Wednesday, May 06, 2009

Body Donation: Pausing from Medical Studies and Patient Care to ... Reflect.

It's unheard of.

Two second-year medical students, Kristin Burke(center) and Jeremy Robbins(right), and a first-year resident in family practice, Dr. Stephanie Carter(left), sit in the lobby at the UMass Medical School in Worcester, MA and, despite murderous schedules ... talk.

Kristin and Jeremy do not have their faces in thick medical tomes and voluminous lecture notes, even though big year-end exams are coming up fast. Dr. Carter is not making rounds and rushing around trying to do what cannot humanly be done. She did, however, rush in late reciting a list of all she had to do and offering apologies.

It is neigh impossible to yank three people like this off brutal, sleep-depriving, and anxiety-riven medical and study treadmills. Yet Dianne Person, Manager of the Anatomical Gift Program managed to do it – with a flurry of back-and-forth, never-say-die e-mails.

Why? So that these three can discuss their experiences and feelings about dissecting the human body and, as it turned out, much more. In the process, they also satisfy the idle curiosity of a cadaver-in-waiting, me, under the supervision of my wife, Barbara.

I am there as a donor to the Anatomical Gift Program. Donated bodies make it possible for medical students like Kristen and Jeremy to learn about the human body, inside and out, and to fulfill their dreams of becoming doctors. They make doctors like Dr. Carter better doctors.

Voluntary donation is a big improvement over the old days when medical schools and freelance anatomists often paid ruffians, so-called “resurrectionists,” to rob graves. My body, nearly 71 (more than a zombie, less than a fully functioning human), walked in on its own without too much decay and with no graveyard dirt or clinging crawlies.

Kristin, 24, appears first, right on time at the appointed hour of 6:30 on a Wednesday evening. Looking around, steps tentative, she seems a little lost in the huge lobby, as if just released into the outside world from some confined place. Typically, she is in class from 8 to 4 p.m., with a break for lunch. In the evening, she studies until midnight, taking time out for a quick run and dinner.

Extending a hand to Barbara and me, she greets us in a soft voice and with a shy smile. It's hard to believe that such young, girlish eyes have fixed on dead bodies for hours a day over months. Yet she has done so. So have Jeremy and Stephanie. And, at the end of their anatomy course, all have taken and passed mind-numbing written and practical tests. Both tests are often given on the same day.

Medical students learn some 10,000 new words in their first year alone and many thousands more in each of the next three years. Kristin arrives with a brain crammed with medical terms and anatomical facts and functions. She has had to learn terms like neural tube, paraxial mesoderm, notochord, endoderm, intermediate mesoderm, and the difference between somatic and automatic fibers.

Making small talk with her until the others arrive, I mention the PBS/Nova TV program, “Doctors' Diaries” that I had watched the night before. It has filmed interviews with seven Harvard Medical School students from their first year in 1988, through graduation, and follows up with them 20 years later in 2008.

“It's fascinating,” I said. “You should check it out.”

“Television, what's that?” she said.

“Of course, you don't have time for television.”

She shakes her head, but not regretfully. She does so in a way that says: TV is a distraction. What I am doing now, I must give my all to.

She is a medical student. By definition, she does not -- cannot -- lead a normal life. I don't mention “Doctors' Diaries” again.

Jeremy Robbins arrives. A fine young male specimen of 26, he greets Barbara and me with a smile that is real and believable. It's the kind that politicians try for, but rarely pull off. His eye contact locks on; it would make anybody feel special. He would be great in a TV reality series about medical interns. Oops. Strike that. As with Kristin, TV is out for Jeremy. He's a medical student.

His eyes are kind. Already, even before learning more about him, I begin to see him as a future compassionate doctor.

Dr. Stephanie Carter, already a doctor finishing up her first year of residency, has had her usual rough, time-crunched day. Though laying eyes on the four of us for the first time, and after quick introductions, she plops right down and animatedly joins the conversation.

To Kristin and Jeremy, she is what they are working toward. At the ripe old age of 28, Dr. Carter is an instant mentor and our two second-year medical students hang on her every word.

Stephanie (we quickly dispense with titles here) brims with dedication and resolve. “Don't tell me I can't do it,” she said.

When she first applied to UMass Medical School, she was turned down. She went out and got a master's degree in molecular biology and applied again. Asked by an admissions officer what she would do if she were turned down again, she replied, “I'll be back next year.”

