The Doctor’s Dilemma by Daly Walker MD

In his new compilation of 16 short stories titled The Doctor’s Dilemma, Dr. Daly Walker provides a stark portrait of physicians facing their own and their patients’ mortality, as well as navigating the practical morality of medicine —striving to do “right” in complex circumstances.  As a retired general surgeon and accomplished writer, Dr. Walker melds intimate knowledge of medicine and particularly the surgical theater with a profound insight into aging, intimacy and loss.  His archetypal character is an aging surgeon facing degradation of skill and encroaching self-doubt—changes that bring a sense of insecurity, a questioning of identity and a loss of control.  His protagonists project outward strength and heroic intent, but struggle to find grounding in fraught relationships and their identity as physicians. This noble effort—to be present and perfect for one’s patients and loved ones, while reckoning with one’s fallibility and insecurities—is familiar to any physician. But that inclination is also highly relatable to general readers coping with the demands of daily life.

 Dr. Walker writes what he knows in vivid, engrossing detail.  Most stories are set in small-town Indiana, where he was raised and worked for decades as a surgeon.  A Midwestern sensibility permeates his work in the jocular traditionalism of the surgeons we meet and in the dignity and modesty of other small-town characters. Dr. Walker brings further autobiographical elements; his characters are often veterans of wartime surgery with wisdom and relationships borne from intense, chaotic environments.

The Doctor’s Dilemma is divided in three sections: Mortality, Morality and Immortality, though these themes are often intertwined.   A group of stories present aging surgeons losing skill and confidence, or on the other side of that deterioration.  In “One Day in the Life of Dr. Ivan Jones,” we feel the confusion and disorientation of a retired neurosurgeon with dementia, as well as his physician son’s grief and struggle with his father’s loss of self. In “Old Dogs,” an aging surgeon has shaky hands and battles through a difficult aneurysm repair with scrutiny from an audience in the OR.   We are asked to consider the value of life as absolute or relative— for a hemorrhaging Jehovah’s Witness patient where transfusion might negate an eternal afterlife; for a death row inmate needing intubation in the setting of scarce resources in a pandemic ridden emergency room. In “India’s Passage,” there is a gripping account of a young woman’s death during a routine laparoscopic surgery, and the oppressive guilt felt by the surgeon as well as the extreme grief and judgment of the woman’s mother.  Ultimately there is reconciliation, but no character emerges unchanged from this tragedy.  

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Daly Walker MD is retired from a general surgery practice in Indiana. He is a graduate of Indiana University Medical school and served his residency at the University of Wisconsin. He served as a battalion surgeon in the Vietnam War. A fiction writer, his stories have appeared in numerous literary publication including The Atlantic. “Resuscitation,” one of the stories in The Doctor’s Dilemma, appeared in the FALL 2020 Intima. 

Author photo: Sally Carpenter

Stories also focus on morality with physicians trying to do the “right” thing for their patients and their loved ones and neighbors.  In “Drumlins,” an older surgeon physically marred by skin cancer surgery compassionately treats a young woman losing her breast from cancer.  In “Jacob’s Ladder,” a retired orthopedic surgeon who lives a solitary life in the woods, having lost his wife, pines for the companionship of a young woman and ultimately saves her from an abusive partner and her son from the consequences of retribution. The idea of responsibilities of son and father comes out in several stories: In “Crystal Apple,” a physician who recently lost his mother is startled by the discovery that his father is not who he thought and grapples with his origins.   In “Nui ba Den,” a surgeon reconvenes with a lover from his time in Vietnam decades later, and contemplates how the past influenced him and how his present self views the past.  Mortality and morality are intertwined in “Blood,” where a mother adamantly refused blood transfusion for her critically ill Jehovah’s Witness son who is a minor; in “Pascals Law” where a physician intubates a man on death row; and in “Resuscitation” (first published in the Fall 2020 Intima) where a man stricken by Covid is intubated though other patients may have a greater likelihood of survival. 

