So can you
By William B. Toms, M.D., M.P.H.
Family physician Bill Toms has been listening for the stories his patients tell ever since he began tending to their aches, pains, and dying wishes. Now retired from Dartmouth-Hitchcock, he helps medical students use writing as a way to learn how to be a better doctor.
"What's this about poetry?" Bill Toms says to a class of Dartmouth medical students, suggesting what some of them might be thinking. "I'm a med student," he goes on in the guise of this hypothetical student, "a scientist, not a poet. If I wanted to be a poet, I'd be getting an M.A. in writing or literature, or staring at a flower or a cloud. I'm a scientist, damn it, so let me go memorize something—quickly."
But Toms doesn't let such students off the hook. He goes on to share a few reflections by famous physician-writers like William Carlos Williams and Albert Schweitzer. Then he reminds the students how supple verse can be. "Verse can be shorthand," he says, reading off a PowerPoint slide that is almost haiku-like in its rhythm and concision. "Verse can be fertile, alive. Verse can be ambiguous like medicine. Verse can adapt to your style, eyes, ears, personality. Verse can personalize."
"Okay, that's nice," Toms now surmises his typical student thinking. "But poetry is too hard to understand. It's too squishy and vague and weird and just . . . out there!" Besides, this jaded student goes on, "I'm a terrible writer—I could never write a poem, especially a poem about medicine."
Toms firmly disagrees on this point. "I think you can," he tells his DMS class. "I think you will," he adds. "And I think when you do, it will, someday, be important to you."
Writing has clearly been important to Toms. "If I can write poems for 40 years, so can you," he tells students. "If I can remember a little better, listen a little better, learn a little better, feel a little better, survive a little better, and maybe be a little bit better doctor because of writing a poem, so can you."
On the following pages are several examples of what Toms calls his "short stories in verse."
Dana Cook Grossman
Some people are better than others at converting their fear of all things medical into attempts to maintain some semblance of control over their lives.
From under a thinning mane of bottled red,
she offers declarations cloaked as questions:
"I'm going home tomorrow, aren't I?"
She grows whimsy into a fantasy challenge,
blurring the harsh lines we impose on her:
"I'm going skiing this winter, aren't I?"
She lives by herself, except for those who cook for her
and pick her up when she falls:
"The next time they're just going to pick me up, aren't they?"
She keeps weighing less
as we push Instant Breakfasts on her:
"You know I don't like that stuff, don't you?"
She denies the air-hunger she knows too well
and aerates her dyed strands with expensive oxygen:
"I'm fine and I don't need this, do I?"
She attempts to convince us that two heart valves
came with a promise, a guarantee:
"That surgeon said my heart would be perfect, now didn't he?"
She shoos away her skeptical friend
with an anemic, grizzled finger:
"I'm just fine now, aren't I?"
And who's to argue?
There's a tendency to think of aging, especially the dementia that may accompany it, as bringing an end to thought and feeling. But, in fact, it's just another chapter—and often a very vibrant part of the story.
She was opinionated.
Whether it was loving you or hating him,
she did it good.
She wore a long fur coat,
and the hell with those who didn't like it.
She had the brightest of bright red lipstick,
and left it on any cheek she damn well pleased.
She looked like she'd been a hot ticket,
and she acted like she knew you knew it.
She was just a tad paranoid,
but her imaginary plots were sure intriguing.
She didn't much understand anticoagulation
and took her pills pretty much when she wanted to.
She didn't like to talk about cancer—
she'd had two, they were gone, and there was no sense looking.
She said she was an old lady,
and she'd die any damn way she wanted to.
And she did.
And her paranoid dementia
didn't harm the truth when she said,
"I love you."
Physicians are scientists—we like to understand why things happen. But often we don't, and that makes disease so much more frightening. (Hemiparesis is a weakness on one side of the body—a condition that is sometimes, though not always, caused by a stroke.)
A lean gentleman with the telltale gait of left hemiparesis—
a hitch in his giddyup, as the locals say—
comes in to talk about his pile of meds.
He's knowledgeable and direct, traits expected
from a retired engineer and military man.
He does two hours of PT three days a week, walks a mile the other days.
He tells me he and his wife were hikers, skiers, and more.
He doesn't say, but I know they're good people.
I suggest Tai Chi and stopping some of his meds.
He agrees. We wish each other well.
Stupid, stupid clot.
He had no risk factors,
no more than me.
Courage does not evidence itself only on battlefields. Sometimes it sneaks up on you when you least suspect it—such as during a "routine" office visit. ("CA" is medical shorthand for cancer.)
A thirty-eight-year-old woman comes in for a physical.
I ask how she is; she responds, "Pretty good."
Her chart reeks of oncology notes, CT scans,
radiotherapy reports, and chemo labs.
The smell leads to colon CA (familial polyposis),
which decided to move on to her liver, her lung,
and her brain—each time to be caught by tumor police
with knives and cautery and scars that didn't hurt.
The devious cells took up in her bones,
where it hurts like the other places didn't,
so the woman doctor radiated her hip and her shoulder.
And it feels better, and some hydromorphone goes further.
She says she really has no other complaints,
and she's actually okay about her husband leaving recently
'cause she realizes she can't take care of him, too.
She's upbeat, courageous, and has an infectious smile.
There's a good faith going on, but it seems more than that:
this person seems to have really climbed her mountain,
when most of us complain about our hills.
I ask her if she writes any thoughts down.
She says no, but she has been considering it.
She seems to have a lot to offer, so I encourage her
to write stories, a diary, anything.
She says, "Okay, I'll do it for my seven-year-old daughter.
I want her to know who I am—or who I was."
Then she gives me that smile
and actually means it.
