Why I, a Physician, Write

“One would never undertake such a thing if one were not driven on by some
demon whom one can neither resist nor understand.”

 – George Orwell, “Why I Write”

I remember my first encounter with great literature. Before bedtime, my
father would read Great Expectations to me, using different voices
for different characters. I remember Pip and Miss Havisham, though I don’t
think I fully understood Miss Havisham’s peremptory and eery commandment
to Pip to love Stella. I remember the stygian scene with the convict in the
graveyard. I also remember reading Sherlock Holmes under my covers, enamored with his brilliance and the game that was afoot. I remember tearing through the Lord
of the Rings
books and the first few books of Robert Jordan’s The Wheel of Time
series. Great stories left a large impression on my childhood. The
thrill of diving deeply into an engrossing world still makes me a bit
giddy. Even when I read books far more socially complex now, books I would
never grasp as a young reader, like Thomas Hardy’s novels, I am reminded of the initial
excitement I once felt discovering new stories.

As a child, these stories didn’t remind me of my own life or people in my
life, they were just thrilling. I fantasized about writing my own stories
one day. I created comic books with different monsters, though my drawing
was appalling. I once sat down to hand-write my own epic fantasy story – I
don’t think I got very far. I suspect, then, that my desire to write and tell stories was present
at a young age. But I lacked the sedulousness to work on my drafts. I would write an essay for school or a story at home and
immediately hand it in or toss it aside, assuming that was the end.

Since then, of course, I have written more and learned more. The process
certainly has not gotten any easier, especially as time spent writing
crowds out time for other things in life like music, friendships, reading,
TV shows, and family. Indeed, the time invested has not been trivial. Just
as an example, I was covering the intensive care unit one night during my
first year of residency and during the few brief quiet moments of the night
I was reading a book about the psychology of the Nazi war criminals

for an essay for the Jewish Review of Books
.

Why do I attempt this seemingly crazy task? It is a question prompted by a recent fellowship
interview, when an interviewer asked me: Why do you write? And
what drives a physician (and there are many physician-writers) to write?

In 1946, George Orwell explored the reasons for his own writing in an essay entitled “Why I Write.” Orwell explains that there are four great motives for writing: egoism,
aesthetic enthusiasm, historical impulse, and political purpose. Writers,
he argues, “desire to seem clever, to be talked about, to be remembered
after death…. It is humbug to pretend that this is not a motive, and a strong
one.” Because of this, serious writers are “vain” and “self-centered.” Of
course, there is an element of solipsism in writing. No writer, physician
or otherwise, writes without anticipating some kind of audience. It does
help give our writing purpose, to know that it affects or influences
others. But such an aspiration is not unique to writers, as Orwell
concedes. All professionals – scientists, artists, politicians, etc. –
desire, to some extent, to be remembered through their research,
art, or deeds. No ambitious citizen can deny that this plays some role,
large or small, in what he or she does. But the entire writing motive is not
necessarily self-aggrandizing: Writers appreciate beauty, “pleasure in the
impact of one sound on another, in the firmness of good prose or the rhythm
of a good story.” An author, no matter what his or her topic, attends to
“aesthetic considerations.” And the content matters, too. Essayists,
novelists, political journalists all “desire to see things as they are, to
find out true facts and store them up for the use of posterity.” In other
words, they aim to portray the world as it is, to draw away the curtains.
And there is also a “political purpose” to this. Though writers do want to see things as they are, they also want to imagine the world as it might be
or “to alter other people’s idea of the kind of society that they should
strive after.” Orwell does not argue that one of these is more important
than the other: “These various impulses must war against one
another,…fluctuate from person to person and from time to time.”

Most of what Orwell says pertains to physician-writers. For some
of them, for instance, politics drives much of their work. Atul
Gawande, a surgeon and public health researcher, is a good example. Gawande’s books, like Being Mortal or The Checklist Manifesto, both agitate in some way for reform of our
medical system. In Being Mortal, he urges us as a society to rethink the way we take care of the elderly and those closest to death
such that we provide them with more independence and choice and less
invasive care. In The Checklist Manifesto, he discusses the
importance of checklists for the safety of patients in a hospital, in
particular during surgeries.

For most physician-writers, however, I suspect that the primary purpose is
to reveal to the reader what the world of medicine is like – a world that contains the kinds of riveting stories that fiction offers.

Physician-writers face unpleasant facts; or, rather, unpleasant aspects of
life. Most of the stories I relate on this blog are tragic in some way – some of this comes out of a frustrating sense of injustice, but a lot of it comes out
of a sense of the inevitability of tragedy and the beauty and rare success
coupled to that struggle. Thomas Hardy

reportedly said
, “The business of the poet and the novelist is to show the sorriness
underlying the grandest things, and the grandeur underlying the sorriest things.” The physician-writer shows the sorriness and grandeur underlying our physical life. In that sense, I write with a historical impulse, “to see things as they
are.” What is medicine really like? What does it mean to be sick and
helpless? What does it mean to be sick and poor? How do physicians react to
all of this?

