Story Specialists: Doctors Who Write

Abraham Verghese i i

hide captionAbraham Verghese is a professor at Stanford University's School of Medicine and the author of the New York Times best-seller My Own Country: A Doctor's Story. Cutting for Stone is his first novel.

Joanne Chan/Knopf
Abraham Verghese

Abraham Verghese is a professor at Stanford University's School of Medicine and the author of the New York Times best-seller My Own Country: A Doctor's Story. Cutting for Stone is his first novel.

Joanne Chan/Knopf

It's not uncommon for writers to have a day job. Lawyers write. Soldiers and teachers write. But there seems to be a special connection between the medical profession and the art of writing. The list of doctors who are also novelists, playwrights and poets is long, and quite impressive: Anton Chekhov, William Carlos Williams, Walker Percy, W. Somerset Maugham and Arthur Conan Doyle, to name just a few.

Doctors continue to add their names to that list. For Abraham Verghese, writing and medicine are inextricably entwined. Verghese, who is the senior associate chair for the theory and practice of medicine at Stanford University's School of Medicine, based his first book, a memoir called My Own Country, on his experience as a doctor treating AIDS patients in rural Tennessee.

"I think I was drawn to medicine with a strong sense of medicine being a romantic pursuit, a calling," Verghese says. "I still really am very much in love with medicine, and I love what I do. And I often think the writing emanates from that stance of being a physician. And I worry that I would become mute if I ever left medicine and tried to write."

Cutting for Stone
By Abraham Verghese
Hardcover, 560 pages
Knopf
List price: $26.95

In his writing, at least, Verghese is inching away from his own direct experience. He published his first novel, Cutting for Stone, this year. It tells the story of a family of doctors, a saga that takes readers into hospitals and operating rooms from Ethiopia to America.

Terrence Holt, who has a new book of stories called In the Valley of the Kings, comes from a family of doctors, but he was a writer and a teacher long before he decided to go to medical school. Holt's new book reflects his fascination with language rather than his life as a physician, but he insists that being comfortable in the world of literature is enormously helpful in the practice of medicine.

Terrence Holt i i

hide captionTerrence Holt is a specialist in geriatrics and a professor at the University of North Carolina School of Medicine. In the Valley of the Kings is his first book.

Terrence Holt

Terrence Holt is a specialist in geriatrics and a professor at the University of North Carolina School of Medicine. In the Valley of the Kings is his first book.

"You are used to dealing with ambiguities if you are familiar with literature, and a lot of medicine is ambiguous," Holt says. Even more important: "You get, vicariously, but in a very useful way, experience with other people that you couldn't get any other way, with seeing the world as other people see it."

Holt, who is on the faculty at the University of North Carolina School of Medicine, thinks writing can help reframe the experience of being a doctor.

"Patients bring us stories," he explains. "We drop into the middle of patients' stories and try to change the plot for the better. First we have to understand it, however. The first thing that happens when a patient comes in is they start telling a story, and you try to figure what it means."

In the Valley of the Kings: Stories
By Terrence Holt
Hardcover, 224 pages
W.W. Norton & Co.
List price: $23.95

"I think narrative is huge in medicine," Verghese says. He adds that if you listen carefully, you will hear clues needed to make a diagnosis: "It's very rare that some extra piece of knowledge in my brain solves the puzzle. Much more often it's the fact that the story I am hearing resonates with my collection of stories. Or there is an element in that story that reminds of something in my catalog of stories, and I go seek out the other element."

In Cutting for Stone, Verghese set out to create an epic story that encompasses family, politics, history, culture and love against a backdrop of life in and near hospitals. In an effort to reveal the inner workings of the world of medicine, Verghese spares no details in his descriptions of often complex medical procedures and the human emotions that surround them.

Visiting a hospital, Verghese says, means that, "Suddenly you are in this crucible where every human emotion, every passion is exaggerated; where great truths and mysteries are revealed for the first time, sometimes to close family. So I think hospitals are inherently places of great drama."

Holt's fiction takes place far away from hospital life, though one of his stories is about a plague that first appears on its victims in the form of a word. In another, a man is so obsessed with the idea that he is dying that he ends up in a tomb from which there is no escape.