She was accepted.

During her years as a medical student, Stephanie kept her rejection notice from UMass Medical and notices from other medical schools that she had failed to get into. After she received her medical degree from UMass last year, she delightfully threw the rejection notices in the rubbish where, in her unshaken opinion, they always belonged.

Even as a little girl in Providence, Rhode Island, Stephanie believed in herself and was curious about everything. She recalls that at the age of seven, she wondered what it would be like to walk on crutches. To find out, she took a couple of
tubes, put them under her arms, and started walking down stairs.

She fell, hitting her head hard on the concrete landing. She fractured her skull and broke her jaw. Her parents rushed her to the ER. When a pediatrician was alone with her, he told her that she was a bad, irresponsible girl who should know better than to do such a silly thing.

Right then and there at the age of seven, Stephanie recalled, “I decided that I could talk to kids better than this pediatrician.” She knew what “pediatrician” meant, too -- taking care of babies and little kids. She felt that this was something she would be good at.

In high school, Stephanie was a “candy-striper” at a local hospital, a volunteer who helped out as needed. The name came from the distinctive wide pink stripes on the slip-ons volunteers wore as they would they fetch magazines, deliver mail, and bring juice and water. It was as a candy-striper that Stephanie had the first inkling of her eventual calling.

However, Stephanie grew up wanting to be an archaeologist. At the University of Massachusetts in Amherst, she majored in science and minored in anthropology.. “Anthropology is all about discovery,” she said. In life and in medicine, Stephanie is primed to ask two things: Where do we come from? What came before?

In her third year at UMass Medical, Stephanie had a vocational epiphany. By that time, she thought she wanted to be a pediatrician. “But then I realized that I didn't want to deliver the baby and then hand the baby over to somebody else.” She wanted to be there for the baby as he or she grew up. She decided to specialize in family practice.

Kristin grew up in Mansfield, MA in an archtypal American family. Her Dad worked for Polaroid and her Mom was an interior decorator. Like Stephanie, she was a self-described “science geek.” Dreaming of some day becoming an astronaut, she studied biology at Wake Forest College in North Carolina.

While at Wake Forest, she volunteered at a hospice – and the experience changed her life. “I saw how much care these patients required and I said to myself, 'I can do that',” she said. That “can” soon turned to “want.”

Like Stephanie, Kristin was also a candy-striper. As with Stephanie, it was as a candy-striper that she first imagined herself as a doctor. What attracted her most was the interaction with people. Her desire to take care of patients was born and, since then, has only grown.

Kristin is far from one-dimensional, however. She has another great passion: music. At the age of four, she played the piano. At age eight, she took up the cello. By the time she was 16 and in high school she was teaching piano to 36 students aged 5 to 50.

“You got paid for it?” I asked.

“Yes, very well.”

“But now you don't have time to play the piano.”

“No.” She says she still has her old baby grand, but hardly ever sits down at it. “I played a little when my mother was visiting and she said my playing was not so good,” she said.

Clearly, both medicine and music are firmly in Kristin's future. She said, “I feel like the hard part of these pre-clinical years of medical school is that I always feel like there is more that I can be studying. ... I know that I will come back to piano some day, but now it is more important for me to gain a solid foundation in medicine.”

Jeremy grew up in the greater Boston area, in Swampscott and Jamaica Plain. His father was a social worker in private practice and his mother was a teacher. Although you would never guess it today, he was physically “reckless” when he was younger.

“Put it this way, “ he said. “The ER knew me.” But he survived to study science and physics at Colby College in Maine and to graduate from there.

What influenced him to become a doctor? Jeremy goes back to his days in the Swampscott public school system where his class was the first to have Down's Syndrome children mainstreamed. He took two of them, both boys, “under wing,”not to please anyone but because it was the “right thing to do.” He says they taught him the importance of “being kind, sensitive, and respectful.”

He credits a “loving, caring, supportive” family for giving him the values and opportunity for college that led him to medicine. He is “especially close” to his parents and “would not be anywhere without them.”

His grandfather was an important role model. “He was a truly great man,” Jeremy said. He was an orphan who was abandoned by his father after his mother died giving birth to him. Growing up during the Great Depression and without family, he “came from nowhere” and worked his way up to become a pathologist. Jeremy describes him as “humble, loving, compassionate,” and as a “father figure” in the lives of many, many people.