Perhaps the thrill and romance from childhood stories has faded somewhat, but the hunger for nonfiction as a grounding tool has taken their place.
This blog provides, among other things, a way to impart the great
complexities of medicine and diseases, which are often only understood by
other physicians and the victims of those diseases.

I wish I could write a novel with the same flair for
storytelling and the same talent for diction and the same eloquence as
Dickens or Hardy. That I cannot is unfortunate. But stories about medicine
are powerful and the most I can offer. And I am “driven on
by some demon” to write about them; a purposeful struggle to put to the page these stories that are filled with
meaning, and that might otherwise disappear.

I will never retire this task, whether it’s through this blog or elsewhere. But as my career
advances I ought to give myself space to breathe. I start my
fellowship in neurovascular disease this summer and have an important specialty
board exam this year, both of which require, I think, all of my
intellectual energy. So things will be quiet on this blog for
now, but look for more in the coming year.

Reflections on Treating the Poor

It is altogether curious your first contact with poverty. You have thought
so much about poverty — it is the thing you have feared all your life, the
thing you knew would happen sooner or later; and it is all so utterly and
prosaically different. You thought it would be quite simple; it is
extraordinarily complicated. You thought it would be terrible; it is merely
squalid and boring. It is the peculiar lowness of poverty that you
discover first; the shifts that it puts you to, the complicated meanness,
the crust-wiping.

– George Orwell, Down and Out in Paris and London


George Orwell’s 1933 memoir, Down and Out in Paris and London,
relates the clear-eyed experience of being homeless and penniless. The
novel’s protagonist lives in Paris giving English lessons and eventually
experiences a stroke of bad fortune and loses his job; money slowly but
surely disappears. He is overcome with “a feeling of relief, almost of
pleasure, at knowing yourself at last genuinely down and out.”

Imagine, Orwell asks of us, what this bad fortune means. You cannot send
letters because stamps are too expensive. At the baker, an ordered pound of
bread weighs in slightly more and thus costs slightly more — and you cannot
pay for it. You avoid “a prosperous friend” on the street so he
won’t see that you’re “hard up.” And you’re hungry. Wherever you walk there
are inescapable reminders of this: bakeries, restaurants, coffee shops.
“Hunger,” Orwell writes, “reduces one to an utterly spineless, brainless
condition, more like the after-effects of influenza than anything else.” Months pass by in between baths. Clothing is pawned. In the midst
of this scramble to live, however, one forgets that there is, indeed, a lot
of time with nothing to do at all: “you discover the boredom which is
inseparable from poverty; the times when you have nothing to do and, being
underfed, can interest yourself in nothing.”

Orwell based such descriptions largely on personal experiences. In 1927 he
spent time in the company of tramps and beggars in London, dressed in
worn-out clothing and sleeping in poor lodging-houses for two or three
days. He subsequently moved to Paris and subjected
himself to similar experiences. In doing so, he eventually brought
attention to the plight of the poor, providing an honest, unvarnished look
at what it was like to be down and out.

~

Rereading the book reminds me of Bellevue Hospital, New York City’s
flagship public hospital. Bellevue, or its progenitor, was originally an
infirmary in Manhattan in the 1660s and became the most well-known of the
public hospitals in the country (I have

written about it
 for Public Discourse). Here physicians treat the uninsured, the
undocumented, and the homeless. It is a rare day when a physician at
Bellevue does not interact with New York’s poorest residents.

Jim Henderson (Creative Commons)

Sometimes they come in search of medical care and sometimes they come in
search of a meal. They stumble in from homeless shelters or from street
corners, inebriated, withdrawing from drugs or alcohol, psychotic,
suicidal, deathly ill or sober. Occasionally they unknowingly enter the
emergency room with lice or bedbugs and nurses delouse them with multiple
layers of permethrin, an insecticide. The physician must approach these infested patients with
a hairnet, gown, and gloves — the lice crawl on the patient’s head, chest,
arms and bed sheets. The smell sometimes overwhelms the doctor or nurse,
too. It may have been months since the patient has bathed, and the odor
percolates throughout the room and the hallway.

As I wrote in my Public Discourse piece, the patient presentations
are frightening and remarkable:

Ride the elevator down, and you will stare in horror as an agitated drug
addict with an infection tries to punch a physician while bolting out of
his hospital room with security guards and nurses in pursuit. Next door, a
homeless patient lies in bed with heart failure. Next to him is a patient
who’s visiting New York from Africa with a raging AIDS infection. Peer into
another room down the hall, and you can watch patients withdrawing from
alcohol or heroin, thrashing about and screaming.