Because doctors deal with death more than most people, Holt says, it should be no surprise that the ones who write would end up exploring the concept in their art.

"I think it is true that death is the mother of beauty," he says. "And an appreciation of human suffering and our limited tenure on this Earth is essential to seeing our lives and seeing the world we inhabit."

In a hospital, where the routine can quickly become a matter of life or death, there is precious little time to sift through the events of the day to uncover what it all means. In their time away from hospitals, it is little wonder that some doctors would turn to that most contemplative of arts, where they can be alone with their thoughts, searching for just the right words to find release or understanding.

Excerpt: 'In The Valley Of The Kings'

In the Valley of the Kings
In the Valley of the Kings: Stories
By Terrence Holt
Hardcover, 224 pages
W.W. Norton & Co.
List Price: $23.95

My Father's Heart

My father's heart beats in a glass jar on the mantel, a steady flickering at the edge of my eye. I try to avoid it, but by dinnertime each night I'm staring. Beneath my gaze it pulses, and perhaps it turns a richer purple. From the jar I hear a low, dull, quick sound, persistent as a muffled watch.

You may know already what a small thing a heart is. Close your fist. Dig your nails into your palm two times quickly. Repeat. There it is. But my father's heart is large — fully as large as my head. The wide-mouth jar upon my mantelpiece once held a gallon of mayonnaise. Now, with the heart inside, it takes but two quarts of saline to brim it.

Atop the fluid, faint ripples shudder. Through them, I see the stubs of the aorta, vena cava, and the pulmonary vessels wave faintly, jerking. I tap the glass, and the tentacles withdraw; as suddenly as a slug surprised the whole mass shrinks, then slowly expands, and pulsates at its former size.

It has been a difficult possession. I am nervous about letting company near it. They might flick ashes in the jar, or jostle it. They might want to take it home. Vacations are, of course, out of the question. Whether the saline evaporates, or the heart in some way consumes it, I cannot say, but each day the level in the jar recedes, and I must top it off. Once each month the whole thing needs cleaning: I plop the beating mass out on the kitchen table — a few minutes in the air don't seem to bother it — rinse out the jar, and refill. The heart retakes its seat unruffled, seemingly oblivious, except for a slight flush around the coronary arteries, a slightly grander bulging on diastole.

But I tap the jar, and it mimes surprise: Don't tap, it says; don't tap. There is a dry, bleachy smell rising off the saline, and the faintest whiff of sweat.

It has learned the trick of propelling itself around the jar. The left ventricle twitches, a wave spurts from the descending aorta, and the whole mass rises from the bottom; a delicate pursing of the pulmonary arteries steers. I have found it at times spinning slowly, tootling an inaudible tune from the upbranching aortal pipes. On each rotation, it brings into view the scarification surrounding one collapsed and knotted vessel. It sees me staring, and with an abrupt spasm turns itself. The tubules wave at me. Go away, it says, go away.

I can't remember when it came into my possession. The question seems odd to me. When I stop and consider, of course I know that it must have come to me, on some day and in some place, but I feel it has always been with me. I know I had it when I went off to school, and carried it around from rented room to room, in and out of boxes for four years, and sometimes never a proper place to put it, hidden or exposed. My sophomore year it was a doorstop, but the gesture was transparent, to me and it, and there was bad blood on both sides.

Lately, I have felt the old antagonism resurfacing. I awake at night, and feel my own heart thudding wildly. I have fears — did I dine on botulism? am I growing bald? — and hear a low, dull chuckling from the other room. It is as mute as Adam when I see it by daylight, but I have suspicions of its nights. I have these past few evenings, about the hour of midnight, tried sneaking up on it with a flashlight. The beam reveals only a sodden lump of flesh, slumped and snoozing, a bubble hanging on the slack aortal lip. My own heart quiets at the sight, although at bottom I feel there lurks a lump of anger — sleeping, but alive.

