“House of God” Author Samuel Shem Speaking at the University of Maryland School of Medicine


Good afternoon, and thank you all very much
for coming. My name is Hamil Safad [phonetic]; Iím a fourth year in the School of Medicine
and on behalf of the Gold Humanist Honor Society, I want to welcome all of you. Before I introduce
this afternoonís speaker I want to just take a moment to thank our sponsors for this lecture.
This lecture was sponsored by a grant from the Arnold P. Gold Foundation. In addition,
we received generous contributions; the Medical Schoolís Chapter of the American Medical
Association, medical students section, from the Medical Alumni Association, and from Dr.
Richard Colgan of the Department of Family and Community Medicine, our thanks to all
of them for making this lecture possible. In the fall of 1988, Dr. Arnold P. Gold, a
pediatric neurologist at Columbia University created the foundation that bears his name
because he felt that the phenomenal advances in medicine in the 20th century had dwarfed
the essential humanistic elements resulting in new physicians who are academically brilliant
but who often lack caring and compassion. The Arnold P. Gold Foundation and the Gold
Humanism Honor Society were established to restore that message. At the University of
Maryland members of the Gold Humanism Honor Society are selected through a peer voting
process and faculty review during the third year of medical school where the goal is selecting
rising seniors that most demonstrate the ideal traits that Dr. Gold saw in the compassionate
physician. Earning membership in the Gold Humanism Honor Society is one of two honors
that is noted on the medical student performance evaluation that goes out with every fourth
year medical studentís residency application. The other honor of membership is being on
the Alpha Omega Alpha Medical School Honor Society. At Medical Schools across the country
the Gold Humanism Honor Society sponsored the annual white coat ceremony, in which members
of the freshman class of medical students received their white coats and take the Hippocratic
Oath as they formally become practitioners of medicine. In addition, at the University
of Maryland our chapter sponsors an annual service project. This year on April 11th we
partnered with Habitat for Humanity to build safe homes in our community. Our goal is to
promote the ideals of compassionate patient care and to raise awareness as to the issues
that hinder physiciansí abilities to engage in such care. And there is perhaps nobody
more keenly aware of these issues than our speaker this afternoon. Dr. Stephen Bergman
did his undergraduate training at Harvard University, which included doing neurosurgical
research right here in Baltimore as part of his senior honorís thesis. He also attended
Oxford University in the United Kingdom under a Rhodes scholarship before enrolling at Harvard
Medical School where he earned his MD. It was Dr. Bergmanís experiences during his
internship at Israel Hospital in Boston that inspired him to write his first and most famous
novel the ìHouse of Godî. Written under the pen-name of Samuel Shem, the House of
God has been described as a novel that, through its biting satire and vivid imagery it does
for medicine what Joseph Hellerís novel, Catch 22, did for the military. Although condemned
by the medical community when it was first published in 1978, over the past three decades
the House of God has become one of the most widely read and most widely respected books
in the medical field, and has been named by the prestigious medical journal Lancet as
one of two most important medical novels of the 20th century. The Harvard Club of New
York writes that, ëSamuel Shem is easily the finest and most important writer to ever
focus on the lives of doctors and the world of medicineí. Dr. Bergman is the author of
four novels; his most recent being the ëSpirit of the Placeí, which won two national best
novel of the year awards, as well as numerous essays, several non-fiction works, and an
Off Broadway play entitled ëBill W. and Dr. Bobí about the founders of Alcoholics Anonymous,
which won the Performing Arts Award of the National Council on Alcohol. Dr. Bergman is
a psychiatrist and served on the faculty of Harvard Medical School as a clinical instructor
of psychiatry for 35 years. He is the winner of numerous awards, has given the commencement
address at over 50 medical schools across the country and had the honor of giving the
Arnold P. Gold Humanism and Medicine Lecture at the 2008 annual meeting of the Association
of American Medical Colleges. Ladies and Gentlemen, please join me in welcoming Dr. Stephen Bergman.
[Applause] Yes, yes, amazing. One of the thingsóthank you, itís a great honor to be here. One of
the things that I also wanted to mention asóthis is the writer partóis that I will be doing
a book signing after the talk, is that right? Theyíll be books here or there or where?
Yeah, you can buy the book and you can have my autograph, which will decrease the value
of it. As you heard, the Universityóthis is the first time Iíve been back to the University
of Maryland Medical School since the summer of 1965 when I was going into my senior year
at Harvard College. And I had wandered into deciding that I would solve the mystery of
the neurobiological basis of learning and memory. And that somehow involved spending
the summer here working with a scientist named Robert Grenell [phonetic] and learning this
neurosurgical technique that you could profuse a little section of cortex. And I went back
to Harvard and they gave me a lab at the mass general and I worked diligently on this; I
was really enthusiastic about this. And it really was because of that, I think, that
I then got lucky and got a Rhodes scholarship to go to Oxford. Usually they donít include
scientists really but they did in this case and my three years at Oxford really changed
my life, changed my life to get out of the country from 1966 to 1969. When I came back
thenówell, I started writing at Oxford when I got over there and I decided I wanted to
be a writer and there was a little thing called the Vietnam War going on at that time. So
after the scholarship was upóyou didnít get drafted if you were in a graduate program
so after the scholarship was up I faced a not too difficult choice between Vietnam or
Harvard Med. So I chose Harvard Med and I always wanted to be a writer and I decided,
okay, medicine will be my meal ticket. And then I finally decided to become a psychiatrist,
partly because I would have my mornings free to write and that worked out well for a number
of years and now Iím just a writer so Iím finally being a little more productive. So
I call this ëstaying human in medicineí; itís a topic Iíve been talking about for
a long time and Iíll tell the story through my journey as a writer, basically, and Iíll
use some of my works as examples, of course, especially, the House of God. And the theme
of this to keep in mind is a very simple one that Iíve come to embrace in various different
ways and that is the danger of isolation and the healing power of good connections. The
danger of isolation and the healing power of good connections. As you heard, when the
House of God came out in 1978, I wasnít the most favorite person at places like the Harvard
Medical School and the Beth Israel Hospital. In fact, I was roundly condemned as you heard.
