The Examined Life
Jerome Groopman writes about doctors and their patients
Why is it that so many doctors feel compelled to write, and that so many do, so compellingly? William Carlos Williams, Ethan Canin, M.D. '89, Lewis Thomas, M.D. '37, S.D. '86, Oliver Sacks, and now Jerome Groopman, Recanati professor at Harvard Medical School and chief of experimental medicine at Beth Israel Deaconess Medical Center, who began writing just four years ago at the age of 44. In that time he's produced two books and become a staff writer for the New Yorker.
At 4:30 a.m., when there's no trace yet of morning light in the January night sky, Groopman is already up and working. During the next two hours, he will write and revise: stories from his own experiences, book reviews, articles. His stories are what might be called medical case-history thrillers. This branch of nonfiction can make powerful reading. In the hands of less-skilled practitioners, the genre amounts to "earnest doctor fights mysterious or terminal disease in heroic attempt to save patient's life," but Groopman's characters, deftly rendered through the prism of his own moral perspective, spirituality, intelligence, and compassion, almost come to life, in the tradition of the best fiction.
At 6:30 a.m., Groopman abandons the pen in favor of the sword as, over the next hour, he and his wife coax their three children, ages 17, 11, and 7, out of bed, to the breakfast table, and off to school. Then he mounts his exercise bike and reads the Wall Street Journal, New York Times, and Boston Globe as he pedals. Groopman exercises twice a day against the possibility that he might suffer the same fate as his father, who died of a heart attack at a relatively young age. Then it's off to work at his laboratory.
Groopman's clinical practice in hematology (diseases of the blood), AIDS, and cancer is world renowned; in his lab, he and an elite team of postdoctoral fellows also study neurobiology. The complex clinical cases that Groopman writes about often lie at the intersections of these fields. Many of his patients have exhausted all proven treatments and come to Groopman as their last, best hope. He keeps pictures of some of them, including the late King Hussein of Jordan, in his office. For those who have died, his stories serve as a kind of memorial.
The desk in Groopman's office is piled high with the scholarly books and scientific journals necessary to stay current in his field--titles such as Blood, Cell, Nature, and Science. He also reads widely for pleasure, about a book a week. Brian Greene's Elegant Universe--"beautifully written," he says--is a recent favorite, as is Roddy Doyle's story of a boy growing up in Ireland, A Star Called Henry.
In person, Groopman is warm and funny--the perfect doctor. When asked, "How did you begin writing?" he pauses a moment and says, with a broad smile and a twinkle in his eyes, "I love my wife." Then he pauses again. This charming non sequitur proves to be an elliptical answer to the question. His wife was the first person to read his stories, back in 1996. "She told me the truth," he says, that "they were terrible." He rewrote and revised. Then, with the encouragement of his friend Martin Peretz, publisher of the New Republic, he took his work to New York and showed it to 11 different publishing firms. One publisher told him, "There are seven steps in character development, and you've missed a few"--and then went on to instruct him that every chapter ought to have an epiphany. There were rejections and more requests to rewrite.
"Writing"--which he jokingly refers to as his midlife crisis--"is incredibly difficult," he says. "You can't overestimate the time and effort that it takes." He makes 14 to 18 drafts of each story, a red-lining process he describes as "the exercise of restraint, to really describe the events and the tension and to develop the character while keeping myself back from editorial judgments."
Today, Groopman is a staff writer in medicine and biology for the New Yorker, an honor he calls "amazing," "a gift," "maybe equal to Harvard tenure in terms of prestige." A friend's agent brought his work to the attention of the magazine, which offered to buy a chapter from what would become his first book, The Measure of Our Days.
That chapter was the story of "Kirkland Bains," an investment banker afflicted with kidney cancer that had metastasized throughout his body. When he came to Groopman, other physicians had given up on him. Searching for something beyond the ostensibly hopeless prognosis, Groopman saw in Bains an intense will to live, and took him on as a patient. After a few weeks of risky and unproven treatments, a recovery was well underway, miraculous by any standard. Bains went home.
Four months later, he was back, and so was the cancer. But the fight Bains had shown during his first bout with the disease was gone. Confronting death, he had examined his own life and found it worthless.
"His story is complicated because it's contrary to all that is celebrated in terms of modern-day appearances," Groopman says. "Here is a wealthy, powerful, successful guy with a big stock portfolio, all the right attributes, and the right pedigree, and yet at this moment in life all of that is stripped away, and there is this harrowing moment when he sees that. It is not easily rationalized. As a doctor, you certainly want to care for [your patients] spiritually and emotionally, as well as physically, but how you do that is complicated; it's a real art and it is not something you are taught in medical school. And I try my best to find something in my own experience and my own background--which is very different from his, obviously--to give to him and see if in some way it can provide comfort, to see if in some way it will allow him the opportunity to create meaning." Groopman encouraged Bains to express his sense of failure to his children. "I don't know if that ever really happened," he says, "which, of course, is the lingering end of the story."
