Dr. Jerald Winakur

ETHICAL CAREGIVING IN AGING AMERICA

— Introduction

My high school homeroom class counted the last seconds out loud together before the final bell each morning. They waited to see if I might make it before Mr. Martin closed the door; or if he, once again, would be forced to reach for his pad of tardy forms and send me to the principal’s office.

If I scuttled through on time the class applauded and I blushed. I have always had a problem with blushing. Mr. Martin, who was also our English teacher, soon stopped sending me to the principal if I was late. I realize now that he watched my approach from his desk, through the window that overlooked the half-deserted school yard. I have no doubt that he saw me there, dawdling after all the others came in. Saw me watching the cardinals call from the tops of the stately oaks, or the eastern towhees forage under the hedges. Or just sitting on the steps watching the last yellow forsythia blooms drop to the ground.

Which is perhaps why, when it was the time of year to engage our class in the “Poetry Unit,” he did something unusual. Something else that made me blush. He called on me to read “The Love Song of J. Alfred Prufrock” out loud to the class just at the end of the period. I knew nothing of poetry then, its power to distill and intensify our own inner voices. Even now I recall the emotions—shorn from conscious understanding—that welled up in me as I read. How my voice caught at times; my face flushed; how I never heard the bell ring; how I sat at my desk for a long moment after everyone had filed out of the room. And how, in some vital way, I have never been the same.

At the end of senior year my grandmother died a yellowing death from pancreatic cancer. Since her home was a refuge from my own, on many occasions I was with her when her kind geriatrician visited, sat by her side, held her hand, and injected her with morphine. Once, near the end, she looked up at me and said, “One day you will help people just like he does.” Somehow she knew what I then did not.

In college, I was a biology major. Bios. Life. I loved the natural world, studied ecology. Every new bird I identified became my favorite. But in pre-med, there was no time for poetry. No time—it seemed to me then—to look differently at the world; to see the thing only for itself. There were just the sciences of deconstruction, smaller and smaller parts: anatomy, physiology, organic chemistry, physics. There was no one in those days who asked: But what about your inner life? Who will nurture your empathy?  What is there once the formulas and theorems are forgotten?

And suddenly medical school. Like generations of students before me—and since—I was formulated, pinned. Mind-numbing memorization. Fear of failure. I was open to patients and their stories; they wanted, needed my attention. I was in awe of their human voices. But science reigned, not anecdote. One mentor asked: How many times can you treat someone with heart failure before you get bored by it? For two stultifying summers I found myself in some research lab learning how to turn living tissue into mitochondria.

Then one of my classmates killed himself. Was it worth it, after all?

I rebelled against the rote-mongers. They almost kicked me out. But then I fell in love with a fellow student and that saved me. Love always does. That and reading, though nothing approved of in that pre–medical humanities era.

I was saved until I learned enough so that I could be of some use to my patients, until the work could save me. By listening to their voices, being attentive to their stories, I could help them. Sometimes I could cure them. And if I could not, they needed my presence, my comforting words, my slowly accreting wisdom. I practiced beneficence; they respected me. There was a kind of mutual love, risky to reveal in this hypersensitive age. In the end, I was glad to be of use.

Almost four decades passed as I scuttled from office to ER to hospital to ICU to nursing home and back and forth and back and forth. My children grew up and left home; I did not nurture my love nor myself. I no longer heard the
singing; I was drowning in the midst of a full life. Eventually my patients—so trusting, so stalwart in the face of what we will all face—died no matter what I did or did not do. My father developed Alzheimer’s disease. Before he passed he no longer knew my name. And I was afraid.

And yet I put one foot in front of the other, day after day, year after year. I never missed work, or a patient on rounds who needed to be seen. I never yelled at a nurse, threw an instrument across the room, drank more than three beers a year, used an illicit  substance, or attempted suicide. And still I was afraid.