And over the years, as youíve heard, itís kind of gotten kosher, however, I found outóI
recently found out I have to be on my guard about the book. This was a potluck supper
for our daughter, Katieís class one time, a few years ago, and I didnít know what to
do. Iím sort of wandering around looking for someone to talk to, and I hear these two
women talking and I get closer, and theyíre both doctors. Great. So I get closer, doctors
at the Beth Israel Hospital, my Alma Mater, something in common. I go over, sit down,
wait for an opportunity; I said, you know, I may not be the most favorite doctor at the
Beth Israel Hospital, and one of them looked at me with venom and said, well, you canít
be as bad as that guy that wrote that book. And there was this delicious pause, right,
and I said, well I am the guy that wrote that book, and she blushed beet red and that was
the last play date our daughter had with her daughter. The House of God had a terrible
start. I never had written a novel before; I had written other things, plays and poems
and stuff. But when we entered our internship we were idealists when we went to medical
school and we entered the internship it was such a bad experience in some ways. And I
figured somebody had to write it. itís what I callówhat drives me as a writer is something
I call, hey, wait a second moments, and these are moments–you probably already had some
todayówhere you find yourself thinking something or doing something or not doing something
you think you should have done, you saidólater you say, hey wait a second, why did I just
do that? Why did I think that? Why didnít I help that person or why did I do this? And
in the internship there are nothing but these hey wait a second moments that I figured somebody
had to tell about them, and that somebody was me. So I started writing the House of
God as a catharsis, really, after what was and probably still is the worst year of my
life. The story of how it got published is kind of interesting and ridiculous. I was
looking for a play agent; I was in my psychiatry residency and someone said there was this
agent in New York who was a play agent. So I wrote her, I said Iím looking for a play
agent; p.s., I have a little bit of a doctor novel Iíve kind of been working on. And she
wrote back and she said well Iím not a play agent but why donít you send me what youíve
got. Well what I hadóI didnít even know you were supposed to double space things,
you know, and this was in the days of a typewriter. Remember, a typewriter is kind of a box, big
box like thing with keys like a piano, you know. So I sent it off. It had coffee rings
on it, it was single spaced, scrawls in the margin, you know, cigar ash, pipe ash, God
knows what else on it. You know, I sent it off; forgot about it, went on with my first
year of psych training. So there I am one day, several weeks later, Iím standing in
the secretaryís office of McLean hospital where I was doing my trainingóthatís a Harvard
Hospitalóand the phone rings and the secretary says itís so and so for you. I didnít even
recognize her name. she said, oh, she says sheís an agent, you sent her something. So
I get on the phone and this is my first feedback, right, of this mess. And her first words to
me were, well I donít know if youíre a mad man or a genius but I really love what you
sent me. And I had the presence of mind, actually, to say well I canít help you there but you
should know Iím speaking to you from within a mental institution, at this time. So, you
know, gradually, you know, nobody wanted to publish it. Eventually, I double spaced and
got a contract, you know, and I remember it was rewritten seven times. I seem to have
to rewrite my novels seven times for some reason. And it was just about to be published
and I met with the publisher and he said, well, you know, weíve got to look at this
legally. Are there any people in this novel that are identifiable? I said, oh God, you
know, who isnít, you know. so I thought Iíd kind of fudge it and I said, well, yeah, actually
thereís one whoís really identifiable; heís the chief of medicine. So he asked me, yeah,
he looks like him, he acts like him, he talks like him, you know, all of his mannerisms
are like him. And, meanwhile, the guy says, oh, oh, thatís bad. And Iím thinking this
book isnít going to get published, you know. And so he looks at me and he says, well does
he have a big red birthmark on his cheek? And I said, no, he doesnít. he said, well
now he has. And if you open your copy the first, and I think only time itís mentioned
is that the chief of medicine has a birthmark on hisóitís called the libel prevention
birthmark. The small miracle department about the House of God, all these years later, the
places that hated me the most were the Harvard Medical School and the Beth Israel Hospital.
And, low and behold, a couple of years ago guess who was the commencement speaker at
Harvard Medical School? And even more amazing, guess who was invited to speak at the Beth
Israel Hospital about a month ago? So the message there for you young people is if you
live long enough the people who hate you are either dead or retired. When I told my buddies
at Harvard Medical School that I had been invited to give the commencement speech, my
House of God buddies, I immediately got three emails. One of them said they must really
be hard-up, we must really be in a depression, right. The second one said there must be some
mistake. Are you sure itís not the commencement address at the Harvard Liquor Store on Mass
Ave. And the third said this is the end of civilization as we know it. Okay, what about
the House of God? This is all in retrospect, you know, I was just trying to, as I said,
it was a cathartic effort and I was meeting with my friends who had been interns and weíd
talk, etc. but years later what I realized is we, often at times, think weíre making
a decision based on some rational data or practical advice or whatever and it turns
out, looking back later, you find out you hadnít the slightest idea of what historical
and cultural forces that were driving you along, carrying you along, at the time that
you made that decision. And that became true years later as I look back on the House of
God because our generation was the ones who at collegeóweíre in the brief, wonderful
period of American History. We had this bizarre notion if you saw an injustice or an inequality
like the 1 percent and the 99 percent now, if you got together and took action you could
change things. What a bizarre idea, right. Well, we helped to put the civil rights laws
on the books and we ended the Vietnam War, okay. So when we went into our internships,
when I went into my internship at the Beth Israel we just naturally were of aówe just
naturally thought that if we saw things we didnít think were right in medicine we could
resist them. And, in fact, you can read the House of God as a kind of a novel of non-violent
resistance; the different ways the different interns resisted what they saw was an unjust
system. And that was what happened. We walked into the system as idealists and we immediately
felt ourselves in a conflict between the received wisdom of this big medical system and the
call of the human heart. Simply put, we were, as in the book, we felt we were not being
understood and we were being forced to treat patients in ways that we didnít think were
humane. And so naturally we kind of took action. Let me read you a short, true piece. This
actually happened in the House of God early in the year. Itís about an intern called
the runt. The runt was having a hard time; he sat down to lunch, he took out a pill box,
put a pill on his hamburger and munched it down. When I asked what it was he said Valium,
Vitamin V. Iíve never been so nervous in my life. Does the Valium help? It makes me
feel sleepy but I feel pretty unflappable. Iím writing orders for it for all my patients.
What? Youíre putting all of them on Valium, too? Why not, he said, theyíre all very nervous
having me as their doctor. After the others had left the runt said he had a confession
to make. Itís about my third admission last night; in the middle of all this trouble with
the yellow man this guy comes into emergency and I couldnít handle it. I offered him $5
if heíd go home; he took it and left. True story. Try it next year for those of you who
are graduating. This other short piece Iím going to read from the book is one of the
joys of writing actually. One of the things you can do as a fiction writer is if youíve
been in a situation and youíre writing about it and you realize you didnít do the right
thing and you wanted to kind of correct it you can kind of do it in writing and youíll
see what I mean in this. The true part of this story is there was a woman who was a
patient of mine, middle aged woman, with metastatic breast cancer who had gone down to surgery
that morning. The surgeons had opened her up, it was too widespread. They did nothing,
and they just sent her back up to the ward. And she was there on the ward, conscious again,
and nobody had come up and told what they had found. And so the nurse came up to me
and said, you know, youíre an intern, youíve got to tell her. And I said, look, Iím notóI
was scared stiff and we hadnít had any instruction on how you give a patient bad news. I mean,
we wereóthis was the dark ages you know. And I said itís her private doctorís responsibility
or maybe a nurses or something. And thatís as far as it went in reality and I just walked
away. I donít know who told her. But in the House of God youíll see this passage if youíre
interested. This is what I wrote when I came to write this. I said, well letísóthis is
whatóI donít know it wasnít conscious, this is what I wrote. The fat man comes upóover
here itís the fat man who is the hero in the House of God laws such as in cardiac arrest
the first procedure is to take your own pulse, right. And the fat man says heíll do it,
right. And then this is the way it goes on. Roy describes a scene. I watched him enter
her room and sit on the bed. The woman was 40, thin and pale, she blended with the sheets.