I have raged at it of late: Leech, I cry: Bloodsucker. It burps clear saline in mild protest; innocence sits on every valve. I am not taken in. It has not been so many years since I have seen it raging in its turn, swollen to the size of a dirigible, as full of gas and fire, stopping traffic across four lanes of Sixth Avenue. A cab driver had refused to carry it: "I don't haul meat." I spent the balance of that day in terror, cradling the jar in my lap (we took a bus), looking into it each time the saline sloshed. It refused to look up.

At times — the oddest times — it has reared up inside its jar and reviled me. Ingrate, it cries. Weakling. Disappointmenttome. I try to explain (I always try to explain), but the heart distends to twice its normal size. There is saline everywhere. I am afraid it will explode.

In an hour it is talking back at the small TV that sits beside its jar. It complains at the commercials. I keep my distance.

Once again I have awakened, and checking my pulse I find it slow, laboring, uneven. From the next room there is no sound. I snap on the light in the living room, and the heart starts, wrinkles into itself, and shields its blinking atria. Wake up, I tell it, knowing it is already awake, but I enjoy the violence in my voice too much to stop. Wake up. It is rubbing its bulging cheeks. I bring my face closer to the brine. Are you listening to me?

I have surprised it. No pirouetting, no calliope tunes: even the look of injured innocence is gone. It blinks up at me blankly, like a baby from a carriage, unsure. My own heart is racing.

Now I am here, I am not sure what to say. It won't wait long. Suddenly I am embarrassed, and, sensing this (it is uncannily acute), the heart starts to regain its buoyancy. Slyly, as if only at the whim of a current, it starts to rise through the fluid. I worry suddenly that it may break the surface, a gaping vein present itself an inch below my lips. I back away, mumble, "Just wanted to see you were all right."

Fantasies of revenge float through my mind all day. When I come home, I will slip it, jar and all, into the freezer. But does brine freeze? I could, while dusting, jostle it off its perch. The hearth is hard, the jar will shatter. It will flop about a minute or so, and then lie still. I am depressed when I arrive home. The key in the lock, the silence behind the door arrests me: what if something has happened? I fear the random violence of burglars.

One morning, I find the heart on the surface, lying on its side, a froth of bubbles around it. It looks an unhealthy gray. I lift it from its fluid, and, unmindful of the wet, I cradle it against my chest. I croon soft words in its direction. It lifts an artery, and quivers.

A week passes, and all is well. It was singing this morning when I left for work, sporting with the bits of toast I fed it. The doctor has taken it off salt. I am cheerful, the morning air expansive in my chest. As I come home that night I am whistling.

It is as if nothing has happened. The heart turns its back ostentatiously as I enter. The television fills the room with cheers. As I try to speak, it waves an aorta impatiently for silence: a line drive into right field; one man comes home, then another; the last holds up at third. The crowd is wild; the heart is assiduously intent. I drop my briefcase on my bed and take a shower.

As the steam climbs up the glass, water gurgles about my feet, the sounds of the next room fade. The thudding in my ears is all my own; the jar on the mantelpiece is empty, a crust of salt at its bottom. Tomorrow, I tell myself, I will throw it away. And suddenly I am sobbing as if my heart will break.

Reprinted from In the Valley of the Kings: Stories by Terrance Holt (c) 2009 byTerrance Holt. With permission of the publisher, W.W. Norton & Company, Inc.

Excerpt: 'Cutting For Stone'

'Cutting For Stone'

The Coming

After eight months spent in the obscurity of our mother's womb, my brother, Shiva, and I came into the world in the late afternoon of the twentieth of September in the year of grace 1954. We took our first breaths at an elevation of eight thousand feet in the thin air of Addis Ababa, capital city of Ethiopia. The miracle of our birth took place in Missing Hospital's Operating Theater 3, the very room where our mother, Sister Mary Joseph Praise, spent most of her working hours, and in which she had been most fulfilled.

