School Slice: Freshman Seminar
The students in Jerome Groopman’s “Insights from Narratives of Illness” wrestle with the profound.
In a tiny sunlit classroom on the second floor of Harvard’s Morton Prince House, the students in Jerome Groopman’s freshman seminar, “Insights from Narratives of Illness,” were heading into the second half of their two-hour class. The cookie break was almost over. Groopman (who supplied the cookies) had left the room 10 minutes earlier so his students could eat and chat in peace—and to e-mail them the next week’s assignments. Now he came bounding back.
“How are the cookies?” he asked brightly. “Anything left?”
“Uhh…” The was a fumbling pause and a sheepish murmur, and then a student handed over a bag of crumbs. Groopman laughed. “Oh boy,” he said. “OK. I guess they were good!…Well—let’s continue with ‘Imelda,’ shall we?”
A hematologist and cancer specialist, Groopman is the Recanati professor of medicine at Harvard Medical School and chief of experimental medicine at Beth Israel Deaconess Medical Center. He’s also a New Yorker staff writer and the author of five books on biology and medicine. He writes regularly, and movingly, about the experiences of patients and physicians.
And for the past 12 years he’s taught this course to freshmen, walking them through close readings of a dozen or so works, from Tolstoy and Turgenev and William Carlos Williams to Andrew Weil and Susan Sontag and Oliver Sacks. The class reads Chekhov’s short story “A Doctor’s Visit” and Samuel Shem’s satirical hospital novel House of God. Later in the semester they’ll read Sacks’s An Anthropologist on Mars, whose essays detail the case histories of seven patients with neurological disorders; and Groopman’s own New Yorker article “The Doubting Disease,” about obsessive-compulsive disorder and the boundary between productive obsession and impairment. (“It’s a profile of the Harvard medical faculty,” Groopman joked to his students, who didn’t quite know whether to laugh with him.)
Groopman salts class discussions with occasional anecdotes from his own life as a doctor—like the time he helped resuscitate a man who collapsed in front of him at the gym, or how it feels to be exhausted and irritable after an overnight ER shift—and with his Queens drawl and his easy, teasing warmth, it’s not hard to picture what Groopman’s bedside manner must be like. But “Insights from Narratives of Illness” is as much a class on literature and writing and critical thought as it is on doctoring or medical perspectives. (“What are the two narrative arcs?” Groopman is fond of reminding his students in what’s become almost a call-and-response: “A person goes on a journey,” his students chime in, “and, a stranger comes to town.”). Some students who enroll in the course are planning to become doctors, but others will settle on English, or classics, or political science, or economics. “The subjects we wrestle with,” Groopman says in an interview after class, “have profound ethical and social resonance.”
This week, the third of the semester, Groopman and his students were reading Letters to a Young Doctor, a collection of autobiographical essays and stories by Richard Selzer, a surgeon and longtime Yale faculty member who, as Groopman once wrote in The New York Times, “helped usher in the modern genre of medical writing in which the physician puts his experiences under the microscope for the lay reader’s scrutiny.”
A Catholic whose writings—like those of many physician-authors the students will read this semester—echo with religious undertones, Selzer views medicine as a calling, an almost holy exercise. The relationship between doctor and patient is sacred. And he finds beauty in disease and suffering. “Rendered helpless by their afflictions,” Selzer’s narrator tells a younger physician early in Letters, the sick “know something you and I do not yet know—what it is to live with the painful evidence of your mortality.” Now 87, Selzer first published Letters in 1982.
On this February afternoon, nine students sat around a broad table that filled up the whole room, and a tenth, home sick, joined in by FaceTime, on a classmate’s phone propped against a water bottle. (“Hello!” Groopman waved at her from across the table. “We miss you!”) Before the cookie break, the class had started in on a story called “Imelda,” whose title character is a young girl with a harelip and cleft palate whom Selzer met when he was a medical student accompanying an eminent plastic surgeon on a mission to Honduras. The surgeon, whom Selzer calls Hugh Franciscus—a name heavy with metaphor—is the center of the story and its tragic figure: when we first meet him, he is remote and affectionless. He shrinks from his patients’ touch. As a physician healing their deformities, however, he is driven, relentless, and seemingly infallible. His colleagues and subordinates idolize and revere him. Describing his white coat as “monkishly starched,” Selzer writes that Franciscus had “the appearance of a prophet.”
“Do you believe that?” Groopman broke in suddenly, stopping the student who’d been reading the passage aloud. “Are doctors prophets?”
A few students vaguely shook their heads. “No,” ventured one young woman.
