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December 15, 1998

Essay: When the Patient, Not the Doctor, Becomes the Hero

By ABIGAIL ZUGER, M.D.

NEW YORK -- Admiring critics have made much of the fact that "Wit," this season's hit off-Broadway play about terminal cancer and chemotherapy, is actually not very sad. Instead, they have used words like funny, tough and diamond-sharp. "By the moment of the stunning, final fade-out," wrote critic Peter Marks for The New York Times several months ago, "you feel both enlightened and, in a strange way, enormously comforted."

By the end of a recent performance, however, one of us in the audience was feeling pretty depressed instead. That was me, a doctor watching yet another scathing indictment of modern medicine and the dubious habits by which some of us are either fortunate or unfortunate enough -- take your pick -- to earn our keep.

The surveys tell us not to worry, that even though Americans are fed up with medicine, with doctors, with health care chaos in general, they still usually like their own doctors and appreciate their efforts. Or, as a patient of mine put it in the middle of a tirade about a referral mix-up the other day, "Oh, don't look so sad. It's not YOUR fault."

It may not be our fault, but even so, we are inevitably a part of it all, every last idiocy and atrocity that combines into the kind of hospital experience depicted in "Wit." And that makes for a painful two hours to sit through, especially for those of us who deliver a lot of bad news, and whose stock in trade are the informed consent forms, the experimental treatment protocols and the "do not resuscitate" orders that punctuate the care of patients with very bad diseases like the metastatic ovarian cancer ravaging the play's heroine.

She is Vivian Bearing, a 50-year-old professor of English literature who specializes in the difficult sonnets of John Donne, the 17th-century metaphysical poet. The play takes her through eight months of experimental chemotherapy that only makes her sicker, a slow decline studded with a few major crises and a hundred minor indignities, all seen through the prism of a scholar's broadening understanding of the poetry of life and death.

All the accouterments of cancer care in a sophisticated teaching hospital are here, from the chilly waits in the radiology department for the technician to come back from his break to the pelvic exam that has to be repeated so that one more trainee can feel her giant tumor. One of Ms. Bearing's doctors is remote and pompous, the other slick and rude. Both talk in medical jargon without translating. Both are hellbent on pumping her full of experimental drugs; they care far more about Ms. Bearing's cancer cells than about Ms. Bearing herself. Only her nurse manages to coat the hospital routines with a thin sheen of humanity.

Is this really the way we are?

Not really, said Dr. Sherwin Nuland, a medical historian and professor of surgery at Yale University, who loved the play. "The patient is a single incandescent character," he said, "magnetic and luminescent. The author knew her very well. But she didn't know the others. The doctor roles are stick figures, straw men, caricatures of the worst, completely unrealistic."

And is this really how experimental cancer treatment goes?

Not at all, said Dr. Larry Norton, head of medical oncology at Memorial Sloan-Kettering Cancer Center in New York. "People think clinical research is removed from the patient, but it's the absolute opposite. Our goal is to make sure that every patient in the study gets the best possible care." Being in a research study is in many ways safer than getting ordinary medical care, he said. "It's the absolute opposite of being a guinea pig. People should know that."

And is this really what being in a teaching hospital is like?

Less and less so. There are certainly young doctors who could use a little education in some basics -- like saying "hello" and "goodbye" to their patients -- but training programs are bearing down on them with an increasingly heavy hand. Whole courses in communication with patients, especially when there is bad news in the offing, are becoming standard parts of the curriculum.

Still, the bottom line is that none of these caveats really matter. What matters is that the vision of "Wit" is the way it is all perceived to be, in one of the few serious works of art of this decade to fold details of contemporary medical practice into its message -- and the way it will be remembered.

Sixty years ago Paul Muni as Louis Pasteur and Ronald Colman as the fictional Dr. Arrowsmith thrilled and inspired their audiences. Now the pendulum has swung around: It is the patients who are the heroes, while the doctors have receded into sketchy caricatures like the foolish, depraved medics Moliere created three centuries ago.

"I'm saddened by the fact that the doctor is never well-represented," Norton said. "What we do and what we are and what we have to deal with has never been captured by art. It's a shame."

"We've gone to the other end of the spectrum," Nuland said. In a generation, perhaps, "we'll get to be ourselves again," he said.

Meanwhile, onstage in "Wit," Ms. Bearing's illness may be her first problem, but her doctors and the hostile, humorless world they inhabit and pull her into are most certainly her problems, too. The audience roots for her against them all, the doctors in the audience as fiercely as anyone else.

But the one thing that Nuland, Norton and I know, even though the rest of the audience, the playwright and possibly Ms. Bearing herself may not, is that in their own limited, inarticulate way, her own doctors are rooting for her, too.




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