Medicine and Beyond

Peter Goldsworthy
MJA 2000; 173: 635-637

1   People often ask how I manage to mix working as a writer with working as a doctor. Or -- an interesting wording -- which are you 'really'? Part of me always resents this: why should the two trades be incompatible, or immiscible? Perhaps the surprise that people express at such a mix -- writing and medicine -- is due to received notions of an Art/Science Great Divide, notions which are much exaggerated, and usually come as a complete surprise to anyone on the science side of the alleged divide, most of whom read novels, watch movies and listen to music avidly.

Sometimes the question comes from the other side, from an opposite set of prejudices: sometimes it's a logistics question. How can a Busy Doctor Have Time to Write Books? There's a subtext here, an accusation that harks back to that use of the word "really": the notion that a 'real' doctor would not bother with anything so frivolous.

Part of me sympathises with this. It's a question I often ask myself, as any good Methodist boy would -- especially late at night, when the work of Making Up Stories often seems rather silly.

I find it's useful to quote Anton Chekhov in such circumstances, especially to myself: "medicine is my wife, writing is my mistress."

Writing is my Golf Afternoon? In fact, I suspect that my temperament is more suited to writing than to medicine. Ever since I treated a fractured right leg in my first year out of medical school by putting a plaster on the left leg I've had a feeling that life held out something else for me beyond medicine. Fortunately no harm was done, except to my ego. I removed the still-wet plaster, red-faced, and reapplied it to the other side. Creative medicine? Or gross negligence? I blame a wandering mind, a mind too often occupied elsewhere. I like to jot down ideas between patients in a notebook I keep for that purpose. Recently a chemist around the corner returned a prescription to me with the note that while he enjoyed the poem, he didn't think it one of my best.

And here is one of the advantages of writing as a career: you don't need to be particularly alert to succeed. You don't need to know the difference between a right leg and a left leg for instance. Or if you do, then you've got a few weeks or even months to think about it, and make up your mind exactly which is which.

But if the literary sensibility offers little help in the practice of medicine -- and might even prove a hindrance -- what of vice versa?

"I don't know a better training for a writer than to spend some years in the medical profession," Somerset Maugham, a graduate of the Class of 1897, wrote. Perhaps, perhaps not. Medicine, like any work which involves contact with a lot of human misery -- and human stupidity -- tends to shrivel the heart. To survive, or at least to sleep peacefully, it quickly becomes essential to maintain some sort of distance between that world and yourself. I think I was happiest during my student years when working in the Emergency Ward of the hospital in which I trained. Emergency ward medicine is medicine at its most personally distant, disproportionately removed from the extreme pain and severity of the illnesses and injuries which ambulances disgorge into that ward at all hours of the day and night. It's a world akin to the Mental Arithmetic tests of primary school (I was good at Mental!), a world of inadequate history taking, too-rapid examinations, forced decisions.

I found Emergency far easier to handle, emotionally, than the protracted problems and pains of patients I came to know in other wards, and in general practice since, daily. There is simply insufficient time in Emergency to worry too much about any single person; there is always another stretcher arriving, another set of rapid decisions to be made.

It's a world oddly free of worry; far too busy for the luxury of worry.

I imagine that many medicos have been in the same emotional boat, if only because the selection processes for medical schools favour (or used to favour) applicants who are are good at Mental Arithmetic, and not necessarily good at coping with pain, theirs or others.

That doctors often come to see the suffering, or dying, of their patients as an intellectual puzzle to be solved is one way of handling the pressures of such an emotionally overwhelming world.

It's a mind-set easy to caricature: the heartless medical students of Pickwick Papers; or Herman Melville's Surgeon-Of-The-Fleet Cadwallader Cuticle come to mind: "He walked abroad, a curious patchwork of life-and-death, with a wig, one glass eye and a set of false teeth ... they say he can drop a leg in one minute and ten seconds from the moment the knife touches it."

Tell me your favourite jokes, and I will tell you your worst fears.

Humour, of course, is another way of maintaining distance: medical school gallows humour. We all, supposedly, remember our first day at school with clarity -- psychiatrists lay great store in the emotional content of those childhood recollections. I'm sure that all medicos remember their first day at medical school, which is also their first day in the Dissecting Room, with even greater clarity. For some that first visit lasts only a few seconds before they bolt for the door; for most curiosity reaches a delicate balance with nausea.

I managed to resist throwing up until I arrived home to face dinner -- when some variant of Murphy's Law ensured there would be cold pork on the table, that night of all nights.

Cold short pork.

I hope I will face my own end with the same courage, and dignity, and tough humour. Organ fights, or flesh fights, were not unknown in the Dissecting Room -- although such irreverence was harshly dealt with by the authorities. I clearly remember being hit on the head by a stray human testicle one sun-drenched afternoon. It's not the kind of event you easily forget.

Richard Gordon (Doctor in the House, etc) made a fortune out of books filled with such undergraduate pranks -- but it's the opposite defence against the unspeakable that is perhaps more interesting to a writer; the defence of coldness, of denial. Over a period of years, working long hours, and with no sabbaticals to allow a refilling of the reservoirs of compassion, the gallows-humour process in many doctors goes too far, and becomes its own caricature: cynicism, indifference.

I've often parodied that too-clinical voice in my own writing -- in part such self-parodies are an exorcism, or an attempted exorcism, although this is not always the way reviewers see it. This, from a review of one of my books by Andrea Stretton in the Sydney Morning Herald:

This sparse and understated prose brings out this reader's bloodlust: the desire for one of these fictional medicos to undergo major fictional surgery -- without an anaesthetic.

His style has an initial bedside manner before slitting open a dark underbelly of irony.