Physicians have the unique privilege at Bellevue to see poverty up close,
which so rarely occurs in upper and middle class professions. But as close
as we are, we don’t really understand the poor the way Orwell did. We don’t
live amongst them or feel the curse of extended hunger or the uncertainty
of when the next meal will come. We don’t experience that odd sensation of
boredom, where there is nothing to do because one has nothing to do it
with. And we cannot fully empathize with their fragile health.

~

This is why Orwell’s book is so enlightening. At least we get a description
of what some of Bellevue’s patients may go through; at least we get a
glimpse. It creates a little less space between the comfortable and the
impoverished.

But Orwell wasn’t wholly right about the poor. He wrote in Down and Out:

The mass of the rich and the poor are differentiated by their incomes and
nothing else, and the average millionaire is only the average dishwasher
dressed in a new suit. Change places, and handy dandy, which is the
justice, which is the thief? Everyone who has mixed on equal terms with the
poor knows this quite well. But the trouble is that intelligent, cultivated
people, the very people who might be expected to have liberal opinions,
never do mix with the poor.

True, there is a closeness between “intelligent, cultivated people” and the
“poor” simply by virtue of being human. However, there are deep differences
that would not disappear if the two simply switched jobs and clothing. For
instance, in 2016,
four percent of U.S. adults experienced a “serious mental illness.” This did not cover patients without
fixed addresses — the homeless. And     
approximately one fifth of the homeless in the United States
 suffer from a severe mental illness. Even if the definitions of “severe”
and “serious” don’t match up precisely, the difference between mental
illness among the homeless and other US adults is huge. And these
differences matter both to policy analysts and to physicians.

Two epidemiologists, Elizabeth Bradley and Lauren Taylor, have written a
thoughtful book dealing with the issue of rising health care costs entitled The American Health Care Paradox. In it they argue that our
skyrocketing health care expenditures (we spend

more than double the share of GDP
 of other developed countries on health care) and poor outcomes (we are in the high 20s or low 30s in rankings among OECD developed countries for maternal mortality, life expectancy, low birth weight, and
infant mortality) are not due to
overspending, but rather to underspending by the United States on social services — affordable housing,
education, access to healthy food, and so forth.

Bradley and Taylor
explain how this happens:

Several studies have demonstrated the health toll of living on the
streets; more than two-thirds of America’s homeless population suffer from
mental illness or substance dependency, while nearly half have at least one
additional chronic condition such as diabetes or hypertension. The high
costs of health care provided to people who are homeless have been well
documented. For instance, in one five-year period, 119 people who were
chronically homeless and tracked by the Boston Health Care for the Homeless
Program incurred a total of 18,834 emergency room visits estimated to cost
$12.7 million.

This makes sense. Many of our homeless patients deal with chronic diseases
like diabetes, mental illness, or congestive heart failure. We stabilize
them in the hospital and send them back to a shelter or the street. Often
they return the next week with exacerbation of their heart failure or
sky-high blood sugars or psychosis, even when medication is provided by the
hospital without charging the patient.

Thus a chasm separates our world and that of the poor, yet they are
entangled. How can you get someone to start eating vegetables and fruits
and whole grains in order to mitigate the effects of diabetes if they don’t
have money to buy these foods? How can you control a child’s asthma if a
family does not have money to clean their apartment and rid it of the
vermin, bugs, and dirt that pervade the nooks and crannies? How can you ensure a psychotic patient takes his medication when he can barely feed himself? The homeless
face a very different and more intimidating set of difficulties than the
wealthy. And these translate into challenges for physicians, who do
not have the time or skill to be both doctors and social workers.

We, as physicians, care for the patients until they are ready to leave the
hospital. Then they face their poverty on the street. Our view is but a
brief and skewed snapshot. In our myopic hospital world, the hospital
stretcher is detached from daily life. And this is necessarily so, to
a certain degree. Physicians can only do so much to fix societal ills — they cannot create a job, a safe home environment, or a loving family for
the patient.

Nevertheless, both wealthy patients and poor patients succumb to cancer,
strokes, and heart attacks. Both undergo the

humiliating process of death and dying
. In this sense, death and disease are often great equalizers. Neither the
poor nor the rich can escape them. They rapidly close the chasm between the
two classes. And at least in that vein, Orwell was right.