I pictured her spine x-rays riddled with cancer, a honeycomb of bone. If she moved too suddenly
sheíd crack a vertebrae, sever her spinal cord, paralyze herself. Her neck brace made
her look more stoic than she was. In the midst of her waxy face her eyes seemed immense.
From the corridor I watched her ask fats her questions and then search him for his answer.
When he spoke his eyes pooled with tears. I saw the fat manís hand reach out and, motherly,
envelop hers. I couldnít watch. Despairing, I went to bed, and then later that night,
after seeing a patient he returns. Roy glances into the room again; fats was still there
playing cards, chatting. As I passed something surprising happened in the game, a shout bubbled
up and both the players burst out laughing. So you see what I mean about being able to
re-do reality and fiction and actually Iíve been told if you think about it that is really
a good lesson for, you know, you who are about to go on to wards about how you deliver bad
news to patients, right. He comes in, sits at eye level, letís her ask her question,
answers it truthfully and he doesnít run out the door. He sits there and he doesnít
say anything, and then we donít exactly know what happens but he stays, you know, he stays
for awhile and, you know, there is some healing that takes place as I described, hopefully.
It doesnít always happen like that. So, in looking back, what are the lessons Iíve learned
that I usually tell to medical students especially about staying human in medicine. Well itís
very simple and, you know, there are essays on the website that go into it in more detail.
Itís SamuelShem.com, the website. The first and most important is, as Iíve already mentioned,
is connection, connection comes first. Once again, isolation is deadly and connection
heals. And itís interesting as we get more and more savvy about the difference between
a patient, say whoís isolated in the hospital and one who has a whole family involved or
friends, those people tend to do better in all kinds of things, things you might think
of like, you know, infections or recovery from surgery but even in much more what we
think permeable or drastic things like really serious illnesses, cancer, and stuff. So I
think thereísówithout going into it too muchóthereís a lot of hints now after all
these years that whatever the qualities are of a good connection with someone they can
affect the body, probably, through the immune system, right. There are some studies that
show immune response goes up and immune response can go downóI remember one studyóif a doctor
delivers bad news in not a very empathic way versus really delivering it in a good way.
So I think weíre sort of getting a hint that connection in the physical world is as important
as in the emotional and psychological world. Part of that is saying, you know, connection
not just in medicine. Medicine is part of life, not vice versa. You know, one of the
things thatís really hard when you become a doctor is to keep your family going, your
family connections going, your relationships going. The one thing that a teacher of mine
once said is that happiness is not an individual matter. That is, you know, in America weíre
taught that, you know, itís a self actualizing, one might say self centered culture compared
to some others. And thereís a lot about how to make yourself happy but the fact is, is
that happiness is not an individual matter; itís a matter of your connections with other
people, your good connections with other people, which Iíll get to later. People, over the
years have kind of called the House of God a cynical book but in response to that I went
through it and I didnít see it as that so much when I wrote it and it turns out there
is one consistent ëmessageí in the House of God that is pointed toward doing good in
terms of connection and that is the phrase, being with the patient. Now Iíll read you
a couple of passages from the bookóa couple of sentences. This is the fat man. I make
my patients feel like theyíre part of life, part of some grand, nutty scheme instead of
alone with their disease. With me they still feel part of the human race. Letís see, yeah.
And this is a patient of Roy, the narrator, Dr. Sanders. What sustains us is when we find
a way to be compassionate, to love, and what mostóand the most loving thing we do is be
with a patient, like youíre being with me. And then Roy, at the end of the book, says,
what these patients wanted was what anyone wanted, the hand in their hand, the sense
that their doctor could care. So even then when I wasnít very wise about these things
I made a kind of aówhat do they call it on the screen where you put a marker on the screen
or something of your computer, you know, you mark it as, being with, was important. The
other three things I mention when I talk about how to stay human, staying human in medicine,
are speaking up is the second one, speaking up or speaking out. Itís important when you
see something thatís not right in the medical system, thatís unjust or unethical that you
speak out not only to call attention to it but because speaking out is essential for
your survival as a human being. If you witness some of these things and you keep it to yourself,
you donít say anything, guaranteed youíre going to suffer and youíre going to spread
more suffering around. The third thing is empathy; learn empathy, and thatís obvious.
I said this to a second year Harvard class I was teaching, seminar group, and a guys
hand shot up, oh, we already learned empathy. Wow, you know, pretty impressive. Harvard,
you know. So I said, well, you know, what did you learn? And he said, oh, it was easy.
It was last year in patient interviewing. I said, yeah. He said all you do is you repeat
the three last words the patient said and you nod your head. Our daughter picked this
up, I think, from Janet and me at one point, and she hadówhen she started doing emails
she had a tag on her emails and sheóit was about empathyóand she saidóyou know, because
empathy is basically putting yourself in another personís shoes and feeling likeóso the tag
she had was, itís important to walk a mile in another personís shoes. That way youíre
a mile away and you have their shoes. How do you learn empathy? In another personís
shoes, obviously, but for doctors itís really interesting. I mean, I heard it again today,
you know, we doctors learn empathy often if weíre treated very well by a doctor when
we were young or we have a family member who is in trouble in a hospital and we see that
person being treated badly. You know, Iíve had the experience sitting in the corner of
a room and I think my mother was sick in a bed, and the hospital team came in not knowing
I was a doctor, and howís our gal today, you know, and treating her like we sometimes
treat people, and I was kind of appalled. So in medicine you canít really powerpoint
empathy; the way you learn empathy in medicine is you watch people who are good at it and
when you find people who are good at it, and I guarantee there are some in the room, you
sort of follow them around. You do rotations with them, you know, you try to get them as
a mentor, things like that. And then the final thing about staying human is learn your trade
in the world. And what that means is the patient is never only the patient. The patient is
the family, the friends, the where the water comes from, where the garbage goes, the toxins,
the climate, the whole thing. Now when I went to medical school out of 100 people in my
class I donít think more than 10 had ever been out of the country, you know, the good
news is that this class, your generation of doctors, young doctors, medical students have
been everywhere. Theyíve done everything, you know, youíve been all over the world
by now and you really donít feel that strangers are strange or foreigners are foreign, you
know. itís a remarkable thing and the diversity in medical school now is absolutely astonishing
so thatís the good news. The bad news is that youíre about to enter a healthcare system,
those of you who are just going into it, thatís a total disaster. Itís a disaster. Itís
worse for the patients, itís worse for the doctors, itís only better for the insurance
company, insurance industry. And I have a lot to say about that. Maybe Iíll hold that
for questions at the end or I can talk a little bit more at the end about it. Simply, you
know, simply put, myóI mean, Iím for a national healthcare system like every other industrialized
company. The question really is why should a healthcare system be for profit? Why should
a healthcare system be for profit? And under the SHEM plan, of course, weíd have a national
healthcare system, we would have tort reform because so much of the cost is in cover your
ass medicine, right. No question. And this is for the medical students and those still
struggling with their $200,000 debts in medical school. Medical school will be free, loans
will be cancelled retroactively from today in returnóyou see why Iím not in politicsóin
return for two years of service after you graduate somewhere in America. How many medical
students would take that deal? Yeah, everybody would. Itíd be exciting; itíd be fun, youíd
learn medicine, you know. the hint about how this should happen, this could happen because
weíre not going to get it from Obama care or the otheróany other politicians is, you
know, somebody said to me once, when youíre in a theater and somebody falls down in trouble,
you know, does the cry ever go out, is there an insurance executive in the house. I meanóthis
is the last thing Iíll say and then Iím going to move onówe are doctors. We and other
healthcare workers do the work. Without us thereís no healthcare so we can get back
to that. But youíre the ones, your generation is the one thatís going to have to deal with
this. I wanted to say one more thing I learned about the House of God before leaving it,
and that is the House of God was one of these big hierarchal systems. Itís called power
over systems where somebody has power over you and you have power over somebody else.