His grandfather's real claim to fame, Jeremy says, was as a “master” teacher at BU Medical School. He mentions something else in passing: “writing the big-deal book.”

Stephanie snapped to. “Robbins Pathology?” she asked excitedly.

“Yes,” Jeremy admitted somewhat reluctantly. “Pathological Basis of Disease.”

“By Stanley Robbins?” Stephanie asked, now on the edge of her seat.”


“Pathological Basis of Disease” by Stanley Robbins, Jeremy's grandfather, is a well-known and widely used medical text. But Stephanie must pull this distinguished heritage out of Jeremy, who evidently has inherited his grandfather's humility.

Jeremy may not yet know his speciality, but he definitely knows the kind of doctor he wants to be. As Dr. Jeremy Robbins, he will earn the “intimate trust of the patient, doing whatever it takes to ensure the health and well-being of my patients, always doing the right thing.”

In addition to medicine and patient care, Jeremy has other loves: his parents who “have so much to do with who I am as a person and where I am today”; watching a Red Sox game with good friends or “going for a hike with my wonderful girlfriend, Aimee”; and “my Italian grandmother's meat sauce.”

There is a very special place in Jeremy's heart for the cadavers he and Kristin dissected in Anatomy Lab as first-year medical students. He and Kristin worked with the Director of the Anatomy Gift Program, Dianne Person, to coordinate the annual May memorial to donors and their families.

Now this future cadaver wants to know something. “The only thing that bothers me about being in the Anatomy Lab,” I said, “is losing my identity. I don't like being nameless when all my life I have been a person with a name, personality, and individuality. When I donate my body, why do I suddenly have to be a nobody?”

I explain that it is different in some other countries and cite Thailand as an example. “In Thailand, “ I said, “they honor the cadavers in the anatomy lab by displaying their photos with names, bios, and life achievements. They refer to the cadaver as 'my great teacher.' Why shouldn't it be the same way in this country?”

While not sure about going so far as the Thailand model, Kristin and Jeremy are both open to medical students knowing more about the cadaver/patients. However, many medical students, who work in groups, prefer not to know details of cadaver/patients' personal lives.

Jeremy recalls his experience in Anatomy Lab:

“The feeling of trepidation while making our first incision (our group of four all put one hand on the scalpel) is something I'll never forget. How much things changed when I peeled back the cloth covering our patient's face and finally had an identity to go with her body. I felt much more at peace (for lack of a better word) after seeing her face; it gave me a sense of wholeness that evaded me previously. I guess after spending days in the anatomy lab, I had begun to become a little detached from the patient, and seeing her face really reopened my eyes to seeing her as I would any other human being.”

Kristin remembers Anatomy Lab this way:

“At first, the task seemed emotionally draining. I had never spent time around a dead body before, and in the first few weeks of lab, I felt a reverence for my cadaver that was almost inhibitory to my learning. I was tentative in my dissections, taking note of every detail that I could appreciate in his body. Shortly thereafter,... I became more in touch with and more curious about what he was like in life. My lab partners and I gave him a name, Hank, so that we could feel more connected with him. We wanted to know about his hobbies, his family. How did he get the scar on his knee? Who held his strong hands? When lab was over at the end of the semester, I went to say goodbye to Hank, and felt like I was saying goodbye to an old friend. By donating his body, he offered me the most selfless gift that I had ever received. I learned through him, not only a lot about the human body, but about my own respect for the importance of the many facets of a person’s life. I hope to carry this knowledge and understanding with me in all of my future relationships as a physician.”

I push a self-serving agenda: “To be honest, what I would really like is for medical students to be required to see the video of my 70th birthday party before they dissect me. I want them to see me in on the deck of my home on a beautiful May day laughing and enjoying life with my wife Barbara, four grown children, nine grandchildren, and a pack of friends.”

“The video could be on a big screen taking up the whole wall,” Kristin said.

“You know, Kristin,” I said. “You are definitely getting with the program.”

I voice another concern: the virtual banning of humor in Anatomy Lab. “I just think that the atmosphere doesn't have to be so heavy,” I said, “and a little humor might be a good way to give medical students some relief from the emotional burden of dissection.”

“You could write a joke on your arm,” Jeremy said, smiling.

I give him a thumbs up. I do not say that I am thinking about what I might write on my arm to coax a smile from stressed-out medical students.