The Distortion of “Death with Dignity”

I recently wrote a short essay for Public Discourse about the “death with dignity”
movement. In the piece, titled “All Death is Death Without Dignity,” I compare the palliative-care movement — which seeks to alleviate the physical pain of death, often in the context of hospice care — to the physician-assisted suicide movement and
find the differences in their respective descriptions of death telling. I quote somewhat extensively from the piece here, in order to then offer some additional thoughts on why the phrase “death with dignity” is a problem.

It has become common to talk of “death with dignity” in the policy world. There’s a

Death with Dignity Act in Oregon
, which permits physician-assisted suicide. There’s a

Death with Dignity Act in Washington
, which also legalizes physician-assisted suicide in certain circumstances. A Death with Dignity National Center exists in
Portland, OR, a nonprofit that advocates for patients to “make their own end-of-life decisions, including how they die” — its website is plastered with
images of smiling faces. The message, it seems, is that if one can control how one dies or when, the dying process is somehow less disturbing, awful, and
humiliating. Instead, it can be dignifying.

Conversely, when dealing with end-stage cancer patients and palliative-care physicians in the hospital I rarely hear the “death with dignity” phrase used;
more often I hear a palliative-care doctor say, “we want him (or her) to be comfortable.” It is a marked difference between the palliative-care movement
and the assisted-suicide movement. In hospice, there is a resignation to the uneasiness and difficulty that comes with any death. With palliation, nurses
and doctors can only free the patient from pain but not from the indignity of dying.

And why does choosing the way one dies have no relevance to whether or not a death is dignified?

Death is not simply a part of life but the end of human life — the end, in some sense, of an entire world. It is the transformation of a living member of our
species into an immobile mass of flesh with no potential for life again. Rabbinic Jewish authorities recognized this in the Mishnah, an extensive
commentary on Jewish law, when they wrote,
“anyone who destroys a life is considered by Scripture to have destroyed an entire world; and anyone who saves a life is as if he saved an entire world.”
Thus, not only are the physical manifestations of death ignoble and viscerally disturbing but, in principle, the end of an individual is tragic, too….

Death and dying detract from life by ending it. There are more or less disturbing ways to pass (you can die while someone is breaking your ribs doing CPR
or you can die without that), but none of them is truly dignified. And choosing to preempt death using physician-assisted suicide doesn’t change this. In
truth, there is no such thing as death with dignity. There is only somber tragedy, as your body lies exposed to the world’s Hobbesian bacteria and insects.

I think there is an important debate to be had about whether assisted suicide should be available in certain, very rare circumstances. But that is a
separate discussion from the point I am making here, which is that the term “death with dignity” is inaccurate and misleading. The phrase changes our whole
concept of death — it is a change that puts a positive spin on dying, a change that detracts from the somber aspects of the end of life.

Wikimedia Commons

This deceptive use of language reminds me of George Orwell, who focused some of his sharpest criticism on the use of language and how it changes our
perception of events and ideas. In his famous 1946 essay “Politics and the English Language,” he condemns the “tendency of modern prose … away from concreteness.” Specifically, Orwell exposes the misuse of euphemisms common in war propaganda — for instance talking about sending people to prison and death camps as the “elimination of unreliable
elements.” Euphemisms can obfuscate the gravity and odiousness of an action, thus creating a false appearance so powerful that it can become tolerable, even appealing.

In 1984, Orwell offers a similar warning. The totalitarian government of Oceania uses its own language called Newspeak, destroying
most of the English language to make way for abbreviations and vague terminology — “cutting the language down to the bone.” As one character explains, “the great wastage is in the verbs and
adjectives, but there are hundreds of nouns that can be got rid of as well.” By manipulating the language, the government of Oceania manipulates the way people think, specifically the political and moral decisions they make. One of its most effective tools is the creation of catchy slogans that utterly distort reality: “war is peace,” “ignorance is strength,” and so forth.

I am not saying that the “Death with Dignity” movement
is an attempt at mind control, like in the police state of 1984. Nor am I arguing that there is only one right way to express an idea. But when it comes to framing an argument
or the context of a debate, we should be very careful when we use language that assumes certain principles that subtly distort reality. In this particular case, the phrase “death with dignity” assumes that death can be dignifying. At its core,
however, death is nothing less than awful:

Indeed, the concept of “death with dignity” is a euphemism for what is one of the most heart-wrenching, difficult, unsettling, and undignified events of
human existence. I think of that patient who chose to make his death comfortable and the image is disturbing rather than heartening. Where is the dignity
in lying in a bed with flies buzzing around one’s head, vulnerable and lifeless?