And in these big systems what happens is the pressure comes down on the lowest down people
and in the medical system, the interns, we the interns were the lowest down, right. And
what happens in the book and what happens in real life, too, is when the pressure comes
down the interns got isolated. Not only did they get isolated from each otheróitís in
the book, one goes crazy, one commits suicideóeach of us got isolated from our authentic experience
of the system itself, right. Each of us got isolated from our authentic experience of
the system itself. You start to think Iím crazy for thinking this is crazy and thatís,
you know, that immobilizes us. Itís like what Chuck, the African American intern, said,
how can we care for patients if nobody cares for us? Now given these power over systems,
thereís only oneóthese power over systems are based on a hierarchy that can be of race,
gender, sexual preference, ethnicity, etc. And the only threat to a dominant group is
the quality of connections among the subordinate group. The only threat to the dominant group
is the quality of connections among the subordinate group. Thatís why the first thing I say stick
together, connection comes first. And connection in your internship; donít get isolated in
your internship, thatís really death. So, once again, the issue is connection versus
isolation and somehow sticking together. Okay, Iím going to move on toóI wrote a sequel
to the House of God. The publisher has tried to hide it for all these years. Itís called
Mount Misery; itís about the same main character going into his psychiatry residency in a big
mental hospital called Mount Misery. I went into psychiatry from the Beth Israel and McLean
Hospital thinking that psychiatrists were really the ones who knew how to be most human
to patients and with patients. And guess what, maybe it was just my experience again but
they were worse. It was really very, you know, people during my residency were brought up
for child molestation, for drinking with patients in the office, sexual abuse of many patients,
all this stuff. You can read about it in Mount Misery. Also there were some funny things
that happened. My work rides on two things, humor and love or sex, love and sex, at best.
This is a true story, a little true story from Mount Misery where Roy is admitting a
psychiatric patient, a middle-aged Italian brick-layer who thinks heís God. How do you
know your God, I asked? Because I was in hell; you want proof. He unbuttoned his shirt, on
his belly was a magnificent tattoo of the last supper. Clearly it had been done many
years before, when what was now his belly had been his chest and when he had been thinner.
For now it had expanded so that Christ and all the Apostles were all wearing broad grins.
What did you think, doc, asked the security guard after weíd locked him up. 298.80, brief
reactive psychosis. You donít think heís God? He may be but itís not reimbursable.
And then, as I did before, this is a one of these things I wish had happened that I wrote
in a way that I wanted to make it better. I had a patient that year that was really
a lot of trouble. She was alwaysóa young woman who was always challenging me thinking
I didnít know anything, which was sort of right at that time. So this is the last session
that I imagined with her. Terrific, she said to me sarcastically, putting me down. She
looked sullenly into her lap. In the past I might have gotten angry at her but suddenly
I understood. The issue wasnít me or her but us. The we in the room which seemed so
solid right then that you could shape it, yet so femoral that it was the unseen historical
forces shaping you. My job right then was to hold this we, this connection with her,
hold it for both of us; that was my job as a doctor. To use my experience with others
who had suffered and my vision born of that experience to bring someone who is out on
the edge, the so-called sick, to current the human, to take what seems foreign in a person
and see it as native. This is healing; this process is what the healing process is. This
is what I signed up for years ago. This is what good doctors do. Weíre with people,
at crucial moments in their lives, healing. That was a little bit of an advance for me
and it leads me to the next thing Iíll mention. My wife and I then started working with men
and women trying to bring them together across differences at Wellesley College, the womenís
center. And to be very brief, what we developed and worked on was kind of a new way of looking
at psychological development and at psychological health. And to be very simple, the notion
of psychological health in western civilization has been that based on the house of this thing,
this person, a person is healthy, right, and the development of a healthy self is the goal
of normal development. Well thatís a male model. If you talk to women itís a little
different. And what Janet basically came up with was that a measure of psychological health
of a person, any one of you, can be looked at as the quality of the connections with
other people. Now that doesnít take away from being a strong self, right. In fact,
think about it, a good relationship makes you feel better about yourself, right. And
so thatísóyou can read about that. We wrote a book called, We Have to Talk, Healing Dialogs
Between Women and Men, which if any of you are in relationships, which I hope you are,
you might, you know, this may be of use to you. Itís on the website. But the application
to medicine is pretty simple in a way. Iíll give youófor instance, in psychiatry, rather
than asking a patient, tell me about your mother or tell me about your father, I started
asking tell me about the connection with your mother or the connection with your father,
the relationship with your mother, and all of a sudden youíre talking about the relationship.
As a doctor using the we rather than the I is very helpful. For instance, the old surgeons,
the patriarchal surgeons, you know, the good ole surgeons, used to say, well Iíve done
all the tests and we have the results and Iím going to operate on you. All right, thatís
an I, you, and itísóthe patient would often say, okay. The newer iteration is the surgeon
will say, well Iíve done all the tests and I think I should operate on you but youíre
welcome to get a second opinion. Not bad. But what if the surgeon said, you know, weíve
done all the tests and now letís talk about what weíre going to do. Now that seems like
a little thing. But what you find out is if you, as the doctor, use the we, what does
the patient say? She says, yeah, okay, letís talk about what weíre going to do. So the
use of the word concretizes the fact thereís a relationship here and comes back to the
person whoís using the word we. So try it with your patients, try using the we. And,
certainly, in surgery, studies have shown whatís the main factor in whether surgeons
get sued or not? The quality of the relationship. If people have a good relationship with a
surgeon theyíre much less likely to sue. So try using the we; itís a shift to the
we. It seems like a little thing but you willóit defines that there is a relationship here.
It strengthens the relationship. The next step for me, aside from the we and the idea
of the relationship came from what you heard about before. Itís a play we wrote, my wife
and I, called Bill W. and Dr. Bob about the relationship between the two men that lead
to the founding of Alcoholics Anonymous, 1935, in Akron, Ohio. Has anybody hear heard of
Alcoholics Anonymous, yeah, okay. Do students have to go to meetings and stuff now? Great,
excellent. Thereís a current epidemic in colleges now; 2000 college students per year
die just of alcohol poisoning, not getting into cars and stuff. Five a day die, and weíre
trying to use the play to do that. Okay, whatís so interesting about Bill W. and Dr. Bob?
