It wasn’t until my mid-40s that I started writing about the world of medicine. Before that, I was busy building a career as a hematologist-oncologist: caring for patients with blood diseases, cancers and, later, AIDS; creation of a research laboratory; publishing newspapers; training of young doctors. A physician’s workload tends to crowd out all but the most immediate concerns. But, over the years, the things you’ve pushed to the back of your mind begin to pile up, demanding to be dealt with. For two decades, I had watched my patients and their loved ones face some of life’s most uncertain times, and I now felt compelled to bear witness to their stories.
After writing and editing three chapters of what I envisioned as my first book, I showed a draft to my wife, an endocrinologist. She read them, then stared at me. “They’re horrible,” she said. I was stunned. I felt pretty good about what I had produced. “They’re overwritten, with endless sentences, filled with fancy words,” she explained. I remained silent, absorbing his criticisms. “I can’t quite understand what you are trying to say here.”
I reread my words and concluded that she was right. Additionally, I realized that many of the issues with my draft reflected the conditioning that occurs during medical training. I had used technical jargon, as if I was communicating with colleagues, rather than addressing a general reader. And I had retreated from the stories, a result of the psychological distancing needed to stay stable while helping a patient cope with a life-threatening illness. Finally, I focused on the clinical details of the cases, instead of exploring the emotional and spiritual dilemmas of the patients – which prompted me to write in the first place.
What I needed was a new kind of training, analogous to my medical training but very different. So I re-read some of the medical authors I most admired: Oliver Sacks, Richard Selzer, Sherwin Nuland, William Carlos Williams, Anton Chekhov. I began to appreciate how they used their individual perspectives and styles to illuminate the experiences of those struggling with illness. They incorporated their own reactions to the story and, in doing so, immersed the reader in a fundamental struggle of the profession: balancing the ego needed to take responsibility for another person’s life with the humility to recognize our capacity for catastrophic error.
Today, my library shelves are filled with doctors’ books, spanning the entire arc of a medical career – from “A Not Entirely Benign Procedure,” a memoir of medical student life by the pediatrician of NYU Perri Klass, at the self-lacerating ‘Do No Harm’ retrospective of British surgeon Henry Marsh, who ruminates on the mistakes made during a long and illustrious outward career. Somewhere in between these I can now insert Jay Wellons’ mid-career memoir, “All That Moves Us” (Random House). Wellons is the chief of pediatric neurosurgery at Vanderbilt University Medical Center, Nashville, and started writing, like me, after twenty years in medicine.
Her book unfolds in a harrowing series of operating room vignettes, explaining the work of her hands while evoking the tension in her mind and heart. Prior to his medical training, Wellons was an English major at the University of Mississippi, where he took writing classes with novelist Barry Hannah and poet Ellen Douglas. This can be seen, both in its narrative mastery and in the freshness of its descriptive touches. Here he is on the first glimpse of a brain – with its tissues, blood vessels and crevices – once the skull is opened:
Wellons’ path into medicine was influenced by his father, who wanted to be a doctor, but whose family could not afford the training. Instead, he became a businessman, and his early ambitions passed to his son. Then, just as young Wellons was graduating from medical school, his father was diagnosed with the neurodegenerative disease ALS “Despite all my uncertainty about how I would spend my life in medicine, this is not only an irony that I would spend my days trying to understand the mysteries of the anatomical system that my father had failed,” he wrote. “I know now that I would come to see it in the patients I cared for, and that I would also see myself in the mourning of the families.”
Wellons writes bluntly of his chosen specialty and “the almost unbearable pain we sometimes have to unleash upon our patients.” For parents, just hearing him introduce himself as a pediatric neurosurgeon can be traumatic. (“As I did, his chin fell to his chest,” Wellons writes of one father.) He recalls acquaintances imploring him to avoid this line of work, citing stereotypes of neurosurgeons as grumpy, selfish workaholics whose patients usually die. But he persisted, inspired by a series of charismatic and upsetting mentors. Eventually, he came to see the gravity of the situations he faces in a positive light, as an opportunity to avoid the most dire consequences – “not always, but most of the time”. The extraordinary plasticity of the juvenile brain, its ability to recover and adapt, offers hope. He is delighted to see young patients become adults and considers that his field offers “the opportunity to fundamentally improve, even bring back, a child who is pure potential, for whom nothing is really determined and all the possibilities exist”. In the moments when he decides that surgery is necessary and feasible, he writes, he “can only see the most hazy version of a life to live.”
We see Wellons operate on patients with tumors, blood vessel malformations, brain swelling, developmental issues, and trauma damage, including gunshot wounds. It also works on the peripheral nervous system, stitching and grafting damaged nerves, and reseals the exposed spinal cords of infants with spina bifida. Although most of his patients range from newborns to teenagers, he has also become a specialist in a new medical frontier: operating on fetuses in utero. In one chapter, he and his Vanderbilt colleagues travel to Australia to teach a team at Mater Mothers’ Hospital in Brisbane how to operate on fetuses with spina bifida. The challenge for the surgeon is to work in a biological dimension never encountered before, he writes: “The tissue was entirely different at twenty-three weeks gestation, similar to the seam of wet tissue paper. The slightest false step would tear the fragile skin.
In Richard Selzer’s short story “Imelda,” an American plastic surgeon named Hugh Franciscus, a cold and imperious perfectionist, goes on a charity mission to Honduras. There, he prepares to operate on a young girl, Imelda, who has a cleft palate. But Imelda suffers a complication from the anesthesia, dying before Franciscus can even make an incision. That night, he sneaks into the hospital morgue and performs the planned operation on Imelda’s corpse, so her mother can bury a mended child. He saved face, in more ways than one, but he’s broken by the experience, unable to recover from an imperfect ending.
Wellons tells a number of stories in which he takes responsibility for irreparable mistakes. He recounts a case where he had to operate on a pair of Siamese twins, connected at the back of the head and born very prematurely. One twin’s intestines would become necrotic, as sometimes happens after extremely premature birth, and the toxins would spread through the common circulatory systems to the other twin. Normally, separating conjoined twins involves weeks of preparation and planning, but here the infection required emergency measures – “a Hail Mary if there is one”. The operation starts well: “Through the skin exposure and the craniotomy and then the dural opening, we had lost less than a thimble of blood.” But suddenly, more than three hours into the operation, profuse bleeding is coming from deep within both brains. Attempts to stop the flow don’t work, and Wellons finds himself “cutting the joined skull with scissors, all hope of delicacy abandoned, trying to pull them apart so my partner and I can each take one and stop the bleeding. ” There is a moment of relief when the bleeding stops, then a terrible realization:
Like Dr. Franciscus de Selzer, Wellons ends up producing, post mortem, a poignant approximation of the expected result. But he is luckier: rather than isolating himself through perfectionism and imperiousness, he has mentors and colleagues who help him through the agony and reconcile him with human imperfection. Indeed, he is skeptical of our tendency to heroize surgeons, and he specifically rejects the “testosterone-driven” culture that has long characterized the field. Noting that, among pediatric neurosurgeons in the United States, a higher proportion of women – twenty percent – than in any other subspecialty of neurosurgery, he writes, “This number continues to grow, and we are clearly better off.”