There is an immediacy to Dr. Daly’s imagery and language; his prose style is straightforward and deceptively simple in light of the issues he addresses, as this passage about a doctor’s thoughts after a challenging day at the hospital from “Resuscitation” demonstrates:

On his way home, Slater drove through the rain. The silent, empty streets and unlit shops conveyed an aura of apocalypse. The drops that splattered his windshield reminded him of contaminated droplets spewing from Mr. Bertini’s lungs. The car’s wipers slapped side to side. Slater had read Camus’ The Plague, and he felt like Dr. Rieux traveling through his plague-stricken city, finding it hard to believe that pestilence had crashed down on its people. He came to Shoofly, a chic bar and restaurant. Through a water-speckled window, he could see young people laughing and drinking, crowded together without masks. Their gaiety and disregard for the virus angered Slater. Don’t they care about others? He blamed them for him not being able to hug his children or sleep with his wife. He blamed them for Mr. Bertini’s illness. He wished they could see his patient and know what fighting for your life is like.

A Doctor’s Dilemma brings fresh insight and reflection to enduring themes of medical and surgical care—how to be human and have immense responsibility for one’s patients; how to balance the personal and professional knowing that perfection is impossible; and how to forgive oneself for that imperfection knowing that good intentions and hard work may need to be sufficient.— Eli Hyams MD 

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Elias Hyams MD is an adjunct associate professor of urology and a robotic surgeon at The Warren Alpert School of Medicine at Brown University in Providence, RI.  He has previously served on the faculties of Dartmouth’s Geisel School of Medicine and Columbia University School of Medicine.  He completed his undergraduate studies at Yale and is a graduate of the University of Pennsylvania School of Medicine.  His residency at New York University-Langone Medical Center was followed by a fellowship at John’s Hopkins. His academic interest lie diagnosis and treatment of cancer of the prostate.

Departure from the Darkness and the Cold: The Hope of Renewal for the Soul of Medicine in Patient Care by Lawrence J. Hergott, MD

The balm for this difficult year can be found in the pages of Departure From the Darkness and the Cold: The Hope of Renewal for the Soul of Medicine in Patient Care (Universal Publishers) by Lawrence J. Hergott, MD. This collection of essays and poems seeks to renew the “soul of medicine,” constantly being threatened by competing pressures commodifying medicine. Both a retreat and a back-to-basics call for engagement, Hergott’s poignant writing confronts the most unifying themes of humanity: purpose, loss, connection and more. 

In the essay “The Time of the Three Dynasties,” Hergott reckons over the tragic death of his farmer brother-in-law, comparing the similarities of his hard labor and work/life imbalance to a life in medicine. The lives of him and his medical colleagues are prestigious but not free from heartbreak: a letter from a neglected daughter, a distant spouse, never making it home before the 10 p.m. news are the emotional fall-out from a life of clinical commitment. He confronts fellow physicians with difficult questions such as “How much work and reward are enough? How much is too much? Who has control? Do we know the real cost? Who pays the price?” 

In the tender poem “Loving Her,” a patient visits his late wife’s grave daily. The visit is more event than chore, more conversation than monologue. This is a clinical encounter with “clinical concerns aside,” where a physician is simply happy for his patient and the content days he spends “near her, or what was left of her, in the ground and in his heart.” The poem is a testament to really listening and knowing who and what is important to a patient, a person with a life outside the exam room that a physician can only begin to fathom. 

Lawrence J. Hergott, MD, author of Departure From the Darkness and the Cold: The Hope for the Soul of Medicine in Patient Care

Similarly, in “The Absence of Something,” the grief and loss patients experience are no different than that experienced by physicians. Hergott is able to relate to his patients’ losses because he too has suffered an incalculable one—the death of his son. “While the circumstances of our loss are uncommon, our suffering is not extraordinary.” He has learned of the “different kinds of absences,” like the loss of personhood in dementia or stroke, committing to always attend to these absences like physiological maladies. 

The author delivers hope and reassurance to the surgical patient in the poem “A Small, Sacred Space.” He weighs the post-surgical outcomes of normalcy, complication, and tragedy all with loving promise. “You will wake up to no difference between who you are and who you are.” A humanistic take on the informed consent conversation, he insists, “You will not be alone. You will not be apart.” Rather than instilling false hope, Hergott offers love no matter the result. 

