Last year I was asked to speak at the New Fellows graduation ceremony for the Australasian College of Physicians in Auckland. Coming up with something worthwhile to say made me reflect on my own medical education. I realised that the formal part of it ended twenty years ago. That seemed like a small place halfway up the hill to stop and look back from. So I did. I asked myself what I’ve learnt over time in medicine that has proved to be the most useful to me in the way I practise now. And so with that in mind I scribbled this speech … and thought I’d post the result here. I reckon it’s best left alone to be what it was intended to be as far as a piece of writing goes. I hope it resonates … or irritates. And don’t forget to send us your own thoughts. Most of the doctors I know hate being told what to think. We’d love to hear from you.
“President of the Royal Australasian College of Physicians, Fellows of the College, New Fellows of the College, ladies and gentlemen, I would like to begin by reading you a poem. It is not my own. I wish that I had written it. I need to warn you that it is irreverent. It is a poem I often read to fourth form boys to show them that one of the great advantages of poetry is that you can swear in a poem and get away with it. More than any other social group doctors remind me of fourth form boys and so I suspect you will also enjoy the visceral thrill of obscenity.
This be the verse
They fuck you up, your mum and dad.
They may not mean to, but they do.
They fill you with the faults they had
And add some extra, just for you.
But they were fucked up in their turn
By fools in old-style hats and coats,
Who half the time were soppy-stern
And half at one another’s throats.
Man hands on misery to man.
It deepens like a coastal shelf.
Get out as early as you can,
And don’t have any kids yourself.
– Philip Larkin
Philip Larkin was a distinguished English poet. I have read you one of his best known poems because there are times when I think that medicine is a giant dysfunctional family full of people who are constantly telling you what to do. We have our own equivalents of stuffy old-style hats and coats. We growl our young and expect them to toe the line. We do things sometimes because that is the way they have always been done. We change our minds frequently but never expect to be questioned. I read it too for little other reason than the subversive thrill it always gives me when I open it up and shake it out. God only knows medicine and its Royal Colleges can do with some subversion at times. A copy hangs on the wall of the youth clinic I work at where only too often it reminds me where the pain in young people can begin. It is also a way of saying beware of all standing up here today banging on. I am standing up here and banging on today and so you should especially beware of me. I rarely know what I’m talking about.
I am here above all other things to congratulate you. There are days in life when it is only right to sink like hippopotamuses in the soft ooze of our own warm mud. And so to all of you being admitted as Fellows to the college today I encourage you to wallow. You have earned the right. It is a magnificent achievement. Life throws up these moments from time to time and it is our job to hesitate for a moment in the great rush and enjoy them.
But I cannot simply pack up and leave things at that … when I was wondering what might be useful for me to talk to you about today I was forced to reflect on my own medical education which formally ended twenty years ago. It was a state of the art education at the time and I do not undervalue it. It downloaded a range of medical information into me that I still bump into now and again when I am trying to figure things out. It was a magnificent assemblage of raw material. But it also occurred to me that in many ways the most useful tools I have acquired in the practice of medicine have been learnt on the job. I will not be able to give you many new insights into medical diagnosis and treatment today but I will open my doctor’s bag and take out three tools that have become vital to me in the way that I practice and survive in medicine now. They are all I have … curiously enough I learnt none of them at medical school.
The first of these was simply the acquisition of experience. Medicine at the end of the day is a practical profession. No matter how much it is based on what has been written in text-books it was seeing things for the first time myself that brought home to me the shape of a particular illness. I was always a frightened doctor and I suffered for that. Playing God, my first book of poetry, was written under a contract I made with myself that allowed me to leave medicine once it was finished. I didn’t of course and I’m not sure when I started to calm down but I did. It took years of paddling to learn how to float. And while part of that floating was brought about by seeing and doing, a significant part was achieved by realising that I would never be able to know everything and that admitting that to myself and to my patients was OK. At least then I could ask somebody else what to do. I think sometimes that we undervalue experience in medicine. It often doesn’t feel like anything specific, just a mountain of thrown away scraps. But it is full of buried treasures and I encourage you to value it and to share it. Medical knowledge is a web best held by all of us as doctors. We need to continually ask of each other. And just as importantly we need to make it safe for others to continually ask of us.
In the years after my formal medical education ceased a second tool also slowly evolved in my practice of medicine. Life occurred. I had relationships … and messed them up. I bought a house. And sold it. I learnt a language. I became a father. I argued with people. I had cars stolen, both of them from hospital car parks. I made mistakes – inside and outside of medicine. I had times of great happiness. I had times of great sadness. I sought therapy. I hurt people. I disappointed people. I disappointed myself. I got sick. I travelled. I learnt things I never thought I would. People came into my life and left it again. People I loved died. I heard myself creak. I watched myself crease. I wrecked my shoulder. I lost faith. I gained faith. I wrote books. My hair fell out. I got up at night to pee. Things did not happen in that particular order of course … but gradually I began to understand, with a lot more patience, what those people who sat opposite me in consultations were going on about. Over time I allowed myself to simply bring that part of me who came closest to what I thought they were experiencing and let it be there with them. Looking back now it seems medicine comes with so many warnings and alarms that it can simply stop us being at times. And being is such a powerful thing in a consultation. It helps if one person in the room is able to sit in their own skin – and for a long time in my experience that had usually been the patient and not the doctor. When I look at you this morning I see so much life in all of you. You have all had such a range of experiences. There are of course times when our lives need to be kept separate from our patients but there are so many times when our experience of being human can teach us how to be with people. It is a huge resource to make use of.
