Thursday, May 24, 2007

How I changed, part 1: life and death

"Any animal’s minute-by-minute life is a constant process—or actually, a system of many interlocked processes. All of us animals are constantly kept alive by our systems of life." Video: the Hemodynamic Cat takes a nap.

“This process must have changed you,” my friend R said, as we were talking about my upcoming graduation from medical school. “But how did it change you?”

I’ve been thinking about that ever since, and I’ll be thinking about it more—this surely won’t be the last that I write about it.

* * *

Life and death changed around me even in pre-medical biology classes, but much more acutely as a medical student. Walking along a crowded beach, or out in nature, or even sometimes in the city, I much more frequently and knowledgeably remind myself of the physiology of the life around me. There are the big bipedal apes (you know, us); the birds; the dogs; the fish in the sea. When I see a dog running down the beach, or children splashing in the waves, or a row of birds flying in formation, I am much more likely now to remember how they are able to do these things. Their hearts are beating, their lungs are taking in oxygen, the mitochondria of their cells are using the oxygen for biochemical reactions which allow them to store energy, and the cells of the brain are using that energy to direct the activity of the rest of the body.

Any animal’s minute-by-minute life is a constant process—or actually, a system of many interlocked processes. All of us animals are constantly kept alive by our systems of life. Those systems are so complex that even after a lifetime of me learning about the biology of people alone (never mind birds, or dogs, or fish), I will die having learned only about a fraction of the cells and molecules and organs that will have kept me alive until that moment.

And if any of it stopped for any of the animals around me, the whole scene would change. A bird would fall into the water. A man would fall down on the beach. A dog would stop moving. The change from my previous life is that I more frequently remember that these underlying processes must constantly be working to allow the life around me to keep living. I more reliably remember some basic information about how these processes work. And so I more often appreciate that their workings all around me—the panting of the dog, the shouting of the children, the bird using its muscles to flap its wings—are each made possible by still more mechanisms. I more frequently notice and love the baroque and beautiful details of life.

* * *

I came to understand emotionally—and not just intellectually—that life is not the default. In fact, life is an improbable and incredible struggle made possible only by a constant cooperative struggle of cells working against the processes of entropy. Death no longer surprises me, though it still can upset me.

I first began to understand my own mortality at around the time a lot of people do, in my early twenties. But my understanding began in the midst of the HIV epidemic. Before medical school, I devoted a great deal of my work life and much of my volunteer civic energy to the cause of preventing new HIV infections. And partly because my consciousness of death came from HIV in the early 1990s, I was always conscious of the possibility of death, but I was always engaged in the effort to prevent it.

A few years after I started doing HIV prevention work, a high school friend of mine was diagnosed with metastatic cancer. I was not much involved in her care, and although we stayed friendly throughout, her social world contracted to a small circle in which I was not usually included. The one thing that my partner of the time and I were able to do to help was to find her and her boyfriend an apartment in San Francisco, which at the time was no small feat. The apartment was immediately below us, so although I did not see her socially very often, I saw her through windows or during comings and goings, and saw her getting more and more skinny and weak. I saw her boyfriend going through many stages of worry and grief. I knew when she died.

Though I knew intellectually that it shouldn’t, emotionally her diagnosis and death surprised me. My friend seemed like a buckle-the-seatbelts, wear-your-condoms sort of person; she won lots of the good student awards in high school. My surprise and shock about her death helped me see that my public health work had an irrational emotional abscess festering within it: the hope that somehow everyone could be saved from death if we all just behaved ourselves. Looking back, I think that her death was one part of my trajectory towards medicine. It helped me towards the very beginning of realizing emotionally and viscerally that death and suffering is a part of life--and not just the product of a particular epidemic that had to be stopped.

When I got to medical school, death gradually became much more a part of my regular experience. Two different anatomy classes (the required one and an optional one) meant that I dissected two different bodies. This required a very lengthy and detailed involvement with the bodies. And that meant a close-up constant literal immersion in the fact of death.

Then there were my patients, many of whom were dying, facing life-threatening diagnoses, or fearing the possibility of death; and some of whom died. I actually gravitated towards some of this in medical school. I took more oncology-related rotations than most people do, and I did an ICU rotation. Before death, there were worries; struggles with families and within families; various forms of physical suffering, and even more forms of emotional suffering. Death started to seem like the simple part. Living near death is much more difficult and complicated.