In documenting his own lessons and heartache in medicine and in life, Hergott offers a manual of wisdom to fellow physicians on how to humanize themselves, their patients and one another. Each poem and essay is a portal into how to frame issues in medicine in ways that can rejuvenate and tackle the burnout that is so widespread to the profession. Medical students, trainees and seasoned physicians alike can all encounter self-transformation in this poet-physician’s timely collection.—Angelica Recierdo

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Angelica Recierdo

Angelica Recierdo works as a Clinical Content Editor at Doximity in San Francisco, CA. She received her Bachelor of Science in Nursing from Northeastern University and her M.S. in Narrative Medicine from Columbia University. Angelica was also a Global Health Corps Fellow in 2016-17. She has worked at the intersection of health and writing/communications, specifically in the fields of healthcare innovation, health equity, and racial justice. Angelica is a creative writer, and her work can be found in Intima: A Journal of Narrative Medicine, Literary Orphans, HalfwayDownTheStairs and The Huntington News, among others. Her essay “Coming Out of the Medical Closet” appeared in the Spring 2014 Intima.

This is Going to Hurt by Adam Kay

This is Going to Hurt by Adam Kay

This Is Going To Hurt is a memoir from British comedian, writer and former doctor, Adam Kay. The book, published by Picador in 2017, follows Kay’s journey from a junior doctor to senior registrar (or resident to attending physician) specializing in obstetrics and gynecology. The memoir is presented as a series of journal entries that he wrote throughout his former medical career, originally intended as a means of cataloguing intriguing clinical cases.

However, his recollections are far from formally academic: Kay’s unabashed bluntness allows for an unfiltered and honest reflection of his time working under the UK’s National Health System (NHS). The book covers a wide array of healthcare topics including the doctor-comedian’s thoughts on the NHS’s treatment of its doctors; his co-workers or “drug-dealing scrotes” that erroneously prescribe diuretics to dehydrated patients; and what he describes as “Eiffel Syndrome”—the common “I fell” etiology voiced by patients presenting with household items lodged in their nether regions. Kay’s wicked commentary keeps the reader engaged with risqué, crude humor that no practicing physician would (rightly so) feel comfortable dispensing.

 A praise-worthy feature of Kay’s narrative is his inclusion of informative and equally entertaining footnotes on the bottom of each page to explain the medical terminology referenced in each account. This makes the book accessible to the non-medical reader, who will learn more than a thing or two about medicine by the time they’ve reached the last page. For example:

 *APGAR scores are the standard measure of how well a newborn baby is doing—they get marks for Appearance, Pulse, Grimace, Activity and Respiration. It was devised by a doctor called Virginia Apgar, which makes me think that she chose arbitrary measures just because they fitted with her surname. Like if I decided that the best measures of a baby’s health were Kicking, Applauding and Yawning. 

 This Is Going To Hurt is steeped in themes of physician neglect, a topic of growing relevance in today’s healthcare climate, with increasing concerns over physician-burnout and resilience that have been elevated during the novel coronavirus pandemic. While the memoir’s title is a nod to the cliché that a doctor tells a patient before inflicting procedural pain, it also reflects the mental and emotional toll physician-hood took on Kay. In one example, Kay cites a traumatic case involving a patient with placenta previa, for which he received no support from the NHS after its devastating effects. The experience was a tipping point for him that led to depression and eventually prompted him to retire his white coat for good. Physicians, Kay reminds the reader, are just people too, something he believes healthcare establishments and patients often lose sight of:

“…patients don’t actually think of doctors as being human. It’s why they’re so quick to complain if we make a mistake or if we get cross. It’s why they’ll bite our heads off when we finally call them into our over-running clinic room at 7 p.m., not thinking that we also have homes we’d rather be at. But it’s the flip side of not wanting your doctor to be fallible, capable of getting your diagnosis wrong. They don’t want to think of medicine as a subject that anyone on the planet can learn, a career choice their mouth-breathing cousin could have made.”

Author, comedian and former doctor Adam Kay.

 Still, he gives equal time to the rewarding feelings he experienced when helping patients, delivering babies and treating couples with infertility issues. At trying times, it made him feel like a “low grade super-hero,” and it was this sense of satisfaction and purpose that allowed him to continue being a doctor for as long as he did. He finally summarizes his medical career with both dreariness and heart:

 “The hours are terrible, the pay is terrible, the conditions are terrible; you’re underappreciated, unsupported, disrespected and frequently physically endangered. But there’s no better job in the world.”