Afraid of making a mistake, missing a diagnosis; of injuring or killing someone in my charge. Hundreds of decisions were mine to make every day. How many could I possibly get right? Or dropping a page, or not hearing the phone ring in the night. My hair was growing thin. Each morning I put on my doctor face; I had no time in the day for myself, for lunch, not even a peach.

For me, coming and going in the rooms on daily rounds was not enough to sustain a full life. I believe many of us in medicine feel this way.

I started to write. Many doctors write. The brilliant ones—W. C. Williams comes to mind—enhanced and advanced the canon; helped us see and hear in a different way. I had no such aspirations; there was no moment of my greatness.

Not that I didn’t work hard at the poetry. I took creative writing seminars at night and the occasional weekend; and then a rare summer workshop week away, to study with some master, to be critiqued, judged. To be alone, to weep, to pray, to make space for a hundred visions and revisions. To get away from the dyings. Even if my metaphors are mixed, I thought, no one will die.

Most doctors who write poetry, I suspect, write for the same reasons anyone does. To try to capture fleeting thoughts or arresting images; to be enthralled by words and their sounds; to make sense out of hard reality; to converse with oneself and perhaps even others. To overcome frustration, fear. To do intellectual and artistic battle with demons. To mourn, to praise, to remember, to love. To feel alive in the face of a certain doom. To find a way to overcome all that afflicts us.

I am retired now. I have more time to read, to reflect, to write, to teach. There is love in my life once more. Lark sparrows and bobwhites forage among the native grasses I have replanted; turkeys at the feeder morning and evening, wood ducks on the pond. Once more there is singing. Even though I am closer to the end than I have ever been, there is singing.

Doctors these days are struggling so. Debt, divorce, drug addiction, alcoholism, suicide. They succeed or fail on professional treadmills; patient encounters are measured out with coffee spoons. The doctor-patient relationship is crumbling. Bureaucratic and corporate masters oversee, make their never-ending arguments of insidious intent. And financial recompense, for most called to minister, has never been the “force that through the green fuse drives the flower.”

The overwhelming questions: Now where to turn? How do we avoid being crushed by the demands of Science, of Perfection, of Expectations? How do we recover the awe we once felt in this world in which we expend our life force every day? How can we find joy in the thing itself once more?

For me it is this: Reflect each day on the patients you care for. Be attentive to those who are struggling with illness, with age, with infirmity, with loss. Hear their human voices; recognize how noble they are in the battles they fight and how important is your role as healer and advocate. See the world through their eyes and do your best day in and day out to help them negotiate the medical morass you know awaits them. Nurture that idealism, that empathic responsiveness that first brought you into medicine long ago. Be glad to be of use.

This is what I try to impart to my students, the ones who find their way into the “Medicine Through Literature” class I co-teach with my poet-novelist-lawyer wife, Lee Robinson. This class is a small part of an educational renaissance, the medical humanities movement.   Each September when I see the young, often worried, reticent, sometimes anxious faces of our students file into our seminar room—after they have spent so long lingering in the chambers of universities and hospital wards—I am so hopeful. I say that we want them to bring their whole selves to this class; that they do not have to fear the feelings they may have buried during that ER Trauma rotation, that time in the neonatal ICU , those daily losses on the geriatric ward. Or that time they, out of fear of retribution, kept silent as one of their own was berated or harassed by someone with power. Tell us these stories, reveal these feelings. Do not dissociate from these events.

I want to help them nurture themselves and their patients-to-be with the readings we have chosen for the year. Stories and essays and poems by the masters, by other health care professionals, and by patients themselves. About the human condition, about crisis and loss; about how to keep from drowning. I want them to know with all certainty that these voices—and their own—can enrich and enhance their lifetime in medicine.

I want the works we explore together to serve as bulwarks against their own trials and losses which are coming—whether they know it or not yet in their young lives. They must proceed fearlessly against the infirmities of their patients—and then against their own.

And while the ethicists preach that autonomy is modern medicine’s guiding principle, I demur. It is beneficence by which we will be redeemed. It is love that swells the singing only you can hear.

I want to take these future patients by the hand—each to each—and say, Let us go then, you and I . . .

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