Most memorable is this, from a review by Brian Matthews in The Adelaide Review:

Ask not for whom the bleeper bleeps, it bleeps for thee.

I find all this use of medical metaphor mildly irritating. But it's probably better to be a doctor reviewed by writers, than a writer reviewed by doctors. This is what happened to Jonathan Swift's Gulliver's travels when it was discussed in an issue of the Psychoanalytic Quarterly:

Jonathan Swift showed marked anal characteristics (extreme personal immaculateness, secretiveness, intense ambition, pleasure in less obvious dirt, stubborn vengefulness in righteous causes) which indicate that early control of his excretory function was achieved under great stress and perhaps too early.

The image in the film Alien, as the pupal-stage alien bursts from the chest of the host human, captures some of the weird other-worldly shock of the first childbirth I ever saw.

Paradoxically, as a doctor, I find my greatest satisfaction now comes from the treatment of, or more accurately the offering of assistance to, the dying. Satisfaction may seem an odd word for this work, which is often emotionally harrowing -- but its satisfactions are deeply nourishing. Palliative care, in the argot, has recently, and not before time, become a growth specialty. Being present at death -- death at home, among loved ones, from which pain has been banished, and in which the dying person has been granted time and space to come to terms with the fact -- to be part of this, in however small and peripheral way, is a huge and humbling privilege. To write about it is near-impossible: firstly, to decide if you have the right, secondly, to tread the fine line between mawkish sentimentality, and too-clinical distance.

Several times I've used a female doctor persona to represent the "feminine" side of these feelings: the caring side. Its opposite, the objective "masculine" practitioner, has variously been transformed into a pedantic Latin scholar, and, more recently, a mathematician, obsessed by that purest of the sciences, a world free from any human contamination.

In part such representations are another exorcism, and no doubt somewhere between the two is an ideal narrator: a narrator who can handle all the stories of horror, squalor, stupidity, death -- and occasional transcendant courage, or love -- for which I can't yet find a proper focus, or tone.

Of course, death is not easily house-trained; it is rarely so amenable to human management and control -- to the schedules of an idealised Good Death. It's more often sudden, or violent, or cruel, or painful, or terrifying.

And its world, and the stories from that world, are almost unfathomable.

A mother injects her baby with poison, repeatedly, to gain it admission to hospital. As soon as the baby is separated from the mother, it improves -- back in her care, it deteriorates. She denies everything, and almost certainly believes herself.

A doctor saves a choking friend's life in a restaurant, and the saved friend cannot bring himself to speak to his saviour again -- the debt is too great to acknowledge, or even admit.

A woman brings in photographs "of my accident" -- photographs of herself, a seriously injured road victim, being extracted from wreckage, bandaged, loaded into an ambulance. The inevitable question is asked: "Who took the photographs?". The answer: "Oh, my husband took the photographs."

What to make of these true, baffling stories? I'm not even sure that they are my business. They do provide a different scale of priorities of importance; an idea of what is, finally, "really" important, to borrow back that same criterion I tossed up earlier in this piece.

And perhaps this is part of the reason I cannot get enthusiastic about much of the highly-praised writing in this country -- and others -- in recent years. So much of it belongs in those underrated literary categories: Plain Silly, or Dead Boring.

Including most of my own. For these are the categories of the puritan, of course: the Methodist boy in me who I have also attempted to caricature, but seem unable to shake off entirely. Too many years of medical training, perhaps, have cemented it permanently in place. If part of me likes to see itself as an upper-case Writer -- a narcissocrat, a junior member of the priest caste of our silly Art-worshipping culture -- another part is always accusing: Fine, But What Are You Going To Do When You Grow Up?

And yet turning these stories into fiction might help towards some kind of understanding, towards finding some essence, beyond curiosity, or voyeurism. Fiction is above all a reordering process, a sense-making process, even when it's black comedy. "Undoubtedly the world is, and her riches can never be circumscribed by art" the Polish poet Czeslaw Milosz has written -- but we have to make a start, especially under immense pressure from the emotions that surround death.

Tell me your favourite jokes, and I will tell you your worst fears, I sometimes say across late-night dinner tables when conversation flags.

Here is mine.

A few weeks before the poet Philip Hodgins' death from leukaemia in 1995, I prepared a newspaper obituary after a request from Philip had been passed on through a mutual friend. Philip had finally decided to discontinue the chemotherapy which had caused him much suffering for many years. I sent him the obituary -- he was curious to read it -- and a few days later received a bottle of his favourite wine, Passing Clouds, accompanied by a congratulatory note: it was "an obituary to die for."

This seems to me one of the great aphorisms, deserving of a place in any collection of quotations -- and a perfect distillation of Philip's stoic courage, and style.

What am I getting at? Sometimes, to use an old truism, if we don't laugh, we cry -- and sometimes even both at the same time, our worst jokes and favourite fears tangled hopelessly together.

Peter Goldsworthy was born in Minlaton, South Australia, and grew up in various country towns, finishing his schooling in Darwin. Since graduating in medicine from the University of Adelaide, he has divided his time equally between medicine and writing. He is a part-time general practitioner whose novels have sold more than a quarter of a million copies in Australia alone, and have been translated into many European and Asian languages. He has also published collections of short stories and poetry. Among his numerous literary awards are the Commonwealth Poetry Prize, and the Australian Bicentennial Literary Prize in 1988. His most recent books are the collection of essays, Navel gazing (where this essay, Death and the comedian, first appeared), and the novella Jesus wants me for a sunbeam. His New selected poems will be appearing next year simultaneously in Australia, the UK and the USA. A book-length study of his work, The ironic eye, by Andrew Riemer, was published in 1994.

©MJA 2000
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