreed on a new cover, and included a new section called "Suggestions for Further Reading." The suggestions were made by teachers of literature and medicine at medical schools across the country. The list is not exhaustive, but is meant to convey something of the wide variety of readings that commend themselves to a medical student throughout a career in medicine.

Some of our suggestions may seem startling at first glance-Mary Shelley's Frankenstein, for instance, or Kafka's The Metamorphosis-but they have all been found provocative and compelling in unique ways. Tolstoy's The Death of Ivan Ilych is as admirable and important a rendering of the stages of dying as those summarized by Elisabeth Kubler-Ross. Albert Camus' The Plague begins with an attack of bubonic plague in a city in Algiers; before it concludes, it has raised profound questions about all plagues. Other suggested readings on the list include Death in Venice, by Thomas Mann; The Doctor's Dilemma, the play by George Bernard Shaw; Awakenings, by Oliver Sacks; Tuesdays with Morrie, by Mitch Albom; and Middlemarch, by George Eliot. And, of course, The Citadel and Arrowsmith are on the list.

Our youngest contributer is Gregory Edwards, who, at the time I first read his poetry, was ten years old, a fourth grade student at Robert Shaw Traditional Theme School in the DeKalb County Schools in Georgia.

The Department of Medicine at Emory University had "adopted" the school. One evening in December, 1999, several faculty members gathered at the mostly-minority school to meet some of the teachers and hear students perform a series of skits. After the skits, we adults began to visit our assigned rooms. I was directed to Ms. Dunn's room, whose fourth graders were well prepared for this event. Her class had been studying poetry and for the evening's event, some of her students had written poems. Ms. Dunn had put together a booklet of her children's poems, and had bound them with ribbon in a bright yellow plastic cover signed by all the kids and emblazoned, "Happy Holidays, Dr. J. Stone." I was impressed, and decided to read several short poems in the booklet for the class gathered around me. I gave each poem in turn my best declamatory effort.

When I came to the poem by Gregory Edwards, I asked Gregory to raise his hand. He was a handsome young man with a broad smile. I liked his poem very much and relished reading it aloud.

The Shot

Going to the doctor
With my father.

The scary, scary doctor!

Dad's gonna get a shot.
He's as stiff as a robot!

The scary, scary doctor!

We are getting closer.
We are in.

The scary, scary doctor!

He got his shot.
All that was left was a dot.

Several days later, at work on the next edition of On Doctoring, I was reminded of Gregory Edwards' poem. I decided to send it around to the other editors, with the recommendation that we consider it for inclusion in the next edition. Why? Because the poem captured so well a child's perceptions of going to the doctor, especially that most-dreaded part of the encounter: "the shot." Because of its sense of drama and its sense of humor. Because it portrayed the intimidation that all of us, young and old, experience when we see our doctors. Because it captured the magic patients hope for from their doctor, that magic bullet delivered without pain. And because, after all is done-and said-it was a good poem.

The editorial judgment was unanimous. Gregory's poem should be included. I called his school and told his teacher, Carole Dunn, who told Gregory, who told his mom. Not long afterward, Dunn called to say the principal had invited me to the next PTA meeting so the whole school could celebrate Gregory's triumph.

The auditorium was packed. Gregory and I sat in little plastic chairs in the front row. Suddenly, I was being introduced. I gave a brief history of the book project to the audience, and mentioned some of the familiar names in the table of contents. "So, next edition, Gregory's name and Gregory's poem will be in this book, along with some other pretty famous writers such as Robert Frost and Alice Walker." The audience rose in unison and applauded.

I told the audience something of my own reaction to Gregory's poem-how it used rhyme, meter, suspense, and humor, all to great advantage. I asked Gregory if he thought his poem was funny. He nodded "Yes" and told the audience why: "I think it's funny because it was my father who was going to get the shot, not me!"

The Impact of On Doctoring

Richard C. Reynolds and John Stone

To recognize entry into the medical profession, many medical schools have developed a "White Coat" ceremony for new medical students. Early in their first year, the students attend a convocation in which they don their white coats, sometimes are presented with a stethoscope, and may participate in the taking of oaths (such as the Hippocratic Oath) about being a physician. This assembly is used by many schools as a setting in which to distribute On Doctoring. In recent years, there has been a national upsurge in the teaching of humanities at medical schools. Assigned reading from On Doctoring has become a mainstay in these courses. The inclusion of the book in medical education confirms our biased perception that the book is worthwhile. And the book still strikes us as the right thing to do. That may be all the justification that is needed.