From being immersed in the bodies of my two anatomical donors, and then also from physical exams, Pap smears, stitching up wounds and draining abscesses, and standing next to surgeons in the OR trying to make myself useful, I got the immediate and now deeply-remembered sense of the physicality of our bodies. Before medical school, I was moved and fascinated by the fact that we were only frail physical bodies. I once wrote a kind of prose poem about it, which I must have in an old notebook somewhere. But I did not regularly make the emotional leap from my intellectual or poetic understanding of this frailty. That emotional leap required learning biology. It required knowing in detail the ways in which we are physical beings. Knowing these details convinced not only my intellect but my emotions that our physical selves must eventually cease to exist.

I am not a religious person: I believe that who we are is contained by our physical selves. Biology is the beginning and end of life, and it is life itself. We live because our cells work. We die because of the built-in limits of our cells and the systems they make. Even those limits are part of our biology.

It shouldn’t be a surprise to me that going to medical school helped me understand life and death in a different way. But I think I hoped when I started that the understanding would come as a mystical or philosophical insight, or some spiritual catharsis on a call night. That’s not what happened. Instead, I learned biology, and learned more biology, and then I started seeing life as biology, and biology as life.

How we feel about all of this, and what we say to each other about it, is important; but how we feel and what we say is also part of the beautiful biology of long-lived social animals. We are bipedal apes; we use tools and language; our hearts beat. Like pelicans and elephants, we are born, we live together, and then we die.

Photo: based on their behaviors, it seems reasonable to believe that elephants mourn the dead.


Zahir said...

i saw this video clip posting and initially thought "goddamn it, joe. why all the cat videos? no one cares about your stupid cat. (or at least i don't.)"
then i read the post (which i quite enjoyed, by the way. i don't have time to say much about it since i should be studying histology--the bane of my existence at this point, and at least for the next few days, but i'll say quickly that the post very articulately said some of the things i've been thinking about too. being knee deep in normal human physiology, and beginning my introduction to basic pathology, i'm more and more likely to see life--and sickness and death--in cellular detail. although my professors would be proud, in many ways, i find it terribly worrisome. does it detract from the humanity that brought me to medicine? am i less able to feel for a metastatic cancer patient when i can't help but think of the metalloproteinases that were such an integral part of her cancer's journey from primary tumour onwards? is this the first step in desensitisation? should i be aiming for that kind of detachment? *is* it detachment, or is it another layer of care? is it just naive to think that i can be as emotionally invested in suffering as i was before i wrote my mcats? anyway, point is, you got me thinking. well done.)
and then i came back to the cat, thinking that the insight i found in the article might be in video form. it wasn't.
that said, the video is still pretty. very surprisingly, i enjoyed it. especially after reading the post it precedes.

Joe Wright said...

Maybe you're tired of cat videos, Z, but I made this in order to try to be the one-billionth cat video on YouTube--I heard the one-billionth will get a lifetime supply of toy rats. Sadly, someone in Japan won, and now I have to wait until next month for the two-billionth cat video prize.

Seriously, though, I don't think that cellular detail is dehumanizing, or at least that it needs to be. People come to doctors because doctors know things they don't. If you didn't know those things there'd be no particular reason for people to come to you instead of a sensible relative who knows them, loves them, and can comfort them.

I think the emotional/moral challenge is to remember that the knowledge is supposed to be used for people--that is, that we're working for them. The knowledge you're gaining is in order to give to them--it is a gift you are accumulating in order to pass on to others.

Obviously people find ways to become dehumanized or to dehumanize others. But, I think sometimes people within medicine blame it on the science because their politics or lack thereof prevent them from being able to blame the system of care and the people who hold power in it. This is where most of the blame must lie.


Joe Wright said...

Not that I'm saying you're dodging being willing to lay that kind of blame on the system, by the way--just reassuring you that you shouldn't blame your own studying and knowledge first.


Drnjbmd said...

As always Joe, I see myself in your writing. Let's just say that some of my best times are spent marveling at how incredible a dog greeting you at the door with a wagging tail is.

Great post!

Joe Wright said...

Thanks NJB--that's very kind. Clinical medicine has made me feel more of a connection to animals--another surprise related to this post, perhaps "How I changed, part 1.2"...


ditzydoctor said...

loved reading that :) thank you. losing humanity is something i struggle with everyday.

(ooh i came here through grand rounds in case you're wondering!)

Joe Wright said...

Thanks--I'm so glad you liked it. And I'm honored that so many folks are coming over here from Medical Grand Rounds.