The logical end of mechanical progress

Marija Piliponyte
(Shutterstock)

When, in 1937, George Orwell wanted to convey the dark side of “mechanical progress” to his readers, he wrote, “the logical end of mechanical progress is to reduce the human being to something resembling a brain in a bottle.” Of course, he said, it is not as if that is really our intention, “just as a man who drinks a bottle of whiskey a day does not actually intend to get cirrhosis of the liver.” But that, he argued, is where the socialists of his time seemed to want to take things. Their emphasis on doing away with work, effort and risk would lead to “some frightful subhuman depth of softness and helplessness.”

Now, very nearly eighty years later, we still don’t want to get cirrhosis. But in a review this week of the finally released Oculus Rift virtual-reality gaming system, Adi Robertson writes, “I love the feeling of getting real exercise in a virtual sword-fighting game, or of walking around a real room to see the artwork I’ve created. Sitting down with the Rift, meanwhile, feels as close to being a brain in a jar as humanly possible.” And just in case you might have missed this wonderful endorsement in what is a pretty long review, the “brain in a jar” quote is repeated as a pullout in a large font with purplish text.

So over time the brain in a bottle can become our intention, it can transform from nightmare scenario to selling point. By “progress” do we mean “slippery slope”?

Practicing Medicine Turns One

As I look back on the first year of this blog and reflect on my four years of medical school, I am amazed at how much I have learned and how much
I have seen. All of it has informed what I have written about here on Practicing Medicine. And many of the issues I have raised remain vital to my experience within the hospital.
Medicine forces physicians to ask questions; questions beyond which IV fluids to give or which antibiotic to use. Medicine demands that we ask the same
questions that any student of human history might ask: What makes us human? What is so humorous about human suffering and pain? Why
do we become numb to human forms of sufferingWhat is the process by which we die? And is it dignified?

How should we view the place of the mentally ill in our society
?

I have also made other, perhaps less broad and less grand, attempts at explicating the practice of medicine. My first post explained why I decided to blog and the awkward place
of medical students within the medical field. This piece
discussed the potent smells of the hospital — they are unavoidable and yet we adjust to them. Stepping into the ED for the very first time, I
explained how a trauma code works and the horrors that
trauma patients face. The kidney-failure patient also faces difficulties,
but they are of a chronic nature due to dialysis, a miracle of modern science with its own drawbacks.

I compared
George Orwell’s experiences in a French hospital in the early twentieth century to my own experiences in a hospital in the early twenty-first; yes, there are major differences, but there are also similarities. This is a pragmatic post on how we ought to think about
scientific studies and evidence-based medicine. I have written about depression and schizophrenia. And, in a more recent post that would have
pleased me greatly as a younger reader, I wrote about Sir Arthur Conan Doyle’s eponymous detective, Sherlock Holmes — it turns out his methods are relevant to physicians today.

Over the next year I hope to continue to write about the big questions and bring up others in relation to what I see and do. I also have a few bigger writing projects in the works, which I will mention here on the blog. If you have suggestions or
comments, please feel free to send them my way. My e-mail address and Twitter handle can be found at the right.

When the Patient Becomes a Specimen

He lay in the hospital bed, belly-up, staring at the ceiling. We knocked as we entered and asked the patient a barrage of questions. How was he feeling?
What doctors had he seen in the past? What other medical conditions did he have? When did he first start to notice uncontrolled nosebleeds? What other
symptoms did he notice? An endless series of questions for a patient already overwhelmed with newly diagnosed leukemia, a cancer of white blood cells. As these cells proliferate uncontrollably due to bone marrow dysfunction, they crowd out other cells in the blood.

Platelets
, for example, which create clots to stop bleeding, decrease in number leading to spontaneous bleeding. White cells malfunction, allowing bacteria, fungi,
and viruses to slip past the body’s floundering immune system. Patients with certain types of leukemia also develop an enlarged spleen, called splenomegaly. This occurs because the body looks for places other than the bone marrow to produce blood
products. The spleen and liver are two organs capable of producing red blood cells (or once were during embryonic development). They enlarge in their
attempts to compensate for bone-marrow failure.

Red blood cells.
Image via Shutterstock

“Come over here and feel this,” the attending physician said to the three of us, all medical students, after interviewing the patient and performing a physical
exam. “Is it alright if they feel for your spleen?” he asked. After the patient assented, the three of us, one by one, began to poke on the left side of
his abdomen, palpating up and down and subsequently tapping and listening for when our taps became dull or tympanic. We searched for where the spleen began
and ended. And there it was, a large, blown-up balloon inside the patient’s belly, squirming around as we attempted to assess its size through palpation.
We stood in line, each excitedly repeating what the previous student had done. It was, after all, the first time any of us had ever felt splenomegaly. In
this particular interaction we converted this human being into a test tube by observing, exploring, feeling, and assessing, detached from the reality of the
patient’s experience.