Cutting For Stone
By Abraham Verghses
Hardcover, 560 pages
Knopf
List Price: $26.95

When our mother, a nun of the Diocesan Carmelite Order of Madras, unexpectedly went into labor that September morning, the big rain in Ethiopia had ended, its rattle on the corrugated tin roofs of Missing ceasing abruptly like a chatterbox cut off in midsentence. Over night, in that hushed silence, the meskel flowers bloomed, turning the hillsides of Addis Ababa into gold. In the meadows around Missing the sedge won its battle over mud, and a brilliant carpet now swept right up to the paved threshold of the hospital, holding forth the promise of something more substantial than cricket, croquet, or shuttlecock.

Missing sat on a verdant rise, the irregular cluster of whitewashed one- and two-story buildings looking as if they were pushed up from the ground in the same geologic rumble that created the Entoto Mountains. Troughlike flower beds, fed by the runoff from the roof gutters, surrounded the squat buildings like a moat. Matron Hirst's roses overtook the walls, the crimson blooms framing every window and reaching to the roof. So fertile was that loamy soil that Matron — Missing Hospital's wise and sensible leader — cautioned us against stepping into it barefoot lest we sprout new toes.

Five trails flanked by shoulder-high bushes ran away from the main hospital buildings like spokes of a wheel, leading to five thatched-roof bungalows that were all but hidden by copse, by hedgerows, by wild eucalyptus and pine. It was Matron's intent that Missing resemble an arboretum, or a corner of Kensington Gardens (where, before she came to Africa, she used to walk as a young nun), or Eden before the Fall.

Missing was really Mission Hospital, a word that on the Ethiopian tongue came out with a hiss so it sounded like "Missing." A clerk in the Ministry of Health who was a fresh high-school graduate had typed out the missing hospital on the license, a phonetically correct spelling as far as he was concerned. A reporter for the Ethiopian Herald perpetuated this misspelling. When Matron Hirst had approached the clerk in the ministry to correct this, he pulled out his original typescript. "See for yourself, madam. Quod erat demonstrandum it is Missing," he said, as if he'd proved Pythagoras's theorem, the sun's central position in the solar system, the roundness of the earth, and Missing's precise location at its imagined corner. And so Missing it was.

Not a cry or a groan escaped from Sister Mary Joseph Praise while in the throes of her cataclysmic labor. But just beyond the swinging door in the room adjoining Operating Theater 3, the oversize autoclave (donated by the Lutheran church in Zurich) bellowed and wept for my mother while its scalding steam sterilized the surgical instruments and towels that would be used on her. After all, it was in the corner of the autoclave room, right next to that stainless-steel behemoth, that my mother kept a sanctuary for herself during the seven years she spent at Missing before our rude arrival. Her one-piece desk-and-chair, rescued from a defunct mission school, and bearing the gouged frustration of many a pupil, faced the wall. Her white cardigan, which I am told she often slipped over her shoulders when she was between operations, lay over the back of the chair.

On the plaster above the desk my mother had tacked up a calendar print of Bernini's famous sculpture of St. Teresa of Avila. The figure of St. Teresa lies limp, as if in a faint, her lips parted in ecstasy, her eyes unfocused, lids half closed. On either side of her, a voyeuristic chorus peers down from the prie-dieux. With a faint smile and a body more muscular than befits his youthful face, a boy angel stands over the saintly, voluptuous sister. The fingertips of his left hand lift the edge of the cloth covering her bosom. In his right hand he holds an arrow as delicately as a violinist holds a bow.

Why this picture? Why St. Teresa, Mother?

As a little boy of four, I took myself away to this windowless room to study the image. Courage alone could not get me past that heavy door, but my sense that she was there, my obsession to know the nun who was my mother, gave me strength. I sat next to the autoclave which rumbled and hissed like a waking dragon, as if the hammering of my heart had roused the beast. Gradually, as I sat at my mother's desk, a peace would come over me, a sense of communion with her.

I learned later that no one had dared remove her cardigan from where it sat draped on the chair. It was a sacred object. But for a four-yearold, everything is sacred and ordinary. I pulled that Cuticura-scented garment around my shoulders. I rimmed the dried-out inkpot with my nail, tracing a path her fingers had taken. Gazing up at the calendar print just as she must have while sitting there in that windowless room, I was transfixed by that image. Years later, I learned that St. Teresa's recurrent vision of the angel was called the transverberation, which the dictionary said was the soul "inflamed" by the love of God, and the heart "pierced" by divine love; the metaphors of her faith were also the metaphors of medicine. At four years of age, I didn't need words like "transverberation" to feel reverence for that image. Without photographs of her to go by, I couldn't help but imagine that the woman in the picture was my mother, threatened and about to be ravished by the spear-wielding boy-angel. "When are you coming, Mama?" I would ask, my small voice echoing off the cold tile. When are you coming?