Bill was a stockbroker from New York, some kind of genius. The only flaw he had was he
was a drunk; couldnít get over it. Dr. Bob was a surgeon in Akron, Ohio, wonderful man
except for one thing, he tooótheyíre both dying of alcoholism. They happen to meet by
a series of really karmic or fate events in Akron. And Bill had the realizationóhe was
alone in Akronóhe had the realization he wanted to take a drink. The only thing that
could keep him sober was telling his story to another drunk, which is kind of bizarre,
right. Telling his story to another drunk would keep him sober; he didnít know if it
would help the other guy. And they met, and when Bill told this to Dr. Bob, Bob wanted
nothing to do with this, but when he told him in that meeting that he realized this
was the only thing that could keep him sober and that his doctor in New York, Billís doctor,
had said, you know, he believed alcoholism was an allergic disease of some kind. And
Bob stopped him and he said, a disease with signs and symptoms, a course, a progression,
implying what, a treatment? And so from that moment Bob the doctor put it in medical terms
and he said, weíve got to see if this treatment works, this treatment of yours works. Weíve
come to think that it had to be a doctor Bill met because that was the crucial step. Thereís
one point in the playóthey do stupid things trying to get other drunks. They chase them
down in bars, they go to their houses, itís ridiculous. And finally Bob says, you know,
Bill, I figured out where weíre going wrong. We need to find ourselves a steady supply
of more reliable alcoholics, and then he says, those already in the hospital. And so he takes
it into the hospital, takes it into the hospital and that was the major step. Now why am I
telling you about AA today aside from the fact that youíre all going to see alcoholics
and drug addicts. Theyíre all going to fool you; youíre not going to recognize them,
youíre not going to treat them right. I hope youíll send them to 12-step programs as part
of the treatment. Well because these guys discovered two things that were new in the
world. One, they started this whole thing we take for granted of same disease support
groups, right. You have a patient with abuse, you send him or her to abuse group, etc. The
other thing they discovered, they said alcoholism is a disease that has physical, psychological
and spiritual elements and has to be treated in all three ways. The start of the holistic
movement, right, in medicine, 1935. So what did I learn? Whatís the point of AA? How
does AA work? AA works because it shows the healing power of mutual connection, right.
Itís not an I program, itís a we program. The healing power of mutual connection. Thatís
been a big step in my understanding. Okay, thatís as far as Iíd gotten, and the next
step, the final step so far, is this new novel. Itís called the Spirit of the Place; it came
out a couple of years ago. In the back, you canít see, but thisóthe cover is an original
Shegal painting. So if you buy the book you can cut it out and put it on your refrigerator,
frame it, whatever. this book isóonce again, one of the joys of being a fiction writer,
a novelist, I always had theówhen I grew up I had this wonderful old doctor, general,
you know, one of these old time general practitionersóIíll read you a little about himówho was very
important to me in my growing up years. He was like a counselor, I went to him for advice,
which he never gave. But he started to take me around with him, you know, and thatís
what got me into medicine. And I always dreamed of going back to that little town, Hudson,
New York, up on the Hudson River, to join him in practice, you know. But it didnít
work out so I did the next best thing, I did it in fiction. Itís about this 40-year old
guy, divorced, running around with Doctors Without Borders, and heís finally fallen
in love with a dynamite, wonderful, Italian, beautiful, sexy, yoga teacher. So I get to
write about that; itís another joy. And heís finally kind of happy after this miserable
divorce and all, but his mother back home has died. Heís missed the funeral because
they didnít know where he was and he goes back and heís broke, he needs money. It turns
out the terms of her will are such that he doesnít get anything unless he lives in her
house in the middle of this town for a year and thirteen days. He hates this town; itís
been anti-semantic, heís Jewish, itís this broken down, horrible wreck of a town. And
he thinks well heíll just go home and the hell with it, heíll go back to his Italian
lover, but, of course, he stays, otherwise there would be no book. I want to read a couple
passages once again. So this is really a more general story about a doctor. Let me just
see, what am I lookingóokay, here we go. It has humor in it, as usual. This is in the
winter, the town is called Columbia. Two Columbian ice fishers and their dog had a bright idea.
It was the end of January, the Hudson River was ice blocked. Even though they never caught
anything much in the polluted river when it was free of ice, many Columbians imagined
that when ice, a foot thick, covered it the fish would reappear. Their greatest difficulty
in ice fishing was not keeping warm; after all they would drink enough beer so it would
act like anti-freeze and they would drag portable gas stoves out to their huts on the river.
The difficulty was cutting through the ice. Many Columbian males had a love affair with
internal combustion, and their favorite was when their manly hands were caressing a chainsaw.
Yet in the dead heart of winter a chainsaw required just that little bit extra presence
of mind from inebriated Columbians to cut through the ice without shearing off a toe
or a foot or a leg. At dawn on this viciously cold day, the two Columbian ice fishermen
and their dog had the bright idea of using dynamite to blast their hole in the frozen
river. True story now. They drove their pickup out on the ice toward the neglected old lighthouse.
They got out, all three. They managed to identify the fuse end of a stick of dynamite, congratulating
themselves on their creative intelligence and hardly able to contain their excitement.
One held the stick of dynamite, from his cigar the other lit it. It sizzled a fuzzy phosphorescence.
The Columbian threw the lit stick a long way away, it sailed in a high sputtering ark out
toward the decaying lighthouse. They watched, first in drunken puzzlement mixed with a hint
of satisfaction at the order of the world, then in drunken horror as their dogódog ownersóran
after the stick of dynamite, fetched it and started barreling back toward them. See the
dog run, see the Columbians run, see how fast the dog runs, see how slow the men run. So
our hero is called to patch that up. Now this is a little love portrait of this old doc
that had such an important effect on me. His name is Bill Starbuck, and Orville goes to
see him the first time heís back in his office. Ushering Orville in, Billís hand was on his
shoulder. As always, Bill was a toucher, a great toucher. You might forget what he told
you was wrong with you or what he was going to do about it but you remembered that touch.
Hours later the place he touched still felt special, warm in winter, cool in summer. Good
to see you, son, Bill said, settling in behind the big cluttered desk and another, yes, smoking
sign. His words came out in a calm, deliberate way with significant torsion of his lips as
if each word was being molded as delicately as an egg and required care to survive. His
greeting blew the scent of fresh scallions of Orville. Billís other addiction besides
nicotine was fresh scallions. When in season his real patients kept him supplied. Bill,
the scallion, Starbuck. Bill shook a Camel free and lit up blowing out two dragons of
smoke. As a teenager embarked on a course of rank failure, when he refused to talk with
his parents or sister about anything close to his heart he was sent to Bill for advice.