We do this regularly during our third year of medical school — we violate patients’ privacy for the sake of our education. Part excited, part
nervous, part sheepish, we come when called by our teachers to listen to lung sounds and heart sounds; to inspect wounds and infections; to feel for
various organs, tendons, and muscles in living human bodies. Though this experience feels new and uncomfortable for us, it is worth noting that medical
students have learned in this way — with a lot less regard for the patient — for quite some time.

In a 1946 issue of Now, a political and literary journal, George Orwell published an essay entitled “How the Poor Die.” In this essay we accompany Orwell, who in 1929 experienced a
bout of severe pneumonia, through a frightening, dark, and even humorous tour of a French hospital he simply calls the Hôpital X.

Image via Shutterstock

Orwell describes the admissions process: “I was kept answering questions for some twenty minutes before they would let me in…. At my back a resigned little
knot of patients, carrying bundles done up in coloured handkerchiefs, waited their turn to be questioned.” From here, with a 103 degree fever, Orwell
disrobed, put on a short hospital dressing gown and walked, without shoes, 200 yards outside on a February evening to his hospital ward. Unfortunately, his
quarters were no better than the journey to them. There was a “foul smell, faecal and yet sweetish,” [my comments on hospital smells are here] and the room contained three rows of beds
“surprisingly close together.” It seems, from Orwell’s description, to have been more of a mess hall than a hospital floor.

In the bed across from him, Orwell witnessed a patient undergoing a medical procedure: “a doctor and a student performed some strange operation on him. First the doctor produced from his black bag a dozen small glasses like wine glasses, then the student
burned a match inside each glass to exhaust the air, then the glass was popped on to the man’s back or chest and the vacuum drew up a huge yellow
blister…. It was something called cupping, a
treatment which you can read about in old medical text-books but which till then I had vaguely thought of as one of those things they do to horses.” (A recent review of the efficacy of this treatment has shown the evidence for it to be largely inconclusive.)

Subsequently, Orwell, who ostensibly also required cupping for his illness, joined in the medical education as “the doctor and the student came across to
my bed, hoisted me upright and without a word began applying the same set of glasses, which had not been sterilized in any way. A few feeble protests that
I uttered got no more response than if I had been an animal.” And in his classically dark humor, Orwell notes, “I was very much impressed by the impersonal
way in which the two men started on me…. It was my first experience of doctors who handle you without speaking to you or, in a human sense, taking any
notice of you.”

On a daily basis, nurses woke the patients at five in the morning and measured their temperatures but never washed them. Orwell remarks, “if you were well
enough you washed yourself, otherwise you depended on the kindness of some walking patient.” The doctor typically dropped by later with interns and medical
students and “there were many beds past which he walked day after day, sometimes followed by imploring cries.” Only if there was a patient with some
interesting medical illness or presentation would the doctors attend to them. The attention they paid Orwell was almost too much for him, with “a dozen students queuing up
to listen” to his chest.

It was a very queer feeling — queer, I mean, because of their intense interest in learning their job, together
with a seeming lack of any perception that the patients were human beings. It is strange to relate, but sometimes as some young student stepped forward to take his turn at manipulating you he would be
actually tremulous with excitement, like a boy who has at last got his hands on some expensive piece of machinery…. You were primarily a specimen, a
thing I did not resent but could never quite get used to.

Orwell proceeds to describe in great detail the other patients in the hospital, a potpourri of
characters. We read about an older man who cannot urinate, and about a veteran of the Franco-Prussian War of 1870, dying as female relatives look on, “obviously scheming for some pitiful legacy.”

Then Orwell discovered a patient with cirrhosis of the liver due to alcoholism (a surprisingly common type of patient in hospitals these days, too).
“About a dozen beds away from me was Numéro 57 — I think that was his number — a cirrhosis-of-the-liver case.” This patient’s liver was so enlarged that he was
“a regular exhibit at lectures.” The physician lectured to the medical students on 57, describing the particular physical findings of someone with chronic
alcoholism and an enlarged liver. The doctor felt for the patient’s liver and showed his students what it was like. “Utterly uninterested in what was said
about him, [the patient] would lie with his colourless eyes gazing at nothing, while the doctor showed him off like a piece of antique china.”

Numéro 57 died in the middle of the night, although no one knew it until the morning. “This
poor old wretch who had just flickered out like a candle-end was not even important enough to have anyone watching by his deathbed. He was merely a number,
then a ‘subject’ for the students’ scalpels.” Orwell, as soon as he had gained enough strength, fled the hospital: “it was a hospital in which not the methods,
perhaps, but something of the atmosphere of the nineteenth century had managed to survive, and therein lay its peculiar interest.”