I would whisper my answer: "By God!" That was all I had to go by: Dr. Ghosh's declaration the time I'd first wandered in there and he'd come looking for me and had stared at the picture of St. Teresa over my shoulders; he lifted me in his strong arms and said in that voice of his that was every bit a match for the autoclave: "She is CUM-MING, by God!"

Forty-six and four years have passed since my birth, and miraculously I have the opportunity to return to that room. I find I am too large for that chair now, and the cardigan sits atop my shoulders like the lace amice of a priest. But chair, cardigan, and calendar print of transverberation are still there. I, Marion Stone, have changed, but little else has. Being in that unaltered room propels a thumbing back through time and memory. The unfading print of Bernini's statue of St. Teresa (now framed and under glass to preserve what my mother tacked up) seems to demand this. I am forced to render some order to the events of my life, to say it began here, and then because of this, that happened, and this is how the end connects to the beginning, and so here I am.

We come unbidden into this life, and if we are lucky we find a purpose beyond starvation, misery, and early death which, lest we forget, is the common lot. I grew up and I found my purpose and it was to become a physician. My intent wasn't to save the world as much as to heal myself.

Few doctors will admit this, certainly not young ones, but subconsciously, in entering the profession, we must believe that ministering to others will heal our woundedness. And it can. But it can also deepen the wound.

I chose the specialty of surgery because of Matron, that steady presence during my boyhood and adolescence. "What is the hardest thing you can possibly do?" she said when I went to her for advice on the darkest day of the first half of my life. I squirmed. How easily Matron probed the gap between ambition and expediency. "Why must I do what is hardest?"

"Because, Marion, you are an instrument of God. Don't leave the instrument sitting in its case, my son. Play! Leave no part of your instrument unexplored. Why settle for 'Three Blind Mice' when you can play the 'Gloria'?"

How unfair of Matron to evoke that soaring chorale which always made me feel that I stood with every mortal creature looking up to the heavens in dumb wonder. She understood my unformed character.

"But, Matron, I can't dream of playing Bach, the 'Gloria' . . . ," I said under my breath. I'd never played a string or wind instrument. I couldn't read music.

"No, Marion," she said, her gaze soft, reaching for me, her gnarled hands rough on my cheeks. "No, not Bach's 'Gloria.' Yours! Your 'Gloria' lives within you. The greatest sin is not finding it, ignoring what God made possible in you."

I was temperamentally better suited to a cognitive discipline, to an introspective field — internal medicine, or perhaps psychiatry. The sight of the operating theater made me sweat. The idea of holding a scalpel caused coils to form in my belly. (It still does.) Surgery was the most difficult thing I could imagine.

And so I became a surgeon.

Thirty years later, I am not known for speed, or daring, or technical genius. Call me steady, call me plodding; say I adopt the style and technique that suits the patient and the particular situation and I'll consider that high praise. I take heart from my fellow physicians who come to me when they themselves must suffer the knife. They know that Marion Stone will be as involved after the surgery as before and during. They know I have no use for surgical aphorisms such as "When in doubt, cut it out" or "Why wait when you can operate" other than for how reliably they reveal the shallowest intellects in our field. My father, for whose skills as a surgeon I have the deepest respect, says, "The operation with the best outcome is the one you decide not to do." Knowing when not to operate, knowing when I am in over my head, knowing when to call for the assistance of a surgeon of my father's caliber — that kind of talent, that kind of "brilliance," goes unheralded.

