I learned about a lot of things in medical school, but mortality wasn't one of them.
Although I was given a dry, leathery corpse to dissect in my first term, that was solely
a way to learn about human anatomy.
Our textbooks had almost nothing on aging or frailty or dying.
How the process unfolds, how people experience the end of their lives, and how it
affects those around them seemed beside the point.
The way we saw it, and the way our professors saw it, the purpose of medical schooling
was to teach how to save lives, not how to tend to their demise.
The one time I remember discussing mortality was during an hour we spent on The Death of
Ivan Ilyich, Tolstoy's classic novella.
It was in a weekly seminar called Patient-Doctor--part of the school's effort to make us
more rounded and humane physicians.
Some weeks we would practice our physical examination etiquette; other weeks we'd learn
about the effects of socioeconomics and race on health.
And one afternoon we contemplated the suffering of Ivan Ilyich as he lay ill and
worsening from some unnamed, untreatable disease.
In the story, Ivan Ilyich is forty-five years old, a midlevel Saint Peters-
burg magistrate
whose life revolves mostly around petty concerns of social status.
One day, he falls off a stepladder and develops a pain in his side.
Instead of abating, the pain gets worse, and he becomes unable to work.
Formerly an "intelligent, polished, lively and agreeable man," he grows depressed and
enfeebled.
Friends and colleagues avoid him.
His wife calls in a series of ever more expensive doctors.
None of them can agree on a diagnosis, and the remedies they give him accomplish nothing.
For Ilyich, it is all torture, and he simmers and rages at his situation.
"What tormented Ivan Ilyich most," Tolstoy writes, "was the deception, the lie, which for
some reason they all accepted, that he was not dying but was simply ill, and he only need
keep quiet and undergo a treatment and then something very good would result.
" Ivan Ilyich has flashes of hope that maybe things will turn around, but as he grows
weaker and more emaciated he knows what is happening.
He lives in mounting anguish and fear of death.
But death is not a subject that his doctors, friends, or family can countenance.
That is what causes him his most profound pain.
"No one pitied him as he wished to be pitied," writes Tolstoy.
"At certain moments after prolonged suffering he wished most of all (though he would
have been ashamed to confess it) for someone to pity him as a sick child is pitied.
He longed to be petted and comforted.
He knew he was an important functionary, that he had a beard turning grey, and that
therefore what he longed for was impossible, but still he longed for it."
As we medical students saw it, the failure of those around Ivan Ilyich to offer comfort
or to acknowledge what is happening to him was a failure of character and culture.
The late-nineteenth-century Russia of Tolstoy's story seemed harsh and almost primitive
to us.
Just as we believed that modern medicine could probably have cured Ivan Ilyich of
whatever disease he had, so too we took for granted that honesty and kindness were basic
responsibilities of a modern doctor.
We were confident that in such a situation we would act compassionately.
What worried us was knowledge.
While we knew how to sympathize, we weren't at all certain we would know how to properly
diagnose and treat.
We paid our medical tuition to learn about the inner process of the body, the intricate
mechanisms of its pathologies, and the vast trove of discoveries and technologies that
have accumulated to stop them.
We didn't imagine we needed to think about much else.
So we put Ivan Ilyich out of our heads.
Yet within a few years, when I came to experience surgical training and practice, I
encountered patients forced to confront the realities of decline and mortality, and it
did not take long to realize how unready I was to help them.