Adam Kay’s memoir is an entertaining account of a physician-turned-comedian’s triumphs and struggles through their medical career. His new children’s book, Kay’s Anatomy: A Complete (and Completely Disgusting) Guide to the Human Body, will be available this year.—Fredrick Martyn

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Fredrick Martyn

Fredrick Martyn is a Canadian writer, poet and medical student at The George Washington University School of Medicine and Health Sciences in Washington, D.C. This summer he will be beginning his residency training in family medicine at Western University in Ontario, Canada. He is a contributing writer for the medical satire website Gomerblog, as well as other online humor publications including Points In Case, Slackjaw and Little Old Lady Comedy. He also acts as a director for his medical school’s comedy show and can sometimes be found performing his poetry at Busboys & Poets, in D.C.

Articulations: The Body and Illness in Poetry by Dr. Jon Mukand

Articulations: The Body and Illness in Poetry (University of Iowa Press, 1994) is a collection of over four hundred poems compiled and edited by poet and physician Dr. Jon Mukand. This is the second medical poetry collection assembled by Mukand, the first being Sutured Words (Aviva Pr, 1987).

What makes Articulations remarkable is the accessibility of the material, primarily through the diversity in the perspective it offers, beyond that of just the physician. The collection is divided into categories that include Patients’ Views of Illness: The Darkness Within Me Is Growing, Views of Caregivers: Gentleness and the Scalpel, By Healthcare Workers: Dissecting the Good Lines from the Bad and Family and Friends: Afraid to Name This Dying. There is also poetry from more marginalized perspectives within the healthcare system with categories entitled, Women: Flowers of Ether in My Hair, Mental Illness: The Shadow of the Obsessive Idea, Disability: Their Lockstep Tight as Lilac Buds and Social Issues: Hungry and Frightened by Namelessness. The inclusion of these latter categories of poetry is especially meaningful and somewhat revolutionary—given that the collection was originally published over twenty-five years ago. These diverse categorical titles are also displayed on the book’s cover art; they circumnavigate an image of a jointed skeletal hand, likely symbolizing the distinct perspectives or “articulations” present within the field of healthcare.

There is a poem for everyone in Dr. Mukand’s book. Some are more generally relatable like “Waiting for the Doctor” and “Blood Pressure.” Others are more specific, like “After Being Paralyzed from the Neck down for Twenty Years, Mr. Wallace Gets a Chin-Operated Motorized Wheelchair.” Some are tinged with dry humor— like “The Urine Specimen,” while many veer far from the lighthearted, including “Rape” and “To A Young Woman Considering Suicide.” No poem in the series is particularly verbose ,and most are no more than a page. This brevity contributes to the poems’ digestibility and accessibility.

Even poems peppered with medical references can still be appreciated by the majority of layman readers. An example is a poem entitled “Peau d’Orange” from Marcia Lynch about a patient with inflammatory breast cancer. Anyone who has completed medical school training will recall the poem’s title as a nod to the dimpling skin changes seen in inflammatory breast cancer, characteristically described as “peau d’orange,” which is French for “skin of an orange.”. In it Lynch writes, “I accept you calling my breast an orange peel, let you lay hands on this fruit.”. While this imagery enhances the piece, it is not a prerequisite to understand and appreciate the poem’s message; it is merely an additional treat for the medically savvy reader. Even without knowing the specific textbook nomenclature, the poem still hits hard with pleading lines like “If you lift the chill, that unravels my spine, I will send you stars from the Milky Way. Sending them spinning down, dancing a thousand-fold. Please let me grow old.”

In Mukand’s introduction to Articulations, he explains that he hopes “these poetic articulations will help patients to cope with illness, friends and family to understand the patient’s condition and healthcare professionals in their challenging work.” The collection achieves this through offering a diversity of well- packaged perspectives from all walks of the healthcare spectrum. It is poetry that is accessible not only by the seasoned physician who regularly reads The New England Journal of Medicine but also by the people in that very physician’s waiting room who have never even heard of such a publication. —Fredrick Martyn

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Fredrick Martyn

Fredrick Martyn is a Canadian writer, poet and medical student at The George Washington University School of Medicine and Health Sciences in Washington, D.C. His poetry has appeared in Pulp Poets Press, Spillwords Press, Bonnie’s Crew and The Online Journal Community and Person-Centered Dermatology, among other places. He is a contributing writer for the medical satire website Gomerblog, as well as other online humor publications including Points In Case, The Establishment, Slackjaw and Little Old Lady Comedy. He also acts as a director for his medical school’s comedy show and can sometimes be found performing his poetry at Busboys & Poets, in D.C.