On one occasion with a patient in grave peril, I begged my father to operate. He stood silent at the bedside, his fingers lingering on the patient's pulse long after he had registered the heart rate, as if he needed the touch of skin, the thready signal in the radial artery to catalyze his decision. In his taut expression I saw complete concentration. I imagined I could see the cogs turning in his head; I imagined I saw the shimmer of tears in his eyes. With utmost care he weighed one option against another. At last, he shook his head, and turned away.

I followed. "Dr. Stone," I said, using his title though I longed to cry out, Father! "An operation is his only chance," I said. In my heart I knew the chance was infinitesimally small, and the first whiff of anesthesia might end it all. My father put his hand on my shoulder. He spoke to me gently, as if to a junior colleague rather than his son. "Marion, remember the Eleventh Commandment," he said. "Thou shall not operate on the day of a patient's death."

I remember his words on full-moon nights in Addis Ababa when knives are flashing and rocks and bullets are flying, and when I feel as if I am standing in an abattoir and not in Operating Theater 3, my skin flecked with the grist and blood of strangers. I remember. But you don't always know the answers before you operate. One operates in the now. Later, the retrospectoscope, that handy tool of the wags and pundits, the conveners of the farce we call M&M — morbidity and mortality conference — will pronounce your decision right or wrong. Life, too, is like that. You live it forward, but understand it backward. It is only when you stop and look to the rear that you see the corpse caught under your wheel.

Now, in my fiftieth year, I venerate the sight of the abdomen or chest laid open. I'm ashamed of our human capacity to hurt and maim one another, to desecrate the body. Yet it allows me to see the cabalistic harmony of heart peeking out behind lung, of liver and spleen consulting each other under the dome of the diaphragm — these things leave me speechless. My fingers "run the bowel" looking for holes that a blade or bullet might have created, coil after glistening coil, twenty-three feet of it compacted into such a small space. The gut that has slithered past my fingers like this in the African night would by now reach the Cape of Good Hope, and I have yet to see the serpent's head. But I do see the ordinary miracles under skin and rib and muscle, visions concealed from their owner. Is there a greater privilege on earth?

At such moments I remember to thank my twin brother, Shiva — Dr. Shiva Praise Stone — to seek him out, to find his reflection in the glass panel that separates the two operating theaters, and to nod my thanks because he allows me to be what I am today. A surgeon. According to Shiva, life is in the end about fixing holes. Shiva didn't speak in metaphors. Fixing holes is precisely what he did. Still, it's an apt metaphor for our profession. But there's another kind of hole, and that is the wound that divides family. Sometimes this wound occurs at the moment of birth, sometimes it happens later. We are all fixing what is broken. It is the task of a lifetime. We'll leave much unfinished for the next generation.

Born in Africa, living in exile in America, then returning at last to Africa, I am proof that geography is destiny. Destiny has brought me back to the precise coordinates of my birth, to the very same operating theater where I was born. My gloved hands share the space above the table in Operating Theater 3 that my mother and father's hands once occupied.

Some nights the crickets cry zaa-zee, zaa-zee, thousands of them drowning out the coughs and grunts of the hyenas in the hillsides. Suddenly, nature turns quiet. It is as if roll call is over and it is time now in the darkness to find your mate and retreat. In the ensuing vacuum of silence, I hear the high-pitched humming of the stars and I feel exultant, thankful for my insignificant place in the galaxy. It is at such times that I feel my indebtedness to Shiva.

Twin brothers, we slept in the same bed till our teens, our heads touching, our legs and torsos angled away. We outgrew that intimacy, but I still long for it, for the proximity of his skull. When I wake to the gift of yet another sunrise, my first thought is to rouse him and say, I owe you the sight of morning.

What I owe Shiva most is this: to tell the story. It is one my mother, Sister Mary Joseph Praise, did not reveal and my fearless father, Thomas Stone, ran from, and which I had to piece together. Only the telling can heal the rift that separates my brother and me. Yes, I have infinite faith in the craft of surgery, but no surgeon can heal the kind of wound that divides two brothers. Where silk and steel fail, story must succeed. To begin at the beginning . . .

Excerpted from Cutting for Stone by Abraham Verghese Copyright 2009 by Abraham Verghese. Excerpted by permission of Knopf, a division of Random House, Inc. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

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Cutting for Stone

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