Daniel Becker: The Rhyme and Reason of Uncertainty and Doubt

The poet and medical school drop-out John Keats, in an 1817 letter to his brothers, described a conversation with a friend after seeing a performance of Shakespeare:

…several things dove-tailed in my mind, and at once it struck me what quality went to form a Man of Achievement, especially in Literature, and which Shakespeare possessed so enormously. – I mean Negative Capability, that is, when a man is capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason – 

About a year before Keats died of tuberculosis he coughed up some blood.  He knew the color of arterial blood and announced to a friend he’d be dead in a year.  He was right. Negative capability does not make it easier to die.  His gravestone, composed by him, states “Here lies one whose name was writ in water. “ He was 25 when he died, 54 published poems to his name, some of the best English poems ever written.  He considered himself a failure.

In July 1973, as a 25 year old third year medical student on the wards at St Louis City Hospital, I asked the intern how he made everything look easy.  He had plenty of doubt and uncertainty, but if he didn’t have the right answer he had an answer that suited the occasion.  We were at hour 24 of a 36 hour work day.  “I’m just flying by the seat of my pants” he explained. Oh.  We can improvise?  There’s more to doctoring than fact and reason?

On June 30, 2017, as the attending at medical clinic, I tell a new resident, at clinic for the first time, to start every clinic visit by asking the patient “how can we help you today?” and then listen without interrupting.

On June 30, 2017, I tell a resident next time a patient goes on and on like that it’s ok to interrupt him and then come get me.

On June 30, 2017, I go in the room with a new resident to demonstrate how to have a difficult time making it look easy.  

On July 4 while writing this essay I notice a hummingbird going from blossom to blossom in a potted hydrangea on the deck outside the window.  I call my wife over, and she thinks she sees it too, then has her doubts but agrees it could have been a hummingbird.  That’s all it takes to let it be a hummingbird. We have plenty of real hummingbirds coming and going around the feeder, red plastic filled with sugar water. Not a flower, not nectar, but the hummingbirds don’t mind. Once one tried to fly into the window I was looking out of.  It got into the screen as far as its beak, then shifted to reverse, flew home, and is probably still talking about colliding with an unexpected layer of reality, either trying to explain what happened or invoking negative capability.

In “Ode to a Nightingale” Keats writes as if taking dictation from the bird’s song and then distilling some meaning.  In “Ode to a Grecian Urn” Keats writes as if all he needs to know is pictured on that clay.  Beauty is truth, truth beauty. Poetry is better at relative truth than absolute truth. In another letter Keats compares human life to “a large Mansion of many apartments.”  He describes two—the thoughtless Chamber and the Chamber of Maiden-Thought.  The rest are shut up and soon enough that second chamber grows dark with thought. There are limits to thinking, and there are different kinds of truth.  Emily Dickinson, 130 years dead and still a modern poet, advises readers to “tell the truth but tell it slant.”  Walt Whitman asked himself:  “Do I contradict myself? Very well, then I contradict myself.  I am large.  I contain multitudes.”  In the mid twentieth century Wallace Stevens taught us there are 13 ways to see a blackbird. Actually, there are more than 13 ways.  Just the other day my wife mentioned that blackbirds mourn their dead.  That puts blackbirds in a new light.  

Late in the twentieth century the poet Czeslaw Milosz wrote “The purpose of poetry is to remind us/ how difficult it is to remain just one person,/for our house is open, there are no keys in the doors,/and invisible guests come in and out at will.”  That house sounds like Keats’ Mansion.  Freud, describing his theory of mind, said “the poets were here before me.”  From Keats to Dickinson to Whitman to Freud to Stevens to Milosz: almost a straight line, a dotted line in this context, a path that also connects Keats to Picasso and Cubism (faces seen from two directions at the same time), to Quantum physics as explained by Schrödinger’s cat, to the use of statistics to sort chance findings from true findings, and to my well intentioned attempts to teach statistics to medical students and patients.  Results of an experiment or a CT scan can be false positive or false negative, maybe yes or maybe no.  We have to worry about both maybes and then accept some uncertainty.  We have to bear in mind all that we don’t know and can’t know. In the early nineteenth century the Romantic movement was interested in the sublime, that which was just beyond the human mind, that which added wonder or terror to lived experience.  What Wordsworth called sublime Keats called negative capability, more or less, and in the context of this essay sublimeand negative capability are close enough.  

Also in the early nineteenth century, the end of  the age of reason and the midst of the industrial revolution, doctors started to figure out the difference between symptoms and disease. Fever is a symptom.  Typhoid is the disease that causes fever.  Doctors began to use science in a systematic way.  Vital signs were recorded. The stethoscope was invented, and when the patient died the body was opened, the lungs were removed and sliced into sections, and a walnut sized tumor was revealed as the cause of the diminished breath sounds in the right upper lobe.  Science, when writing about science, began to use the passive voice.  That walnut growing in the lung was interesting, but not sublime. Pre-med chemistry teaches that dry ice melts, or sublimates from solid to gas, at room temperature.  Is sublimation sublime?  Think about it.  Pre-med is to sublime as a keg of beer is to Poe’s cask of amontillado.  Nevertheless, it is possible to take a lot of literature courses in college and still get into medical school.  