Bill never gave any advice; he sat and smoked and told stories of the 14 point buck and
the gun slinging doctor and what was in the office safe. The summer after a desolate sophomore
year when Orville was bored half out of his mind and depressed out of the other half,
Bill began to take him around with him, let him help out in the office, go on house calls
out in the county, learn about medicine. What a time that had been, deliveries, deaths,
and everything in between. The shy boy opened up to the kindly man. Orville had been enthralled
by the realness of doctoring. The intense contact with people at the crucial times of
their lives had often helped them heal. It was incredible for the boy to see that things
actually happened in life, actually got done. And thatís one of the great things about
medicine. Now starting across the desk at the old doctor, Orville realized that for
Bill to, given his suffering with his handicapped only child who had died young, their friendship
had not only been an opening but a rejuvenation. Bill got in the habit of calling Orville when
there was a particularly interesting house call or emergency. Have I ever felt more at
peace Orville wondered, then in the dawn light, alongside Bill in his black caddy on the drive
home from delivering a baby somewhere out in a godforsaken shack in the middle of nowhere.
This man had grown him up. And then Bill says at the end of their meeting, yeah, there are
a lot of rumors in this town. The only person who really knows whatís going on around here
is me. People tell the truth in here. A fellow like me gets to lift up the lid, peak in under
the edge and see past the bullshit. And thatís another reason I wanted to write this book
is because I realized that if youíre any good as a doctor, if you listen, if you really
listen, empathically, you will hear the truth. Youíll hear the truth from your patients.
It may take awhile, a couple of visits, but youíll hear the truth and the truth is usually
the best clue to diagnosis, even now. And also in our societyóoh, the other thing about
being a doctor in a small town is you hear the truth in your office and then you hear
the lies, socially, when youíre mixing with people, you know, which is kind of interesting.
And in the era when truth is less and less a cherished commodity in our society, you
know, given all the advertising and political stuff. As a doctor itís very rewarding to
be in that reality, right. The last thingóas I said every book I write is a love story,
and this has oneóis one. Heís finally stayed in the town for awhile, part of that year.
Itís still the winter and heís fallen in love with a historian named Miranda, and this
is after theyíve had their first intimate contact. But heís on call. His beeper roused
him at 2:00 in the morning, the delivery ward, something urgent. The nurse had paged him
for a delivery of twins. Heíd been tending the couple through pregnancy, her first. They
were poor and black, a man and woman heíd known vaguely as a girl and boy. Thereís
something wrong, the night nurse was saying, come quick. Wrong, big time, he realized.
The tap of death on a babyís shoulder. He explained heíd have to do an emergency c-section;
the couple agreed. He scrubbed in fast and did the section. Twin boys, one was well formed,
robust, squalling. The other microcephalic, his head the size of a dolls but with lips
and nose and eyes crammed together with no forehead giving it a frog like look. Trunken
legs normal but for a remnant of tail; it was horrible to see yet transfixing like something
you see in a bottle of formaldehyde in a medical museum. The nurse took the healthy baby to
the father, leaving Orville to wait for the other to die. Luckily, and quietly by the
time he had gotten done with closing the groggy new motherís abdomen it did. Orville went
out to the father; he was still holding the healthy baby in that awkward way that new
fathers do. The nurse had told him the other had died. What happened, the man asked, in
shock? The other baby lived only a few minutes, it was deformed. Can I see him, doc? Orville
hesitated. The older doctor in him, the good ole Doc Starbuck would have patted him on
the shoulder, no son, better you donít. The younger doctor applauded his wish, though
knowing that once seen, it would be indelible. Orville said, you can, sure. I just want you
to know youíll never forget it. Him, the man said, I want to see him. The nurse took
the healthy baby; Orville and the father went into see the other son. Heíd been cleaned
up so he looked better, less frightening. The father reached out a hand and touched
a perfect shoulder and then the squashed head. He bowed his own head and then crossed himself,
in the name of the Father, the Son and the Holy Ghost, Amen. He looked up at Orville,
his eyes were wet, sorrowful. He said, thank you. And you, Orville said, feeling in this
man the power of facing into in a world that as a rule turns away. I think sheíll want
to see him, too. Fine. The father picked up the dead baby to take him to his mother. Orville
got beeped away to tend to a drug overdose from the Bliss Towers Housing Project and
a stabbing victim from a happy household, and a car crash and several Christmas specials,
including a Sheppard from Austria that was sure he was picking up radio free Europe through
a metal plate recently placed in his skull. A normal night. Later during a break in the
action he walked out into the parking lot and searched in his pockets for the half smoked
Progie cigar and matches. The night was crisp, the little town was iced up and the air tasted
like cold quarters and seemed stretched tight as an eardrum so it was like you could hear
everything. He thought of the dead twin who would always be almost there floating there
like all the dead, and the live twin. He thought of Miranda, of their histories, of their love
making and he whispered out loud, this is the one that will survive. So
when you write a novel you really donít know
what itís about, you know. Youíre not interested in what itís about because youíre so involved
in the characters, in the story and itís kind of writing itself, etc., and youíre
using all of my 40 years of skill at this, until somebody tells you what itís about.
So a friend of ours, a woman, said, hey, you know what this is about? And I said, what?
She said, well, itís like itís about this youngish doctor who comes back to heal the
town and the town heals him. Heal is an interesting word; heal goes both ways, you know, to heal,
right. And thatís right. One of their viewers said about this book that itís a perfect
bookend to the House of God because the House of God is on the wards and it shows you how
to kind of get through that experience. This is about how you be a doctor in a town, in
your life. This is how to be a doctor in your life, kind of, right. What happens is this
guy comes back to this broken down, horrible town and heís forced to be in relationship,
be in connection with a whole slew of these towns people and he canít leave. And through
that process something else happens. So this book is really about something more basic
than the others. Itís a story not just for doctors but for everybody. And itís about
suffering; we all suffer, everybody is going to suffer. You canít get around that; thatís
the first noble truth of the Buddha, right, there is suffering. The issue is not the suffering;
the issue is how you walk through it. If, as, you know, one model of this is if you
decideóand this is more of the male modelóIím going to gut it out, Iím going to stick it
out, Iím going to, you know, get through this no matter what, myself, youíre going
to suffer more and youíre going to spread more suffering around. And one of the things
this hero here is at a crucial point in this book, itís like he hears a voice in his head
when he has to make a decision and it says, donít spread more suffering around. Whatever
you do donít spread more suffering around, which is not a bad thing for doctors to know,
too, right. Donít spread more suffering around. If you walk through it alone youíre going
to spread more suffering around. If, on the other hand, you walk through the crucible
of suffering with others, with caring others, and thatís where we come in, rightóas I
said these crucial moments where weíre thereóif you walk through this crucible of suffering
with caring others you will suffer less and you will not spread more suffering around,
and you might even come out of it with more understanding and even redemption. Thank you.