Finally, Orwell offers an incisive comment on hospital medical care: “Whatever the legal position may be, it is unquestionable that you have far
less control over your own treatment, far less certainty that frivolous experiments will not be tried on you, when it is a case of ‘accept the discipline
or get out.’” Orwell directs his social critique at hospitals which treated and took advantage of the poor — forcing them into crowded quarters, ignoring
their cries for help and even operating on them without anesthetic.

Despite the comparative pleasantness of my own experience in my medical studies, whenever I read this essay I wince at Orwell’s descriptions because of how familiar they are to
me. The instances of the patient as a kind of specimen resemble in some remarkable ways the example I gave at the beginning. To be sure, we always thank a
patient, ask if we can perform the appropriate physical exam maneuver, and acknowledge the patient’s right to refuse an exam. Nevertheless, we treat the
patient as a test subject, which, however unfortunate, is necessary for our future profession. As patients we must ask ourselves whether we want to be
treated by physicians who have never heard wheezes on a physical exam or never felt for an enlarged liver. Patients at teaching hospitals indeed make
sacrifices for our education and for the welfare of our future patients.

Orwell also points out the patients’ abdication of privacy in the hospital. Unquestionably, this is accurate even today. When patients arrive, they put on
a hospital gown, or uniform, depending on how you look at it. The gown is, humiliatingly, almost completely open in the back except for a meager string
that, even after being tied, barely holds the back together. With the uniform on, they become hospital patients under the supervision and care of the
nursing staff and doctors. Each patient has the same gown with the same color scheme. Each patient is similarly under our watch.

When we enter a patient’s room, the knock at the door is more of an announcement than a question. Overnight, patients are poked and prodded for their blood
samples. How strange that even their blood seems to be property of the physicians, nurses, and lab technicians. Many patients are attached to an IV pole
which holds bags of fluids and medications being pumped into their veins. And thus, they cannot get up without dragging hospital property along with them.
Of course, the staff does not usually treat patients like hospital property; of course, patients can choose to leave at any time; and of course, patients
are there so they can get better. Regardless, the situation is one in which a patient submits himself or herself to the hospital so completely that,
inevitably, some aspect of the patient’s sense of privacy, independence, and humanness is lost.

Even taking all these similarities into account, Orwell’s hospital experience is more of a nightmare from our perspective. But the parallels should give us pause. Has
something of the atmosphere of the nineteenth century managed to survive even in the latest and best conditions? Must it?

The “Gamepocalypse” and Why We Don’t Heed “1984”

CNN has a rather silly (what else?) piece up called “Why games will take over our lives,” interviewing Carnegie Mellon professor Jesse Schell. Among other things, it speculates that within the next five years, “toothbrushes will be hooked-up with Wi-Fi Internet connections,” so that when others know how often we brush, we will have an incentive to brush more often. From this, the piece moves in short order to the central thesis:

Schell says dental hygiene — and, really, just about everything else — will become a game. He thinks the “gamepocalypse,” the moment when everything in our lives becomes a game, is coming soon — if it’s not already here.
The article usefully illustrates what seem to be two recurrent features of futurism. The first is one of the most basic moves of futurists celebratory and alarmist alike: take some techno-social trend, blur its boundaries to near-dilution, and thereby extrapolate to everything, so that in just a few short years all of society will be defined by it. (Speaking of which, remind me to write about the looming portmantocalypse.)
This move is particularly evident in fictional futurism of the self-consciously “cautionary what-if” variety: think Repo Men and Surrogates, just to name two recent cinematic examples. And all transhumanists seem to have some rapturous vision of the future as defined by their favorite technology. But this move is also evident in much futurism of less extreme varieties, both contemporary and historical.
All this is obvious enough, but there is something of an equal but opposite problem that is much more subtle: it seems that the combined popularity, fervency, and specificity of futuristic speculation winds up blinding us to how basically correct much of it turns out to be. When we (legitimately) dismiss the “gamepocalypse” scenario, it becomes that much easier to shrug off the extent to which gaming, virtuality, and digital immersion really are altering our lives. The extreme predictions end up functioning like a disinformation campaign.
The problem of futuristic specificity is particularly acute in fiction (which all speculation is to some extent). This is because much of the power of fiction is aesthetic: For example, we aren’t just repelled by Orwell’s 1984 as a philosophical response to its narrative, but also because we are drawn into its world, imagining ourselves in it and experiencing the dread of what it feels like to live in its dystopia. But the moral repulsion that 1984 teaches us to recognize then becomes linked to our aesthetic sense of it. Rather counterintuitively, because our own world still feels like our plain old everyday world and not like what we read, 1984 remains emotionally hypothetical, numbing us to how our society has come to resemble that of the novel in some ways (e.g., especially, surveillance). Even if we might recognize it on an intellectual level, it’s hard to find the resemblance nearly as worrisome with reference to the book — not because we’re unfamiliar with the book, but rather, in a way, because we’re too familiar with it.
(hat tip: Ann Kilzer)

wait — where did it go?