Speaking of the age of reason and the birth of scientific medicine: shout out to George Elliot and Middlemarch,which I read for the first time in my second year of medical school.  I reread it last year. It’s the book I’d take to the desert island. One of its main characters, Dr. Lydgate, is a physician with a microscope (not many of those in the 1830s) and the conviction that cell biology could explain the human condition: mind, body, soul.  George Elliott carefully drained all the negative capability out of Lydgate.  She let him keep his stethoscope. 

Early in med school a drug company gave my whole class stethoscopes and doctor bags. Cheap stuff.  It took me a few years of medical school to realize that listening to patients takes more than a stethoscope.  You’d think someone on the faculty would have mentioned that in the first week of medical school.  If so, I wasn’t listening.  I was busy memorizing.  In those days the mind was separated from the body and the language that mattered was logical positivism.  What mattered had to be measurable.  Data matters. Like most students, I had a few false starts before figuring out that the word data is plural.  The early data show, not shows, my mentor explained in a red pencil while editing a draft of a grant proposal.  The secret to writing a good grant, after asking an answerable question, is the strategic use of colons followed by dependent clauses and semicolons.  Fearsome symmetry, like William Blake’s tiger, gets its message across.  When you need to cram a year of research into a 300 word abstract, every word matters.  Like a sonnet. Or haiku. Or limerick.  How to learn to write?  Read good books.  Write scientific abstracts.  Write a sonnet. How to learn to think like a doctor?

As any medical student or resident or attending knows, you don’t have to be Shakespeare or Keats or Milosz to neither have nor need the precise answer to a clinical problem, to be of two minds. Thinking can be dangerous.  The intern who taught me to fly by the seat of my pants also told me “when you hear hoof-beats, think horse not zebra.”  Thinking like that allows you to misdiagnose the occasional zebra who shows up at clinic.  He also reminded me that if I think it’s a duck, I should also rule-out turkey, goose, chicken.  Mixing metaphors was not an issue for him.  There’s more.  When it looks like it, and smells like it, and feels like it when you step in it, you don’t need any more tests or sensory data.  For medical students that counts as wisdom.  The other day at clinic a patient came in with a sore throat. Looked like strep and the rapid strep test was positive.  But the patient also had a CT scan that lit up the appendix.  Why did the clinic doctors get the CT?  Because the patient also had abdominal pain and tenderness in the right lower quadrant of the abdomen.  Is strep associated with appendicitis?  No, but no law against it.  Willie Sutton the bank robber, asked why he robbed banks, answered “that’s where the money is.”  Sutton’s Law. And so we test for the obvious explanations.  William of Ocam taught us that one explanation is usually better, more correct, than multiple explanations.  But not always.  Sometimes we need to look for other answers.  Sometimes we need to wait and see.  The test of time is not only accurate, it is also cost- effective.  Voltaire defined the art of medicine as entertaining the patient while nature cures the patient.  Or, the patient entertains the doctor. I have some funny patients and I schedule them for the last appointment of the day.  They like to leave me laughing.  The nurse will ask “what were you guys laughing at?”  In Willie Sutton’s autobiography the revised answer to “why rob banks” is “because it’s fun.”     

Can doctoring be fun?  Dr. Seuss, speaking through The Cat in the Hat, taught “it’s fun to have fun but you have to know how.”  We don’t teach that in med school, aside from warning students and residents about the dangers of black humor.  Nor is a sense of humor required for admission to med school.  We do talk about burn-out, and one sign of burn-out is when the resident doesn’t smile when the patient and I find something to smile about.  Fun is an understatement.  Doctoring can and should be gratifying.  It is not always enjoyable, but on occasion?  Sure.  Doctoring, like poetry, should light up most of the brain.   

Much of the young doctor’s brain is organized into causes and effects, practice guidelines, outcome based medical evidence, formula for estimating risk, algorithms for justifying treatment, a precise awareness of the on-call schedule, an equally precise awareness of the clinic schedule, hope for an easy night on-call, breakfast aspirations and if not breakfast at least real coffee from the coffee boutique next to the hospital cafeteria.   Whatever is on the doctor’s mind, most of it goes out the window when the patient tells you he wants to go home and die, maybe not in comfort but at least with a view of the garden he planted.  Some doctors then obey the impulse to do a home visit, where, rather than stand there and feel helpless, the hospice nurse teaches “don’t just do something, stand there.” 

Presence is magic.  At the bedside of an old patient, a retired doctor who just had cancer surgery, I hear about how great the surgeon is.  Not technical prowess in the OR nor vast knowledge of the basic and clinical science that led to state of the art care.  Which the surgeon did have.  Rather, how much time the surgeon had to sit and listen to the patient. Sit?  Often the only place to sit is on the bedside commode.  Time?  I watched the surgeon go in and come out of the patient’s room.  Five minutes. Eternity in a grain of sand.  Is that negative capability?  Going back to the Keats definition the operative phrase is being in.  There’s room for more than one person to be in that space.

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Daniel Becker practiced and taught medicine at the University of Virginia School of Medicine until he retired on June 30, 2018.  He was re-hired for part-time work, after passing a background check and showing his passport to UVA HR and ace-ing the aging physician cognitive assessment, in October 2018.  He now teaches medical students one half day a week, helps cover clinic when the clinic schedule is desperate, and works a half day a week at the opioid treatment clinic in Psychiatry.   His book of poems, Self-Defense, is in perpetual revision.

Copyright 2019 Daniel Becker