“No,” Groopman affirmed. “Uncertainty and unpredictability are essential to medicine. They call it the uncertain science; you can do everything absolutely right as best you know, and the outcome for the patient is poor. But Hugh Franciscus is a ‘prophet.’ So he’s a seer—maybe.”
In a Honduran village, whose landscape and people Selzer calls airless and made of clay—godforsaken, in other words, missing the breath of life God gave to Adam—Franciscus’s pedestaled perfectionism crashes into reality. Young Imelda has a toxic reaction to the anesthetic and dies on the operating table before Franciscus can make his first cut.
“So,” Groopman said, “now let’s look at this great monkish starched Hugh Franciscus on page 30.” He signaled a student to pick up the reading at the passage where the surgeon comes out to tell Imelda’s mother that her daughter is dead. Trying to maintain his aloof untouchability, Franciscus begins by standing over her—“why all the stage directions? Look at what they’re saying,” Groopman said, looming over a student to drive home the point. But instead Franciscus breaks down. He cannot speak. The mother rises to her feet in front of him, and she is the one who finds the courage to speak the awful truth: “Muerte.”
“Suddenly he’s losing it, this guy who was so controlled,” Groopman said. Standing up behind his chair, he paced back and forth slightly, and then took over reading Selzer’s text: “At that moment,” he read aloud, Franciscus “was like someone cast, still alive, as an effigy for his own tomb. He closed his eyes. Nor did he open them until he felt the touch of the woman’s hand on his arm, a touch from which he did not withdraw.”
Groopman halted, looked up from the page. “Remember, no one touches this guy,” he told the students. “All of a sudden he’s humbled, he’s falling apart. And this mestizo woman, whose daughter is dead—at his hands, presumably—is touching him. She becomes the healer. She becomes the comforter.”
That night, Franciscus goes into the morgue and fixes the harelip on the dead girl’s face.
“Why would you do that?” Groopman asked the class. “Why would you have the most meticulous sutures of your life on a dead body?”
A young man at the other end of the table spoke up. “To reassert the control that he lost.”
“Right. He’s reasserting his perfectionism.…Let’s read on.”
A couple of pages later, the class arrived at Groopman’s favorite line in the story: “She was his measure of perfection and pain—the one lost, the other gained.”
“That’s a beautiful line of prose,” Groopman said, interrupting his student and reading it again, more slowly, drawing out the words. “And what does it mean? I mean, it rhymes; it’s poetic. What does it mean?”
“That she was the breaking point—,” the young man at the end of the table offered.
“OK,” Groopman said. “And what does he gain and what does he lose?”
“He loses perfection.”
Groopman: “Is anyone perfect?”
Another young man, sitting at Groopman’s left elbow: “No.”
“If you imagine yourself to be perfect, what happens to you?” Groopman looked around the room.
“You break, ultimately.”
“Right. Because there’s going to come a time when you’re not perfect.”
Franciscus ends the story as a hollowed, haunted man. Reading the last lines, Groopman pressed his point about perfection one more time, and it seemed perhaps he was talking about more than just Hugh Franciscus. “So, if you have a god complex, you’re in trouble,” he told the students. “Whether it’s in medicine or law or business or teaching or whatever, you strive for perfection, because the stakes are high, but recognize that you’re not perfect. And you have to have this psychological and emotional ballast, right? Anybody know what ballast is?”
They did, sort of. Something about a boat and balance and weight. Groopman filled in the gaps. “And without ballast,” he continued, “there’s nothing to keep Hugh Franciscus up. He’s in free fall.”
Groopman paused to let “Imelda” sink in. There was still a little time left. He turned to another page in his book—to a shorter Selzer story called “Mercy,” on which the group spent the last 20 minutes of class. This one is about a doctor who promises to help a terminally ill patient commit suicide but, at the last minute, can’t do it. “He sees himself as the man who’s dying,” Groopman said during the discussion. “It’s the physician recognizing that this alleged distance between him and the patient is an illusion. Because one day he’ll be the patient.”
It was almost 3 p.m., time to quit. The students gathered their books and papers into their bags and over the sound of their shuffling Groopman announced the next week’s assignments, which were also waiting in their e-mail inboxes: two articles, one in Harper’s Magazine, about a plastic surgeon who wants to build wings on people; and the other a New York Times Magazine piece about a family thinking of conceiving a baby to serve as a bone marrow donor for their gravely ill child. “Is that ethical? Are they right to do that?” Groopman wanted the students to study both stories and write a “cogent and concise” op-ed about one of them—double-spaced, “so I can line edit.”
The students were hustling away now, leaving one empty cookie bag on the table. “OK!” he said. “See you next week!”