As for me, I would choose neurosurgery as my specialty. The choice, which I had been contemplating for some time, was cemented one night in a room just off the OR, when I listened in quiet awe as a pediatric neurosurgeon sat down with the parents of a child with a large brain tumor who had come in that night complaining of headaches. He not only delivered the clinical facts but addressed the human facts as well, acknowledging the tragedy of the situation and providing guidance. As it happened, the child’s mother was a radiologist. The tumor looked malignant—the mother had already studied the scans, and now she sat in a plastic chair, under fluorescent light, devastated.
“Now, Claire,” the surgeon began, softly.
“Is it as bad as it looks?” the mother interrupted. “Do you think it’s cancer?”
“I don’t know. What I do know—and I know you know these things, too—is that your life is about to—it already has changed. This is going to be a long haul, you understand? You have got to be there for each other, but you also have to get your rest when you need it. This kind of illness can either bring you together, or it can tear you apart. Now more than ever, you have to be there for each other. I don’t want either of you staying up all night at the bedside or never leaving the hospital. Okay?”
He went on to describe the planned operation, the likely outcomes and possibilities, what decisions needed to be made now, what decisions they should start thinking about but didn’t need to decide on immediately, and what sorts of decisions they should not worry about at all yet. By the end of the conversation, the family was not at ease, but they seemed able to face the future. I had watched the parents’ faces—at first wan, dull, almost otherworldly—sharpen and focus. And as I sat there, I realized that the questions intersecting life, death, and meaning, questions that all people face at some point, usually arise in a medical context. In the actual situations where one encounters these questions, it becomes a necessarily philosophical and biological exercise. Humans are organisms, subject to physical laws, including, alas, the one that says entropy always increases. Diseases are molecules misbehaving; the basic requirement of life is metabolism, and death its cessation.
While all doctors treat diseases, neurosurgeons work in the crucible of identity: every operation on the brain is, by necessity, a manipulation of the substance of our selves, and every conversation with a patient undergoing brain surgery cannot help but confront this fact. In addition, to the patient and family, the brain surgery is usually the most dramatic event they have ever faced and, as such, has the impact of any major life event. At those critical junctures, the question is not simply whether to live or die but what kind of life is worth living. Would you trade your ability—or your mother’s—to talk for a few extra months of mute life? The expansion of your visual blind spot in exchange for eliminating the small possibility of a fatal brain hemorrhage? Your right hand’s function to stop seizures? How much neurologic suffering would you let your child endure before saying that death is preferable? Because the brain mediates our experience of the world, any neurosurgical problem forces a patient and family, ideally with a doctor as a guide, to answer this question: What makes life meaningful enough to go on living?
I was compelled by neurosurgery, with its unforgiving call to perfection; like the ancient Greek concept arete, I thought, virtue required moral, emotional, mental, and physical excellence. Neurosurgery seemed to present the most challenging and direct confrontation with meaning, identity, and death. Concomitant with the enormous responsibilities they shouldered, neurosurgeons were also masters of many fields: neurosurgery, ICU medicine, neurology, radiology. Not only would I have to train my mind and hands, I realized; I’d have to train my eyes, and perhaps other organs as well. The idea was overwhelming and intoxicating: perhaps I, too, could join the ranks of these polymaths who strode into the densest thicket of emotional, scientific, and spiritual problems and found, or carved, ways out.
—
After medical school, Lucy and I, newly married, headed to California to begin our residencies, me at Stanford, Lucy just up the road at UCSF. Medical school was officially behind us—now real responsibility lay in wait. In short order, I made several close friends in the hospital, in particular Victoria, my co-resident, and Jeff, a general surgery resident a few years senior to us. Over the next seven years of training, we would grow from bearing witness to medical dramas to becoming leading actors in them.
As an intern in the first year of residency, one is little more than a paper pusher against a backdrop of life and death—though, even then, the workload is enormous. My first day in the hospital, the chief resident said to me, “Neurosurgery residents aren’t just the best surgeons—we’re the best doctors in the hospital. That’s your goal. Make us proud.” The chairman, passing through the ward: “Always eat with your left hand. You’ve got to learn to be ambidextrous.” One of the senior residents: “Just a heads-up—the chief is going through a divorce, so he’s really throwing himself into his work right now. Don’t make small talk with him.” The outgoing intern who was supposed to orient me but instead just handed me a list of forty-three patients: “The only thing I have to tell you is: they can always hurt you more, but they can’t stop the clock.” And then he walked away.
I didn’t leave the hospital for the first two days, but before long, the impossible-seeming, day-killing mounds of paperwork were only an hour’s work. Still, when you work in a hospital, the papers you file aren’t just papers: they are fragments of narratives filled with risks and triumphs. An eight-year-old named Matthew, for example, came in one day complaining of headaches only to learn that he had a tumor abutting his hypothalamus. The hypothalamus regulates our basic drives: sleep, hunger, thirst, sex. Leaving any tumor behind would subject Matthew to a life of radiation, further surgeries, brain catheters…in short, it would consume his childhood. Complete removal could prevent that, but at the risk of damaging his hypothalamus, rendering him a slave to his appetites. The surgeon got to work, passed a small endoscope through Matthew’s nose, and drilled off the floor of his skull. Once inside, he saw a clear plane and removed the tumor. A few days later, Matthew was bopping around the ward, sneaking candies from the nurses, ready to go home. That night, I happily filled out the endless pages of his discharge paperwork.
I lost my first patient on a Tuesday.
She was an eighty-two-year-old woman, small and trim, the healthiest person on the general surgery service, where I spent a month as an intern. (At her autopsy, the pathologist would be shocked to learn her age: “She has the organs of a fifty-year-old!”) She had been admitted for constipation from a mild bowel obstruction. After six days of hoping her bowels would untangle themselves, we did a minor operation to help sort things out. Around eight P.M. Monday night, I stopped by to check on her, and she was alert, doing fine. As we talked, I pulled from my pocket my list of the day’s work and crossed off the last item (post-op check, Mrs. Harvey). It was time to go home and get some rest.