A New Hampshire Couple
There are some people, some situations, some lives where words just get in the way.
They come in together—
as New Hampshire a couple
as the law will allow.
Been married over seventy years.
Some would say they're a right cute pair.
They're lean, move briskly,
and spare their words.
He's always got a story,
she's always got a smile.
Sooner or later he usually shares his "secret" with me—
"Blackstrap molasses, Doc."
And she demurely whispers
that the secret of their longevity
is that he can't hear.
Taking the Time
In medicine, time is frequently one's enemy. For the physician, there is never enough time to do everything you want to do, need to do, must do. But somehow, you have to find the time.
Taking the time to think—
that's all, just think
about the intracellular flux
of potassium and calcium:
Taking the time to consider—
that's all, just consider
the microvascular injury pattern,
the burst endothelium:
Taking the time to ponder—
that's all, just ponder
the ischemic effects on the cerebral cortex
at four minutes:
Taking the time to reflect—
that's all, just reflect
about the person around
the heart you're shocking:
Taking the time, that's all.
Taking the time.
We physicians are often asked to predict the future, but we should always be very careful when we do so, as there are some things we simply don't understand. (Cheyne-Stokes is an abnormal pattern of respiration that may—or may not—presage death.)
Solemnly, I walked out of his room
and told his family he was going to die, very soon.
He was Cheyne-Stoking, no output
from hepatorenal syndrome, deeply comatose.
They understood his drinking
had finally caught up with him.
Twenty-five years later, he and I met on Main Street.
He said he just got back from Vegas,
offered me some gold coins,
and showed me his beloved pit bull sitting placidly
in his even more beloved Pontiac convertible.
I asked about his wife and kids. "Good," he said, "I'm a lucky man."
He hadn't had a drink since that day
I played know-it-all doctor.
Now I go the other way—responding, when asked,
"Yes, you're going to die, some day."
Everybody does. I think.
Aging and death routinely try to uncouple love stories. They rarely succeed.
Her room is compact, a condensation:
the well-loved farmhouse, to the renovated condo,
to this "pleasant and well-appointed room."
Home now to her books, books she's read or written.
Home now to her giraffes; there's seven of them, you know.
Home now to her bed, her chair, her bureau.
Home now mostly to her pictures—
kids, grandkids, a few of her.
But mainly pictures of him—with his seaman's hat,
his welcome smile and his arm
around her, touching her, holding her.
He is everywhere in this compact room,
here with her, as he would want to be,
as she wants him to be. She understands.
With the peace of a good Quaker, she accepts.
She says only, with a deep, unseen tear,
"He was a nifty guy."
The brevity of a laconic New Englander's dialect can mask the depth of emotion and portent behind it. (A lacunar infarct is a stroke caused by a blockage in one of the tiny arteries that supplies blood to the brain's deepest structures.)
Some little artery, no bigger than the thread
you use to sew your cardinals on a throw pillow,
just got smaller.
So you have a spot on a CT scan,
a lacunar infarct. Exotic, like it's from far away.
But it's not, and your right side doesn't move.
And you're angry?
You get pneumonia
or heart failure—we're not sure which,
so we treat both. You get better.
But while you were sicker they asked you,
"If your heart stops, do you want us to restart it?"
You said, "Ask my doctor, he knows."
So I hold your hand,
or you hold mine.
I paint the picture straight and ask,
"Is this what you want?"
You look at me and see cardinals,
bake sales, the West Swanzey Library,
your brother, and more cardinals.
We physicians must be lifelong learners. But there are some things—like how to mute your feelings when you decide to stop keeping someone alive at the end of a "code"—that some of us never quite master.
The insertion of vastus medialis oblique,
the differential diagnosis of hypercalcemia,
the progression of joules to defibrillate,
the side effects of the little white pill,
and, of course, the Krebs cycle current
disguised as the cytochrome P450 system.
All, and infinitely more, need to be learned,
used, forgotten, relearned, used, forgotten, relearned.
It all gets jangled, passed, related, and guessed at.
But eventually forgotten and, maybe, relearned
just before it's needed again, just before.
After forty years, some of it comes easier.
A lot of it comes harder, but the learner's not as bright.
Most of it now is evidence-based, and that's good.
But there's one concept this man has never mastered,
despite all the protocols and too much experience:
When the shocked heart has had enough,
and the deprived brain has extended its magic four minutes,
but the person's body is still warm—
if only because of our bottled oxygen,
pumped around by our sweaty, doubled hands—
while a nurse marks the time for the recorder,
how do you call a code without
getting that bottomless, hollow chill?
Physicians are taught early on to keep patient interactions on a purely professional plane and never to let things get too personal. Later on, many of us feel bothersome questions tugging at our white coats: Should we? Can we?
Talking about life and death is part of the profession.
You get used to it, at least the life part.
"Congratulations, you're pregnant!"
"You have a beautiful baby girl!"
"Your son is growing perfectly!"
The other part? Not so much getting used to it,
practice sure isn't making perfect.
You try to be honest and direct,
yet compassionate and considerate.
Sure, you try. But who knows if you are?
You've learned to stick to the facts, honor honesty,
hold a hand to offer compassion,
look in an eye to connect.
You've learned these things and you try.
You've decided not to say,
"Look, we're both going to die,
and I can't face it,
but it's important that you do."
You've decided not to say it,
but you know it,
just like you know that talking about life and death
is part of the profession.
Toms has practiced family medicine in New Hampshire for over 30 years, retiring in 2005 as medical director of Dartmouth-Hitchcock Keene; the same year, he was named New Hampshire Physician of the Year by the New Hampshire Hospital Association. He still practices part-time in rural Maine, where he enjoys hearing his patients' stories.
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