Thursday, September 06, 2007
Dead Man Wasting
Even as I questioned the value of dog labs, I wonder still more about the most hallowed and time-honored tradition of medical school: the dissection of cadavers to which all first-year students are subjected. Because the bodies have been knowingly donated, it's not really an ethical issue, except to the extent that those who've made the gift might have a more exalted view of its value than is accurate. And before I say my piece, I must admit it's just one opinion, from a ways back. I'd hope more recent, and current, students might chime in and set me straight, if that's what is called for.
I'd guess we've all seen classic paintings, like Rembrandt's "The Anatomy Lesson." We've heard of grave-robbers hired on the sly to supply medical schools, of Michelangelo becoming one himself to facilitate his artistry; and we know the extent to which these dissections have been carried out, more or less in the exact way, for centuries. So in pushing yourself through the portal into the anatomy lab, you feel as if you're entering a space hallowed by history; taking up a challenge and a charge handed down by people willing to risk their freedom to advance science. Maybe more than anything I can think of, you're stepping into the past. Unlike, say, those who re-enact wars, or who sail on resurrected galleons, this is more than play. It's not make-believe. This is becoming what was, experiencing exactly (sort of) what the pioneers of our field felt, and did. In a couple of important ways, though, it's also a great deal less.
Much as I might have liked to be wearing the flowing clothes, the fuzzy collars and broad hats of Rembrandt's vision, it was rubber gloves and plastic aprons. If I'd imagined being in the thrall of a master lecturer and demonstrator, it was in fact a bunch of clueless students trying to follow written instructions, wrestling alone and together with their conflicted thoughts, working out who'd do what, with a lab assistant sometimes wandering by. (Was that a smirk on his face?) As far from life-like as they could be, the tissues reeked of formalin, and were leathery and hard, belying and opacifying the mystery they held. Or had held. And they were greasy. There's not much to be gained from the process of finding one's way through, by dissecting such unnatural material, spending lots of time getting there and often missing a turn. To the extent that there's knowledge to be revealed, in a preserved cadaver it's in the arriving there, not in the travelling. And marvelous and awesome as is living anatomy, what's revealed in a cadaver is a wooden shadow; as removed from real as a dried and pressed flower is from a bloom.
There was a need to acknowledge the gift this person had made, and there was a desire to turn away from it. To look at the face; simultaneously to absorb and to erase. Tightened, tanned, transmogrified, the body had already been dehumanized more than our dissection would do; still, in making the first strokes of the knife, there's an inward voice saying, "Sorry... sorry... sorry."
Is it like removing the sword from the stone? There's a sense in which this feels like a rite of passage, a symbolic qualification for being allowed to learn the long-guarded secrets. If you faint, if nausea overtakes you, if you can't get past the sense of transgression, you ought not be here. So it seems. Does it harden you? Or soften you up? For most, it's the first encounter with a real live dead body. There's fear of how you'll react, of embarrassing yourself. Some students have ceremonies of thanks to the person who gave their gift. Whom's it for? Is it being actual sensitive, or see-me-sensitive? To the extent that this dissection is ritual, we respond with ritual. We dance with the corpse, and it dances with us. So it raises a question: is it necessary?
In my view, there's only so much -- not much -- that you can get from working with stiffened sinews and pickled pieces. The anatomy I really needed, the relevant relationships I began to understand as a surgeon, I got in the operating room. Or in the basement: I participated in autopsies of unpreserved bodies, and the ones on patients of mine were infinitely more emotional -- and instructive and useful and important -- than that work as a first-year student. The sequence seems wrong: if such dissection is to be done, it ought to be by those more knowledgable and honed. Absent context, it can become clutter. Cardiologists need to have the experience of holding a heart in their hands (and to see one beating in the operating room); how much more meaningful to do it later in the process. As students, it's like a White House document dump: too much information, no hooks on which to hang it. Even books, with their diagrams and plastic overlays provide more understanding once you figure out what it is you need to know. And now, of course, 3-D imaging and computer programs allow interactive and highly effective work.
At the time I went there, my medical school was the leader of a revolution; it broke the timeless tradition of curricular structure. For ever, it had been anatomy, physiology, pathology, pharmacology, lined up in sequence and out of sense. Where I went, they'd just rearranged into teaching by system: cardiovascular, for example, including the anatomy, physiology, pathology, organized in ways to make it meaningful. So the old-fashion dissections were out of synch, and therefore out of use to a much larger extent than at other schools. We did, in other words, much less in the cadaver lab than our contemporaries. In hearing of that, at first I worried that I'd come out unprepared, anatomologically. It was almost embarrassing to reveal to college friends at other med schools how little time I'd spent doing the dissections and taking the tests that they and our forebears had done. But it's clear to me now my time was better spent. And whereas I do think all doctors need a working understanding of the anatomy of all systems, it needn't be -- and in fact isn't -- those first-year dissections which provide it. I'd go so far as to say that, other than imparting a sense of having walked over the same coals as everyone else, the first-year cadaver lab is over-rated and under-important.