Yeah, obviously this book is written and it sounds like youíre training in the 70s, and
thereís been a lot of changes trying to make the practice of residency and internship [inaudible]
with our limitations and different bureaucratic as well as, you know, sort of mentoring type
of person. How different do you think it is now compared to as far as formulating physicians
who have been [inaudible] or better suited to care for these things. Well, thatís a
good question. Itís better and itís worse. I mean, I know thereís a lot of controversy
about limiting hours and there are good arguments on both sides actually. Iím not exactly sure
where I come down. But I do know from my experience, and itís written in the House of God, and
anybody whoís been on call every other night for awhile know the worse thing for you and
a patient is if youíre exhausted. You canít think straight, you know, and so I applaud
limiting hours. Although, as I say, I know there are other sides to that argument especially
surgeons. What do they say in the House of God, the only problem with admitting every
other patient is you only get to do half the operations or something like that. The things
that are better are, number one, women in medicine. You know, when I wasómy class of
100 had 10 women and now itís 50 or 60 percent in every medical school Iíve been at. And
the good thing about that is that women are valued more in the culture for the qualities
of empathy, care, concern, maintaining relationships, those kinds of things. And those things do
translate into the hospital environment. I think we have seen that in some ways. The
problem in terms of really getting those kinds of ways of being with patients, more embedded
in the culture of the hospitals and the academic institutions is that there are many, many
feweróas you know, women that stay in the system to become professors or administrators
than there are men so that kind of gets lost, and there are certain reasons for that. But
women is one big thing; I think thatís helped. Another thing is the thing that we used to
call the new age movement, which is now taken for granted. All these other ways of helping
patients, you know, I mean, acupuncture, we didnítóI didnít know what acupuncture was
when I was in, you know. You name it, thereís all theseómeditation, you know, John Cabotís
work on using meditation may help reduce stress, all that stuff. Anyway, thatís another thing
thatís better now. The whole, I mean, I worked for awhile in a biotech investment company
and so we saw all of the last ten years of, you know, the greatest inventions all over
the world. The things that we can do now, you know, Iím the proud possessor of a really
good hip and, you know, both things. You know, the things we can do now are amazing; theyíre
absolutely amazing. The technology for how we can deal withóthe other thing that I think
is a great thing is the hospice movement. That never existed back then either. We didnít
know what to do with these aging people and thereís a whole new field for ontology. So
there are a lot of very good things that have happened. There are a lot of things that are
not good. One is just the direction of society where families are fragmented, you donít
have contact with patients for an extended period of time, the patients donít usually
live where their supports live, that whole thing. You know, I already mentioned, I think,
theóweíve got it backwards in terms of what good healthcare is, really. I mean, you know,
there are starting to be some movements but preventive care is so much more important
in some ways, you know. I mean, where do we start. Talk about what people eat, you know,
talk about what people eat. At the Inter Quality meeting I heard just one statement on the
radio yesterday driving in the car; in the 50s the poor segment of the population ate
the best and the upper classes ate the worst, you know, and now itís absolutely different.
As you know, I mean, if there are any divertologists [phonetic] here, there is going to be this
tsunami, right, this tsunami of obesity associated with diseases. So on a lot of different fronts
I really am worried. You know, we have the capacity to really save people and do better
but in the bigger world, you know, weíre going to have a hard time delivering that,
we really are. And one other just quick thing about healthcare, you know, we have a house
in Costa Rica, my wife and I, and, you know, we chose it partly because itís a country
that in 1948, by Constitution, said they could not have an army. Now you have to understand
I was born in 1944. From the day I was born until what looks like an extension past 2014,
that Obama announced last night in Afghanistan, right, what is that? Thatísóhow many years
is from 19444 to 2014ófrom a lot of yearsómy whole life this country has been at war, mostly
declared, sometimes not. And Costa Rica uses all the money that they would have had for
the Department of Defense and maintaining an army, they have an incredible healthcare
system, free, totally free. They have a good educational system thatís free. I mean, in
this little village down in the mountains, somebody who was with us hurt their head,
brought them down there. You know, it was a bit of a severe laceration, walked into
this little tiny clinic, immaculate, just like the best youíd see around here, fully
trained doctor, fully trained nurse, fully trained pharmacist, saw him, did everything
right. Pharmacist handed him antibiotics and boom, that was it. I mean, you canít have
it both ways. I think the biggest problem for healthcare in this country is, you know,
over half of my tax money going for the Department of Defense. And, of course, the other big
tsunami thatís going to hit are the vets, you know, the vets from these two wars now.
As everybody knows, horrible, lasting intensive care diseases. I donít know where that money
is going to come from. The VA is one of the best systems. Anyway, better and worse. The
best of times and the worst of times. Yeah? Hi, thank you for your talk. I have a two-part
question. The first part is about the inner world and the second part is about the outer
world. Good. So the first part, it sounds like most of your career youíve been juggling
being a writer and being a doctor and I was wondering if you ever experienced the tension
of wanting to be
a good doctor and wanting to be a good writer and if those were competing with each other?
I mean, it sounds like one informed the other in both ways. So how did you deal with that
tension if you had it because time to spend on one thing is time away from the other?
And my second partóletís do the first part. Okay. Iíll forget it thatís why. Thatís
a very good question for any of you who want to be writers as doctors. You know, you find
out what your passion is and mine wasóIím happiest when Iím writing so that was going
to survive. And I think you have to be practicalóif you want to write things from your heart then
you have to have another job, you know, I faced that choice. If I wanted to be a writer
and support myself I would go to Hollywood or, you know, TV or movies. Thatís where
the money is. But I didnít want to do that; it was too important to me, you know. So then
itís a question of, okay, what job can you choose, and for me, as I said, it was, you
know, Iíd already been accepted at Harvard Medical and I loved medicine. I didnít like
the pre-clinic years but once I got into the clinic I loved it. My heroes were doctors
as writers, you know, Chekhov, he was the greatest doctor writer. I have a letter from
him up over my desk, you know, and many others. You have to find something that will allow
youówell if you want to write what I write, which are novels, which are long things, they
take a lot of years or plays, which also if you do it right take time. You need something
that will allow you time every day. If you notice, to my knowledge, maybe Iím wrong,
there are no surgeons who have written really good, long, I mean, quality long novels or
just novels. You know, you donít see surgeons very often writing novelsóyou know, they
write thrillers and stuff, but I mean, things that really, you know, might be around for
awhile. Like my friend is a wonderful writer [inaudible] you know, he does what most surgeons
do, he writes short pieces, you know, essays, a book of essays, non-fiction. I think also
one thing you might want to learn if youíre thinking about becoming a writer or a doctor,
I thoroughly convinced that you either have a non-fiction brain or you have a fiction
brain. I do not have a non-fiction brain; it kills me to write non-fiction. I like,
you know, going places. So, you know, if you want to write non-fiction things then it doesnít
matter what you choose in medicine because you can write essays, short stories, etc,
that will work. If you want to write longer things I think you have to choose something
that will allow you time every day. And I was delighted to find that with psychiatry
I could have the mornings free. Now the problem with thatóthat sounds easy but itís very
difficult. I had to learn toóitís like when you do physical exercise. I had to do emotional
exercise to, you know, write fully in the morning and stop around 11:00 or so and then
switch to, you know, listening to people fully in the afternoon. And it didnít work sometimes;
Iíd be sitting there with a patient and Iíd think aboutóone of the novels I had been
working on, it was in China, set in China. Iím thinking Iím still in China. So itís
a skill to learn. I think you could be good at both but itís wearing. Itís much easier
now. For about five years I have just been a writer. But Iím afraid, in this day and
age especially, if you write crap you need another job. You know, itís amazing whatís
happened in publishing now. The thing that publishers are looking for now, mostly, frankly,
sounds like kind of like sophisticated blogs. You know, theyíre lookingóthey literally
are looking foróthey go and search blogs of people to turn into, even fiction. Anyway,
whatís the second question? Well you lead into my second question, which was the practicalóhow
you write dailyóthe question was, do you wake up in the morning and what kind of practice
you had in the afternoon that allowed you to take the mornings off. Just the practical
andójust likeóI appreciate the discipline youíre saying then. Well I can tell you a
little more detail. I mean, I think if youíre planning the business for thoseóif you want
to be a writeróif youíre planning to try writing you have to find for yourself what
is the best time for you to work and how many hours and, you know, do you use your typewriteróI
know you donít. Actually, you know, I have been part of thisóIíve been part of the
revolution because I certainly worked on the typewriter and then I was one of the first
to getóanybody here remember a Wang word processor? They had this great word-processing
program back in 1982 or something so I made the shift. I said this is going to be a lot
easier, you know. And actually my friend John Updike, he was so impressed by this, you know.