But now the mentor, Stephanie, weighs in. “The reality is that when Anatomy Lab begins, everybody there is a stranger. You don't joke around with people you don't know. So much humor depends on people knowing and feeling comfortable with each other. And now add cadavers and nobody wanting to disrespect them and you have another huge reason to keep things serious and professional.”

I instantly rethink humor in the Anatomy Lab.

Perhaps there could be some lightness toward the end of the Lab when students know each other better and the inevitable initial emotional turmoil has subsided somewhat. So, as a cadaver, I'm thinking I'll save any comedy routine for toward the end when students may appreciate it more.

Stephanie, Kristin, and Jeremy all strongly believe that there is no substitute for human dissection. For all of them, intimacy with the deceased human body is necessary to prepare doctors for intimacy with the bodies of living human beings. Human dissection, all three agree, is essential for future doctors.

Dr. Christine Montross, author of "Body of Work" and a resident in psychiatry at Brown University, describes the value of human dissection this way in a recent New York Times article:

“We learn to heal the living by first dismantling the dead. The dissection of cadavers also gives young doctors an appreciation for the wonders of the human body in a way that no virtual image can match. It is awe-inspiring to hold a human heart in one's hands, to appreciate its fragility, intricacy, and strength.”

In his study of medical students in anatomy class, sociologist Frederick Hafferty sees them divided into two basic groups. One group looks upon the cadavers as purely biological specimens, like cats, frogs, and earthworms dissected in other classes. The other group views the cadavers as formerly living human beings.

The two groups have very different mindsets. A student from the first group, quoted by Hafferty, said: “To me the cadaver is a complete nonperson. You really don't think of it as being your body or somebody else's. It's just like a rubber model. When somebody says that a cadaver died of something, it sounds pretty strange. You don't think of it that way. I think it's pretty stupid to be squeamish with cadavers.”

Now listen to a student from the second group, also quoted by Hafferty: “There are people working in lab with me who never express their emotions. If they don't have that emotional sensitivity now, they'll be doing the same thing later on. There are going to be a lot of patients you are going to have to care for that will be physically, or whatever, unable to react to you, just like a cadaver, and you've got to be able to make yourself aware of the patient's feelings, his pain or discomfort ... something you must have if you're going to be a good doctor.”

Hafferty would undoubtedly place Kristin and Jeremy in the second group, and so would I. With their great empathy and respect, they can hold my no-longer-beating heart in their hands any old time. They are everything that any cadaver candidate could hope for.

But what if my precious bod ends up with students from the other group, who see me as a big frog and treat me like one? No problem: feelings don't matter when you don't have any. They are still young people there to learn. And my body is there to be their great teacher.

Of course, there is a chance that some students in the “froggies”group will acquire a habit of depersonalization. Without realizing it, they can easily and seamlessly transfer this mindset to their treatment of live patients. It happens.

But let's not be too quick to damn the “froggies” and praise the “weepies.” Mindset as a medical student does not a doctor's destiny make. Some students in the weepies group may well get too emotionally involved to focus properly and get the job done. Not learning is just as bad as too much depersonalization, perhaps even worse.

As a cadaver, I will do my part to the best of my inability.

So long and keep moving.

Postscript: For historical perspective, see an excellent account in the journal Academic Medicine of how human dissection in medical education has evolved over 500 years. Published in 2000 by George S.M. Dyer and Mary E.L. Thorndike when they were third-year medical students at Harvard Medical School,the account remains valuable today. It credits the University of Massachusetts Medical School for being "in the vanguard for incorporating emotional lessons into its learning objectives for gross anatomy" and for asking medical students to "confront and develop their attitudes toward death and dying, and also to discuss them with their instructors."

E-Books by George Pollock

"State Kid: Hero of Literacy" is fiction based on his  real-life experiences  growing up in foster homes; "Last Laughs," is the true story of how five foster kids (he and four younger siblings) found their way in life and each other. "Killers: Surprises in a Maximum Security Prison," is the story of the author being locked up for 23 hours with killers in a maximum security prison;  "I, Cadaver" is about the author's postmortem adventures and mischief in the anatomy lab at UMass Medical School. “A Beautiful Story” demonstrates the art and process of creative writing as a 16-year-old boy goes all out to write a story good enough to get him into an exclusive college -- on full scholarship; and "A Long, Happy, Healthy Life," which is about how to live the title every single day.

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