The Me in Medicine: Reviving the Lost Art of Healing by Patrick Roth, MD

For more information about the book, go to The Me in Medicine: Reviving the Lost Art of Healing.

What follows is a typical visit to the physician for back pain in the United States: A person hurts his or her back and sees a doctor for a complete workup. The clinician, careful not to miss anything, orders an MRI that is subsequently read by a distant radiologist. The report is sent back to the physician who, depending on the results, calls for a follow-up appointment to discuss outcomes. It is likely that the patient is sent to a physical therapist, who provides a therapy regimen based on the radiology imaging and his or her own experience without need for the physician’s specific prescription. While much can and has been written about this typical medical experience, from its inefficiency to its reliance on medicalization and overdiagnosis, it is the fragmentation and lack of contextualization that Dr. Patrick Roth has highlighted in his latest work, The Me in Medicine: Reviving the Lost Art of Healing.

With an increasing reliance on technology and the expansion of artificial intelligence in medicine, Dr. Roth paradoxically calls on physicians to embrace their philosophical faculties. He proposes that narratives, developed through introspection, as well as teaching, mentoring, and writing, are the missing components in our medical system today. The onus is on both patients and physicians to develop individual and, when they come together for a clinical encounter, shared narratives on health, disease, and treatment for better overall care.

For the patient, narratives mean coming to understand how he or she views health and disease. As Jerome Groopman explains in his book, Your Medical Mind, and Dr. Roth highlights in his, people have a spectrum of temperaments with regards to intervention: Some believe strongly in the human body’s regenerative capacity (naturalist) and others believe strongly in science, technology, and medicine (technologist). These proclivities are important for the patient to consider when making medical decisions, but only represent one piece of the puzzle.

Patients must also consider unconscious cognitive biases they have when making their decision for treatment. Common cognitive biases include the availability heuristic, a mental shortcut in which a person makes decisions based on readily available examples, and hyperbolic discounting, in which a person discounts future reward because of the time delay between the decision and the reward. For instance, using the availability heuristic, a patient may be hesitant to undergo a procedure because a friend had a similar procedure that did not end well, whereas using hyperbolic discounting, a patient may prefer a procedure because they perceive the reward as immediate as compared with the longer treatment course of physical therapy. While highlighting the patient’s decision-making heuristic is certainly not easy, it serves to both increase patient autonomy and satisfaction with outcomes.

The complexities of these medical decisions is the space where physicians, equipped with their own medical narratives, help the patient decide what is best. The physician has the ability to provide the context necessary for the patient’s choice. For this reason, it is incumbent on the physician to become a good storyteller. It is not enough to lay out all the options with statistics or paternalistically make the decision. Rather, believes Dr. Roth, the physician most effectively communicates through anecdotes and analogies for understanding disease ontology and treatment decisions.

There are a number of tools at the disposal of physicians and patients to accomplish these lofty, yet achievable goals. With honed doctoring skills, the physician can extract the patient’s motivations and contextualize them to reach a sustainable and satisfactory outcome. Further, the physician can foster self-efficacy and promote a deep education about disease. The patient, on the other hand, possesses knowledge that the physician is not privy to, i.e., the phenomenology of the disease. By joining support groups and forming online communities, patients empower themselves and shape the narrative of their needs for the medical community. Engaging in these exercises shapes not only the character of the patient and physician, but the disease process too, as it reforms a patient’s reality through changes in their thoughts and perceptions.

Medical science and technology naturally lend themselves to a reductive materialism with an approach that parses apart reality into molecular cascades and biotargets on which intervention is possible. Analogously, medicine, as a distinctly human endeavor, naturally lends itself to storytelling—the currency of effective communication and change. As such, Dr. Roth makes a formidable case for narratives as a staple of holistic medical practice. Narratives reform environmental context, which in turn shapes us and our health. With technology and specialization playing an ever-expanding role in our healthcare system, it will remain paramount to scrutinize our narratives and ensure they are always in service of our patients. — John Paul Mikhaiel

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JP Mikhaiel is a medical student at Georgetown University School of Medicine. After earning his BS in neurobiology and philosophy at Georgetown University, he spent two years at the NIH researching brain-related disorders. He is currently a member of the Literature and Medicine track at Georgetown University, and serves on the management board for the coaching program, A Whole New Doctor. His work has been published in Scope, Georgetown’s literary journal. Mikhaiel plans to pursue a career in neurology.