He thought, hey, I could be more productive, tooóproductive, right. So he got one, and
guess what? It made it harder for me to write. It took longer. Guess why? Because in the
past when you when you were on the typewriter and you had youróif you had a bigger correction
and you had to re-type the whole damn page, you were pretty damn ready by the time you
got to type you knew what you were going to do. Not everything, but you knew pretty much
your intention before you hit the screen. You know, now as our daughter isóboom, everything
is up on the screen. You think you can fix it later and in non-fiction you canít but
in fiction itís a lot more difficult. But anyway you find the way that you write. I
happenómost people do it in the morning. And then you have to find out, you know, once
you get your whatever media, whatever youíre doing and what kind of writing, fiction, non-fiction,
etc, how do you rewrite because, as I said, I have to do these things seven times. I take
comfort from the fact that Tolstoy rewrote War and Peace seven times. Actually, thatís
not quite true. His wife rewrote, he dictated to her. It finally got to the point where
his editoróhe wanted to revise it and his editor said, will you stop your infernal scribbling.
Itís a great book. So, you know, how much you have to rewrite and, you know, the emotional
how you do it, how you get that critic out of your head, you know. Maybe one more and
then weíllóyeah, sureóand then weíll stop. Thank you; Iím a big fan of you Dr. Bergman.
Thank you. I have a question, a recent survey; it just came out this weekend, so it said
that 54 percent of doctors, if they had to do it again, wouldnít. So I guess this is
a two part question for you. One, reading the House of God made it seem likeóI was
actually shocked at how low that number was. It seemed to me that most of the characters
in the House of God seemed like they would do it again if they could. It wasnít a very
difficult process to go through. Do you think itís gotten better in that sense is the first
question. The second questionóokay, repeat theóI didnít quite get it. Whatís gotten
better? Do you think medical education, in general, or the process of becoming a doctor
has gotten better? Do you see the process getting better or worse? And the second question
is if you, personally, had to do medicine again, would you? Yeah, those are good questions.
Medical education has, I think, gotten better and worse. I think the pre-clinical years,
you know, all the different ways theyíre being taught now with more of an awareness
of actual patient, I think thatís all better, I really do. You know thereís so much that
you really donít have toówell, Iíll go back. Someone once said to me you forget information
but you never forget when you understand. And, you know, I still remember my first interview
patient in medical school. You know, like where Kennedy was shotówhere were you when
Kennedy was shot or the World Trade Towers. Youóitís an interesting thing in the brain.
You never forget something thatís linked to an emotion so I think thatís a key thing
to medical education now and I think itís a much kinder, gentler way and all the new
age stuff and meditation for stress and all comes in. I donít think that the clinical
yearsóI mean, Iím not in it so much right now but I have been up untilóI donít think
the clinical years are much better, I really donít because these systems, as I said, wellóshift
that a little bit. I think the smaller medical schools itís better because they focus more
on the kinder, gentler specialties like maybe family medicine or things like that, pediatrics.
Harvard, you know with Harvard, itís probably the mostóyou know, in a culture as [inaudible]
noticed, itís very self-centered. Itís the most self centered of the self centered so
I notice in Mount Misery these people are sitting there interviewing their patients
with an eye on what paper they can publish, you know, theyíre half with the patient and
thatísóthat wonít work. So in the big medical academic centers, I think itís worse because
thereís this tremendous competition for grants, promotions, etc., and the other factors I
said. But I have come across really wonderful training programs that go right through residency
and theyíre usuallyówell, Iíll just think of one. Like in North Dakota, you know, I
spoke there and the wholeóthere are several states, actually, where they really put an
emphasis on if you go to this school we expect you to go back and practice in this state,
Southern Illinois and North Dakota Medical School. In the last year, both of those things,
I think they absolutely find a doctor to work with them for a year, you know, and thatís
a wonderful experience. Theyíre ready to go. I mean, one of the real good changes,
I think, in my lifetime, in medicine is that it used to be that doctors would make the
most money and have the most prestige in their communities, right. Every survey, I mean,
rich people in my town were doctors and they had the most prestige. That ainít so anymore,
and thatís kind of good because people are coming into, you know, 60 percent from Harvard
go into finance every year. But the people who go into medicine now theyíre doing it
because they want to be doctors, you know, most of them, and they bring those skills
there. Would I do it again? Well thatís aóas I said, Iím not sure that my choice was very
relevant here. You know, Iíll tell you one last piece of that. When I graduated from
medical school and was thinking of doing an internship I knew I wanted to be a psychiatrist
at that time. And I could have gone directly into my psychiatric training without ever
having done any medicine in a hospital, right. I could have skipped a whole year. But I said,
lookófor some reason I said, look, I want to know how to do this. Iíve spent all my
lifeóI was still afraid of writing an order to give aspirins to a patient, you know, they
werenít trained in some internships in those days, you know, we knew nothing. At Harvard,
we knew so little at Harvard Medical from our clinical rotations that the most attended
course was just before we graduated somebody, I forget his name, ran a two day course of
all the things you really had to know to go into your internship. Everybody is writing,
you know. But I didnít have to do an internship atóa medical internship. But I wanted to
complete, I wanted to be able to say Iím a doctor, I know how to treat patients. And
actually I moonlit that after the internship. Well guess what, if I hadnít made that choice
there would be no novel. I probably would never be hereóI know I would never be here;
I would have been writing plays, you know, and not doing very well. So itís hard to
say; Iím thrilled at the way itís worked out. Those are good questions; thank you.
Thank you. Now everybody can go and buy a book. [Applause].

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