The third great revolution for me in my medical education, and possibly the one I value most, did not so much rely on the need for time to pass as the first two I have mentioned. Writing, for all that it relies on words, at some point is not really about writing. It is about looking and longing. All art is in a sense. As is all science. And by longing I mean that curiosity we cultivate about what lies beyond, coupled with a desire to be intimate with the universe in some way. Practising a creativity, whether it be in writing, or in music or in visual art or indeed in science or medicine teaches us to look at the world more closely. This is the journey that one goes on over time and which is then reported on in words or with paint or sound or by the asking of exquisite questions. And this journey is in many ways a journey towards looking at the world with a particular kind of compassion.
Art and science make us look at the world with what I call ‘wet eyes’ – that combination of wonder and care that makes us well-up. This may be a response to the fact that the world is full of layer upon layer of remarkable detail that pulls us ever deeper into it the longer we look at it. But it is also due to the fact that at some point our eyes also reflect a startled wonder at the symmetries, connections, beauty and helplessness that we see. We fall into a sort of love with the world in a sense. When we are looking well our eyes become both portals to look through and mirrors that reflect. I started down the path towards being a writer twenty years ago without having any idea that that what it was really demanding of me was to put down my pen and look at the world more inquisitively and more compassionately.
A few years ago I began to write about medicine again for the first time since composing the poems that became part of Playing God. I began to interview some of my patients and record their stories in more detail for a literary project. Of course to do this I needed to use those ‘wet eyes’ that were part of being a writer. All of a sudden I found that I began to bring that same sensibility into my consultations. Medicine changed for me at that point. Instead of a day fighting my doubt and the waiting room, a day full of consultations became a day spent in a Dickens novel. It was not something to be endured but appreciated. Art taught me to see things with my chest and so I began to look at my patients with my chest. I found that it was possible to see each of them as a poem. It only took a trick of the eyes. Soon I wanted to know more about them. I turned them over in my mind and handed them back to themselves excitedly saying, ‘Look, look, I can see something there, and there. It’s remarkable.’ I’m not sure it made me better at diagnosis or the management of any particular illness, although I suspect it did to be honest. What I did notice is that patients liked the experience of being looked at with ‘wet eyes’. I suspect it was that mirror in them that they were responding too. They wanted to see themselves in the way a poet would see them. There’s is a medicine in ‘wet eyes’. It says we are doomed but doomed beautifully and I am with you. For the last few years that poetry has been an essential part of my consultations. Not that I rhyme my scripts or regale patients with ‘The Man from Snowy River’ – although less effective therapies have been championed by our profession over the years. But that part of poetry which is about how we look at things has become integral to what I do now.
And this is something that people can learn. The young can learn this sooner in their medical education than we think. In fact often it is the young and the old who are more open to such magic than the middle aged. The way we look at people and listen to them is a medicine. Sometimes people need surgery, or an insulin infusion, or thrombolysis. But sometimes they need ‘wet eyes’ too – not in the least because ‘wet eyes’ also help to calm the doctor looking out at the world through them.
I began writing this speech sitting on a post storm beach at Otaki and want to take you back there to complete it. Picture for me the sea unsettled and barking. Salt is beginning to obscure the view of the sun which is setting in front of me. The clouds are tangling into grays and pinks. The fist-like stones that make up the beach are strewn with driftwood and interrupted by patches of spinifex and succulents. The wind gusts over the top of a long and steady moan. Kapiti sits to the south rapidly turning to silhouette. D’Urville curls behind. Taranaki waits to the north, and the Tararua’s overlap behind. Foam is blowing up over the curve of the beach. The lights go on all the way down the coast. Everything is hunkering down.
I know this landscape well. Those of you who have spent any time in our country will. And I feel as though it knows me. It attracts and repels and fills us with both melancholy and a desire for warmth at the same time. It builds in us the delight for exposure and shelter and reconciles those opposites into a strange whole. It is not a picture of warm and cold, and love and hate, and past and present, but of warm-cold, love-hate and past-present. Doctors watch a human landscape unfold in a similar way in front of their eyes every day. Human beings also morph in and out of happy-sad, well-unwell and knowing-unknowing. If we look at them with the same wonder that we look at our landscape then we can remain with them in the doubt in between those spaces with a little more ease until their eyes adjust to the same wonders that we see. When the time is right we can so often simply light the fire and sit with them beside its warmth.
I began with a subversive poem and I would like to finish with one as well. One that explains how I came to see some light in all those shadows that consultations can cast at times. It was one I wrote to capture that experience of looking at patients with ‘wet eyes’ that I have been talking to you about. I wish you well in your careers. My warm congratulations to you all.
Doctor to patient
(on ornithology and the practice of medicine)
You have brought me a bird.
I have seen this before.
When you say,
‘I am sore,’
I see a bird.
When you say,
‘I cannot breathe,’
I see a bird.
When you say,
‘I lie awake,’
I see a bird.
You have brought me a bird.
There is a bird
in the room.
Should I stand on the table?
Should I stand on the chair?
It is singing.
Listen, it is singing.
It is there, in the corner of your eye.
It is there, on your shoulder.
Here, in the pit of your stomach.
Now, between your legs.
Inside your rattle-cage,
when I press
my ear to it,
I hear a bird.
Behind your knee,
in the creep-
hops a bird.
And in your sorrow-joy,
hangs a bird.
Give me your hand.
Here, it is in your hand.
It is breathing.
Listen, it is breathing.
Should I dance?
I should dance my old man’s dance.
You have brought me a bird.
How can this be?
You have brought me a bird.