The Faith of a Doctor: Learning to See beyond the Symptoms
Nussbaum, Abraham, Commonweal
As a young physician, I often struggle with how I am supposed to "see" my patients. History-taking, physical examination, diagnosis, and treatment: a physician tries to see patients with a dispassionate gaze, so that he or she can sort out the modest complaint from the life-threatening one.
Looking at patients dispassionately does not come naturally. You have to learn it, and the process can be a shock. I recall the first autopsy I witnessed during medical school. All rituals have their associated vestments, and for this one I "gowned"--put on scrubs and plastic apron, safety mask, latex gloves. Entering the dissecting room, I saw an elderly African-American man lying on a steel table, his hands by his sides. He looked kind and paternal, like a sleeping grandfather. Pink, puckered suture lines ran up each leg, where the man's hips had been replaced; his right foot was blackened and yellowed by diabetes; but his hair was well groomed, his face at ease, his hands open. He had died three hours earlier while waiting for a leg amputation.
The autopsy had all the solemnity of thieves stripping a car. As the resident pathologist greeted me warmly, her assistant moved silently about the body, opening the grandfather's chest with a long, deep incision from the top of the sternum to the break of the hips. Within five minutes, he was cutting open the grandfather's rib cage; within ten he was examining the organs. He tied off the bowels with kite string, making a long and convoluted sausage, which the resident untied in the sink, spilling out feces as she "ran the bowel," searching for occult disease. While up to her elbows in partially digested hospital food, the resident extolled the virtues of pathology as a medical specialty, encouraging me to consider its high-paying, low-hours glory. "And one thing about pathology patients," she joked. "They never miss an appointment."
Back at the table, the assistant placed lungs, kidneys, heart, and what remained of the gastrointestinal tract in a bowl. The resident then began slicing each organ as if it were a loaf of bread, all the time looking for pathology. The assistant, meanwhile, cut the grandfather's scalp from ear to ear, then opened the skull and drew out the brains for the resident's inspection. Finally, he rolled the flesh back into its original shape, toweled off some blood, and sealed up the body for the undertaker, who would arrive within the hour and begin the process of making the grandfather presentable to his kin. His work done, the assistant left, and the pathologist stood alone with a bucket of still-warm organs and one incredulous medical student.
I inquired if she was a vegetarian. No, she said; why did I ask? There was no use explaining that those human organs looked like fresh beef to me. As all physicians must, she had learned to see organs instead of a grandfather, to gaze with the eyes of a pathologist rather than those of a granddaughter, a neighbor, or a friend.
In The Birth of the Clinic, Michel Foucault writes that it was precisely by dissecting corpses that modern physicians learned to see their patients as collections of diseased organs. He describes the "great break in the history of Western medicine" as the moment, two hundred years ago, when clinical experience became dependent on the "anatomical gaze," an intimate sense of how bodies are ordered and disordered beneath their skins. Foucault quotes Marie-Francois-Xavier Bichat, a physician reared in an older medicine--one not dependent on pathological anatomy--who complained in 1801 that years of bedside note-taking all too often left a physician facing "incoherent phenomena" that resisted accurate diagnosis. But "open up a few corpses," Bichat wrote, and "you will dissipate at once the darkness that observation alone could not dissipate."
And so the modern medical clinic depends on the cadaver in the anatomy suite, the corpse in the coroner's refrigerated offices. …