Suzanne Koven, Letter to a Young Female Physician

The clinic is cool and dimly lit. I lie on a none-too-comfortable gurney, enrobed in the standard, unmanning hospital gown. Around me, machines whir and click; air enters through the hospital’s HVAC system, a white-noise whoosh. The resident, when he steps through the door, is gowned as if for surgery — he sports a tunic of lifeless green, his hair shrouded by something like a giant, paper brioche.

I must confess something here — I’ve made over the last couple of years a hobby of, well, “educating” residents (and, really, medical personnel in general). When you’re quite possibly dying, you need something to keep you distracted and amused. Upon this particular guy, I deploy my standard line for these moments when medical sorts snake their fat, rubber tubes down my throat and snorkel about my midsection. This comment, though, is not aimed to provoke — rather, it’s born of my own terror.

In the three years since I started treatment for esophageal cancer, I tell him, I’ve married a woman so precious I’m surprised she gave me the time of day, much less tied her life to a life as contingent as my own. I’ve just walked away from a Ph.D. program and started to write. I’ve got part custody of two little kids. “So you can’t find cancer,” I finish. “Anything else, abandoned tires or rusty fish hooks, all well and good, but don’t you dare find a tumor — I mean it.”

This guy’s training, rigorous as it no doubt was, did not prepare him for this. His body language goes full panic-mode and beads of sweat pop out on his forehead. “Well, you know,” he stammers, “I…I can’t tell promise that. I mean, there…there…there’s no way we can know…I mean about the cancer…until we get in there and — “

At this instant, Dr. Weiss slips into the room. We’ve been together, this man and I, since the beginning of this unwelcome journey. He was, in fact, the doc who first diagnosed this thing that possesses so much potential to kill me. “I just ordered your resident not to find cancer,” I say. “I might’ve freaked him out…”

Weiss uncorks a self-assured grin, positions himself at the top of the gurney, ready with a syringe of knock-out juice and his endoscopy tube. “Don’t worry,” he says. “We won’t.”

I turn back to the resident. “When someone tells you what I told you,” I tell him, “that’s how you answer.” He remains silent as Weiss places his thumb on the plunger that will catapult me to lala land. He smiles his sweet, humorous smile. “Goodnight,” is the last thing I hear.

That was twenty-six years ago, so Weiss’ prediction turned out to be correct. But it could’ve been otherwise. In 1995, esophageal cancer killed 95% of its sufferers within five years of treatment. Quite possibly, it does still. So by any rational measure, the resident had the right of it. Obviously, there was no way he could assure me that my cancer, so boisterously lethal, hadn’t come back. He acted, in that instant, like a proper medical professional, a perfectly appropriate clinician.

But Weiss, with those rash words, “We won’t,” was something more in that moment, something greater, yet less guarded — a doctor. Sometimes, to be a physician, a great physician, one has to go, in the words of doctor/writer Suzanne Koven, “off the charts.”

Koven’s writing of Letter to a Young Female Physician was sparked by an exercise given to newly hatched interns, which invited them to write letters to their future selves. Turning that logic on its head, and nearing the close of her career, Koven wondered what she might say to her younger self as a new fledged doc. 

In this series of essays, she touches on death, medical education, personal insecurities, the early AIDS epidemic, groundless belief in physician invulnerability, misogyny and racism in the medical profession, the impact of financial constraints upon the practice of medicine, the frailty and death of aging parents, difficult (me) or noncompliant patients, struggles with food, her own development as a writer, and, finally, the everyday heroism of medical personnel simply coming to work in the face of Covid-19.

Laced through all of this is Koven’s learning to recognize her particular strengths, her journey from insecure intern to the doctor she’d ultimately become — from the twitchy propriety of my gastroenterological resident to the comforting, if somewhat buccaneering, assurance of Dr. Weiss. Letter to a Young Female Physician is the story of her learning, in short, to go off the charts.

“When I first went into practice,” Koven writes, “I had rather firm notions of the proper boundaries between doctors and patients…An older colleague found my rigidity amusing…’You’ll loosen up in time,’ he told me…I think I feared that as a young female physician I wouldn’t be taken seriously unless I maintained an austere facade.”

This task of “loosening up,” however, is confounded by a malady she considers particularly acute in women.

“I believe women’s fear of fraudulence is similar to men’s, but with an added feature: not only do we tend to perseverate over our inadequacies, we also often denigrate our strengths.”

Still, over the years, Koven learns to embrace her less obviously medical strengths, learning at last to adopt an expansive notion of doctoring, one in which technical prowess works in tandem with one’s role as a human being.

“As my colleague Jim predicted, I found my initially rigid standards nearly impossible to meet over time. After all, a doctor is not simply a repository of information but a human being with a personality, a sense of humor, and a point of view.”

And,

“…I always feel like I do my best work when I play the boundary, when I bring myself to the patient as a person. When I go off the charts a little…when I talk with my patients about issues not strictly medical, I feel most like a doctor.”

Letter to a Young Female Physician is a work of near staggering vulnerability. Koven walks readers through her fears of personal inadequacy, her uneasy relationship with the nuts and bolts of chemistry and biology, her early acceptance of inequity in the medical system, her professional fallibility, her struggle to be both daughter and medical advisor to failing parents. We watch her bring her humanity into her medical practice and become a greater physician for it. At points, her militant honesty leads her to suspect herself of worse motives than she likely possessed.

To care for the ill, to really care for them, one must come to them as more than a body of knowledge, a set of technical skills. “I’m not sure that even holistic medicine fully acknowledges the difficult-to-measure therapeutic effects of empathy, attentiveness, humor, intuitive reasoning, the ability to inspire hope, and other qualities sometimes called ‘soft skills’ (or more appreciatively ‘the art of medicine’) and which are as useful in my practice as antibiotics and MRIs, if not more so,” Koven tells us. “Similarly, when I’ve been a patient myself, or when someone I love has fallen ill, I’ve been struck by the importance of these qualities to healing.”

Me too, pretty clearly — sometimes, “the art of medicine” means telling a frightened guy with his bottom hanging out of a hospital gown that you won’t find a tumor that may in fact be there, taking that risk, “inspiring hope,” bringing to bear all of one’s technical prowess yet keeping one tyvek-covered foot firmly off the charts.

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