Witness

We are constantly surrounded by objects and phenomena from the realm of death.

— Knausgaard, My Struggle (Knausgaard, 2012)

In Henry Marsh's Do No Harm, he quotes René Leriche: “Every surgeon carries within himself a small cemetery, where from time to time he goes to pray — a place of bitterness and regret, where he must look for an explanation for his failure” (Marsh, 2016). With every death and failed operation, a small, tooth-shaped tombstone gets added to the imagined grassy memorials.

It is in the journey of any doctor to come face to face with mortality and serve as a vessel for the memories of their patients. It would be a Sisyphean task to try and remove yourself from its proximity, and even harder still to remove responsibility when a patient in your care dies. Marsh, a neurosurgeon, writes about his operations, miraculous at times and tragic at others, but always operating under the highest stakes.

This unyielding pressure can translate into a crippling fear. Yet Knausgaard describes Marsh: “The role of surgeon gave meaning to his life, lifted the meaning outside of himself, into a system — It kept the wolf from the door” (Knausgaard, 2015). The wolf, being the triviality of disease and death, the “petty, pathetic and meaningless parts” (Knausgaard, 2015) of ourselves, and the truth.

But I argue differently. Practicing medicine does not protect you, nor does it barricade the entrance — it only gives you the will to fight. The wolf is not at the doorstep. The wolf is already in the house, snapping its open jaws and lunging at you. And you are just in its balance, tackling it to the ground, struggling to pin it down, and keeping it from consuming your entirety. It is a dance of sorts, one of life and death and one that cannot stop. One that points your heads toward each other in equal rage, limbs intertwining as you interlock. Until, from far away, you cannot tell one apart from the other.

*****

Last summer while researching at the Yale School of Medicine, I shadowed Dr. Robert Lee, in the oncology department, who specializes in urologic and prostate cancers. His office was surrounded by doors that led to small exam rooms. Fitted with an examination table, two sitting chairs, and a computer monitor, patients well enough to meet with Dr. Lee would receive health updates regarding their current prognoses.

Every two weeks, Dr. Lee also performed emergency rounds for patients in critical conditions. During my first week, we talked to an admitted patient, Masha, who was diagnosed with late-stage bladder cancer. She presented to the emergency room with acute back pain after a particularly severe coughing fit. Following an X-ray, they found that her bones had fractured as a result of metastases. A follow-up MRI caught dark splotches dotting the grey matter in her brain. The doctors in the radiation room circled the area with red outline, the tumor dark and resolute on the low-resolution image.

The doctors gave her one more month. Dr. Lee recommended home hospice. She can stay at the hospice or at home. To die, the doctors did not need to clarify. Home is better, he advised, the hospices are understocked and overfilled. She'll be more comfortable at home. Home, Masha's daughter repeated, staring at the doctor. Masha stared into the distance.

*****

In Marsh's struggle with the wolf, there is an obvious question: Does it ever end? Will we conquer the wolf, or will we be consumed by it? Do we lose the battle when a patient dies? Is the reason the wolf and self-doubt exist because we did not try hard enough to treat them or missed something that seems obvious in retrospect? Where do we find acceptance or the strength to move on?

The act of practicing medicine is the prescription of treatment, but it is just as, if not more so, an act of witnessing. When physicians are on the battlefield, surrounded by a mystery of CT scans, hematocrit statistics, and histological slides, it can be easy to get lost in the minutiae. Watching a patient sink deeper into the kingdom of sickness is personal, emotional, and raw, and brings out an inescapably scared part of ourselves. But that is not when we lose the battle. There will be patients who cannot be saved. There will be mistakes. We only lose when we lose sight of the battle itself. When we can no longer recontextualize the struggle, take on a birds-eye view, and watch as we grapple with the wolf, or transcend the role of a physician and step into a role as a witness.

We lose the battle when we forget to remember.

*****

Due to COVID-19 precautions, families could opt for telehealth visits instead of coming to the clinic. As Masha was very ill, Dr. Lee scheduled a meeting for Wednesday morning to check on her condition after she settled in at home. I sat in the corner of an examination room as Dr. Lee set his smartphone on the table, leaning it against the desktop. He took his mask off to see the family. Masha's daughter picked up the call, a little flustered, and ushered her young daughter out of the room before handing the phone to Masha.

Dr. Lee said hello and asked if I could be present during the call. He pointed the camera toward me as I waved, weakly. Masha smiled and said yes. He pointed the camera back toward himself.

She was sitting, facing a small window with a white lace curtain. She held the phone in her hand, looking down at the screen, at Dr. Lee. He remarked that she was looking much better today than when she was in the hospital and that she was much more coherent and present. She smiled and nodded. He cleared his throat and asked if she knew why she was in the hospital in the first place. She looked confused. He informed her in a measured tone about her disease, reminding her about her cancer, the fractured bones, and the brain metastases, pausing to ask if she understood. He explained how the focus of her treatment now was to make her as comfortable as possible and to allow her to spend as much time as she could with her family. Her lip quivered, but Dr. Lee did not falter. He paused, making sure she comprehended what he was saying. There comes a time when we all have to face death and our own mortality. I have to do it, you have to do it, everyone has to do it, he began gently. He leaned toward the screen, his fingers holding the edge of the phone, and I realized that I was so grossly unprepared for this moment. There I sat, silent in the background wearing an oversized lab coat, holding a useless notepad and pen in my hands — lost, helpless, but most of all feeling like I was intruding on a sacred moment. I stifled the sound of my breathing.

I had never seen the life drain out of someone's eyes. That moment when they are forced to become acutely aware of their own mortality and have nowhere left to hide. Her smile fell away and was replaced by… was it fear? Anguish? Emptiness? Her life hung in the balance as the physician, on the other end of the phone screen, carried an indescribable burden. How do you tell someone that you are powerless in helping them? That you can do nothing except tell the truth?

Thank you doctor. I understand doctor. Thank you doctor. You tried your best, was all that she could say. We sat in silence for a while. The wolf raged.

*****

There are millions of people who have read Marsh's memoir. The memories of his patients find new life in the consciousnesses of others, and through the multitudes of other narratives, diaries, and personal essays, there is a different type of archiving that takes place. It is not just the readings of blood pressure, hematocrit, or differential diagnoses that get remembered. It is instead the act of witnessing a patient, in all of their beauty and the entirety of their emotion — the very act of remembering that lives on past death.

I am not yet a physician, but I do something that all physicians must. I believe that the practice of medicine is one of bearing memories. Connecting, listening, and being present for a patient's story, at times can serve more than any treatment could. These shared experiences when committed to our minds and immortalized in writing are how we can practice a collective healing of both ourselves and for those who can no longer do so.

These words are a recollection. One that I can place on a small shelf in the corner of an imagined library. Pale underneath the weak sunlight, one that stands enough within itself, and something to which I — and you — can only bear witness.