David Pogue, from here:

This morning, hundreds of Amazon Kindle owners awoke to discover that books by a certain famous author had mysteriously disappeared from their e-book readers. These were books that they had bought and paid for—thought they owned. But no, apparently the publisher changed its mind about offering an electronic edition, and apparently Amazon, whose business lives and dies by publisher happiness, caved. It electronically deleted all books by this author from people’s Kindles and credited their accounts for the price. This is ugly for all kinds of reasons. Amazon says that this sort of thing is “rare,” but that it can happen at all is unsettling; we’ve been taught to believe that e-books are, you know, just like books, only better. Already, we’ve learned that they’re not really like books, in that once we’re finished reading them, we can’t resell or even donate them. But now we learn that all sales may not even be final. As one of my readers noted, it’s like Barnes & Noble sneaking into our homes in the middle of the night, taking some books that we’ve been reading off our nightstands, and leaving us a check on the coffee table. You want to know the best part? The juicy, plump, dripping irony? The author who was the victim of this Big Brotherish plot was none other than George Orwell. And the books were “1984” and “Animal Farm.”

Fulford on Orwell

Here are the first two paragraphs of George Orwell’s famous essay “Politics and the English Language”:

Most people who bother with the matter at all would admit that the English language is in a bad way, but it is generally assumed that we cannot by conscious action do anything about it. Our civilization is decadent and our language — so the argument runs — must inevitably share in the general collapse. It follows that any struggle against the abuse of language is a sentimental archaism, like preferring candles to electric light or hansom cabs to aeroplanes. Underneath this lies the half-conscious belief that language is a natural growth and not an instrument which we shape for our own purposes. Now, it is clear that the decline of a language must ultimately have political and economic causes: it is not due simply to the bad influence of this or that individual writer. But an effect can become a cause, reinforcing the original cause and producing the same effect in an intensified form, and so on indefinitely. A man may take to drink because he feels himself to be a failure, and then fail all the more completely because he drinks. It is rather the same thing that is happening to the English language. It becomes ugly and inaccurate because our thoughts are foolish, but the slovenliness of our language makes it easier for us to have foolish thoughts. The point is that the process is reversible. Modern English, especially written English, is full of bad habits which spread by imitation and which can be avoided if one is willing to take the necessary trouble. If one gets rid of these habits one can think more clearly, and to think clearly is a necessary first step toward political regeneration: so that the fight against bad English is not frivolous and is not the exclusive concern of professional writers. I will come back to this presently, and I hope that by that time the meaning of what I have said here will have become clearer. Meanwhile, here are five specimens of the English language as it is now habitually written.

In a recent column for Canada’s National Post, Robert Fulford argues that, though “We cannot be reminded too often of Orwell's central thesis that slovenly writing produces slovenly thought and foolish thought leads to ugly prose,” Orwell nevertheless got it wrong:

That opening, coming down to us from just after the Second World War, seems, when you consider the historical context, thoughtless. Can we still say that the English language in 1945-46 was in a particularly bad way? In retrospect, it seems to have been used in the mid-1940s by some remarkable stylists, Evelyn Waugh and Graham Greene, among others. The funniest English writer, P. G. Wodehouse, was spinning out an endless series of books in never less than superb English. T. S. Eliot and W.H. Auden were hard at work. Most important, at that moment the English language had just given the greatest political performance in its history, turning away from England's shores the most formidable of all military machines, Germany's. In the hands of Winston Churchill, language rallied the British, sustained them through desperate years and led them to victory. It was the supreme political accomplishment of Britain in modern times. How could Orwell, writing at precisely that moment, have ignored this central fact of his and England's existence? In an essay called "Politics and the English Language," how could he have failed to notice both the pre-eminent English politician of the century and his uniquely effective eloquence?

I think Orwell could have neglected the “central fact” of Churchill’s eloquence, and the perhaps equally central facts of all the other wonderful writers Fulford mentions, because they were not his concern. What worried Orwell was the state of English as practiced by the average relatively-well-educated person, and indeed by the average super-educated intellectual. If those people, several of whom he quotes to discomfiting effect in his essay, had learned from the examples of Churchill or Waugh or — O consummation devoutly to be wished! — the incomparable Wodehouse, Orwell would never have had to write his essay. By Fulford’s logic, English in America couldn't possibly be in bad shape: just look around at Marilynne Robinson, Michael Chabon, the just-recently-deceased John Updike, et al. Alas, language don't work that there way.