Caring for Bains proved a life-shaping event, Groopman says. "It was such a powerful experience, and to me such a jarring and disturbing experience, that I would say it was one of the pivotal moments in my decision to begin writing." Caring for the terminally ill, Groopman found that his patients' search for meaning was reflected back on him, both by his attempts to understand and assist them, and in the resulting impetus to examine his own life. Writing about these cases "was a kind of catharsis," he says. "The story of Kirkland Bains set the theme and arc of that first book, which is the issue of facing mortality, trying to identify what is substantial in your life. I needed to get these stories out, to reflect on them, find a meaning, and share them with others."
Groopman grew up in a working-class neighborhood in Queens and attended public schools in New York City. "I was pretty wild and not a good student up until my senior year in high school," he says. Even so, he entered Columbia at 16. At first, he thought he'd become a chemist, not a doctor--much less a writer. "I loved chemistry," he says, "particularly synthetic organic chemistry." But he was dissuaded from this path, which might have led to a cloistered career in a laboratory, by the concern that he would become "removed from the flux of daily life," from the "immediate and real," as he puts it. He stayed at Columbia for his M.D., and went on to a residency at Massachusetts General Hospital. "A physician occupies a unique perch. You really do see the mysteries in life and you have incredible access to every recess of a person's experience." Medicine also presented "the opportunity to live a moral life."
"It's not that I'm a saint," he avers. "A friend told me about this saying from the Talmud: 'And the good doctors will burn in hell.'"
"The Talmud is full of these kinds of enigmatic sayings," he explains. Like many religious texts, this one is subject to interpretation. Groopman spoke with a rabbi friend about it, and now reads it as a "warning to doctors who believe that they are good, or who let it be known that they are good to attract patients, when they might not be." For him, "the lesson of this one is humility."
"I've made mistakes, as I acknowledge in my books," he says. "Nobody is perfect, especially in the face of imperfect knowledge." Medicine will not always be this way, Groopman believes, but for now, he says, "There are some very tough decisions that need to be made and it takes a lot of courage to face them."
Judaism is a source of strength for this man who, ministering to the gravely ill at the limits of medical knowledge, lives with the uncertainty of his own recommendations. He has read the theologian Paul Tillich, whose argument that doubt is an essential part of faith resonates with him. "If you are doubting something, then you are thinking about it," he says. "That kind of skepticism is part of what it means to be a good doctor to one's patients."
Doubt is a central theme of Groopman's latest book, Second Opinions, published in March. Nowhere is this more dramatically demonstrated than in the story of "Alex Orkin," a young physicist whose bone marrow had stopped producing blood. Groopman's account shows how it is possible to be moral and yet to be wrong. Orkin's doctor, a senior hematologist whom Groopman calls "Frank Hochman," recommended a bone-marrow transplant. But a matched donor could not be found for Orkin. Hochman then suggested an unmatched transplant, which, Groopman says, "would either have killed Orkin or consigned him to a life of severe debility." Groopman wanted more time to try to learn in his lab why Orkin's bone marrow was dying. What ensued between the two doctors was nothing less than a battle for their patient's trust. Orkin decided to follow Groopman's advice, but, with a compromised immune system, nearly died while waiting for the results of Groopman's tests. Ultimately Orkin lived and, extraordinarily grateful, resumed an apparently normal life. And yet for Groopman, doubt remains even after this apparent vindication. "When Alex Orkin says at the end, 'How did you know?'" says Groopman, "well, I didn't know, and the burden that I carried in not knowing was extraordinary because he could be dead."
Despite his newfound success as a writer, Groopman says that it is his patients and his doctoring that matter to him most. He never writes about a patient without permission, and he suspends his popular writing when applying for grants. In the last year, he has received two NIH grants and written "10 or 12 scholarly papers." "I could give this up," he says of his avocation, though it is clear he doesn't want to. Nor, by and large, do his colleagues want him to; they have told him that he shows how hard it is to be a doctor in the face of uncertainty. "There is some very high-level guesswork that goes on here and the stakes are life and death, or perhaps the chance of life versus near-certain death," he says. "I wrote this last book to educate patients. Helping people matters to me."
Could it be that many doctors are really humanists in lab coats? That they share with writers a special ability to empathize with human joy and suffering? Groopman explains his own experience more simply, by saying of his stories merely, "They've all happened to me."