David Kopacz, MD
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Learning To Save the Self
Unpublished | Written 1998

This article is an expanded version of the presentation “Learning to Save the Self: Samuel Shem’s Portrayal of Trauma and Medical Education” which was given at the annual meeting of the International Society for Traumatic Stress Studies, Washington D.C, November, 1998. It examines the defense patterns that are typical of exposure to trauma that lead to dehumanization of the self of both the doctor and the patient. It also looks at Shem’s prescription for saving the self through preserving humanity and human connection.

Samuel Shem’s novel, The House of God, is a narrative account of the protagonist, Roy Basch’s, internship year in medicine. The book depicts a young, idealistic intern's struggle to learn medicine and stay human while immersed in death and illness. This struggle occurs between Roy's developing idealized medical self and his non-medical self. The values of the medical self are objectivity, certainty, and calm in the face of death. These values often conflict with the human characteristics of emotional subjectivity, uncertainty, and fear in the face of death. There is a cost to the development of Roy’s professional indoctrination; he begins to lose his capacity to feel emotions and to relate meaningfully with others. Eventually, Roy rejects the idealized medical self as incompatible with the capacity to be fully human, and he comes to view the profession itself as a disease. He embarks on a project to recapture his humanity, which entails reconnecting to himself and to others. As he begins to feel again, he feels he has to write to bear witness to what he has gone through.

Roy's account begins looking back at his internship from the perspective of a beach in France where he and his girlfriend, Berry, are sitting. Roy states that Berry is "trying to teach me to love as once I did love, before the deadening of the year," (Shem, The House of God, 11). However, Roy cannot be fully present with his girlfriend in this idyllic setting. As he admires her beauty, he has an intrusive parallel dialogue of medical pathology and scientific "objectivity." He visually dissects Berry seeing the Cooper's ligaments of her breasts and the symphasis pubis of her pelvis. His medical training and his experiences intrude into every aspect of his life, tainting his ability to be a non-medical person. Despite being in a relaxing location with someone he loves, Roy states, "I struggle to rest and cannot," (Shem, 11).

Dehumanization is a central theme that Roy introduces in the first paragraph of his book when he speaks of the "deadening of the year." The perspective of dehumanization raises questions about the effects of exposure to death and illness during the process of medical education on one's sense of self. Exposure to death and illness are intrinsic aspects of medical education, they can be considered "hazards of the trade." Early on, however, Roy's potential mentors fail to teach him honest and healthy responses to death. These extrinsic, institutional aspects of medical education are not necessarily part of becoming a physician, but rather are artifacts of the existing system. These dishonest responses to death include the extremes of cynicism, which rejects the possibility of healing, and the formation of an idealized medical self, which looses touch with the inter-relatedness of life and death.

Roy's first mentor is the "Fat Man," a senior resident. Roy is repeatedly struck by the Fat Man's apparently cynical approach to medical care, which includes reducing people to notes on 3x5 cards, not going to see the patients, not attempting heroic or even standard invasive treatments, and accepting that he is not going to defeat the natural process of death and aging. While Roy is initially shocked at this approach, soon enough he joins in the dehumanization and is calling old people "gomers." The term gomer is an acronym for "Get Out of My Emergency Room," and is defined as a "human being who has lost - often through age - what goes into being a human being," (Shem, 424).

Robert Stoller has described the use of dehumanization as an aspect of perversion, which he describes as a psychological defense against emotional intimacy. Stoller writes, we "anatomize them...because we cannot stand the revelations of intimacy, we deprive others of their fullness," (Stoller, Observing the Erotic Imagination, 32). This reduction of the other as subject to body or body part can occur "if we have reason to feel unsafe...there is an even more primitive threat: if I let someone in - if I thereby merge with that person - may he or she not, like an evil spirit, possess me, take me over entirely? Then the great terror, I shall lose myself. It is against such fundamental menace that perversion is invented," (Stoller, 29).

While the comparison of physician's in-group language with perversions may at first seem extreme, there is a great deal of trauma literature on the risk of loss of self when confronted with overwhelming exposure to death. Des Pres has written that, "Too close a knowledge of vulnerability, of evil, of human insufficiency, is felt to be ruinous," (Des Pres, The Survivor, 41-42). And Lifton has written about what he calls the death taint or the death imprint to describe the ability of traumatic experience to taint the self, analogous to Stoller’s threat of possession, like an evil spirit, leading to a loss of self. [reference] In this sense, dehumanization which seeks to preserve the self from the potentially traumatic exposure to death does seem to have some relevance to our discussion of the tendency of physicians to dehumanize patients. This can be seen as a perversion-spectrum condition, the humanity of the other is sacrificed with the hopes of preserving the self. Roy describes this process when he observes that, "[m]ost of us had learned enough medicine to worry less about saving patients and more about saving ourselves," (Shem, 150).

Death can be considered the source of threat to self which must be defended against. Additionally we can consider events which symbolize death, such as pain, suffering, aging, and frailty as also being a threat to the physician's sense of self. These symbolic precursors of death have been called "death equivalents" by Lifton, (The Future of Immortality, 16). Thus, it is not only the confrontation with death that is potentially traumatic, but any event which symbolically represents death, such as illness, suffering, and aging. The task which the physician faces is how to be in the presence of suffering and death without succumbing to the use of dehumanization to save the self from the taint of death. As one of the policemen in the House of God puts it, "[h]ow hard to deal honestly with death," (Shem, 201).

The very nature of objective, scientific medicine encourages the reduction of individuals into categories, such as anatomical parts or diseases. Developing the medical self creates a tension between the scientific and humanistic roles of the physician. In the House of God, the humanist role has apparently been lost, and dehumanization is used by Roy and his colleagues when dealing with both patients and staff as one of the ways to save the self from the threat of death. The fact that scientific objectivity supports this dehumanization provides institutional sanction to this process of dehumanization. The other is then viewed not as an individual human being, but as a body. The body is something concrete, objective, more certain and less threatening than the emotions and humanity of the other. In the House of God, "the emphasis was on doing everything always for everyone forever to keep the patient alive," (Shem, 26). As one resident states, "we are going to win this war against death," (Shem, 344).

The shared language of objectivity and dehumanization is the vehicle for indoctrination in the House of God. The term "gomer," as defined earlier, represents "a human being who has lost - often through age - what goes into being a human being," (Shem, 424). We can raise the question, is it the gomer who has lost this fundamental something, or is it the physician who has lost the ability to see it, or even actively blinds him or her self to the humanity of the other? To what extent does scientific medicine create the gomer? What is it that is so threatening in seeing the humanity, including aging and frailty, in the other? Perhaps it seems that the self can be insulated from the exposure to death and suffering by denying the humanity of the other. This attitude is consistent with a philosophy of healing based on cure and eliminating suffering rather than acceptance and suffering with another.

Roy describes the interns as, "mostly gone, caught in a net of silence and pain where it might just be that the dead did lie, restless, and even in death fearing something worse...I did not feel sad. I was not tired or mad...I imagined I felt what the gomers felt: an absence of feeling," (Shem, 316-317). Roy becomes that which he had most feared and despised, a gomer, one who has lost fundamental humanity.

In viewing the other as a body, not only is the emotion of the other avoided, but also one's own emotion. An insulation of emotion occurs in both self and other. Stoller has examined this in the context of sexual fetishism in which the humanity and emotion of the other is reduced to a body part. He writes that this reduction is a defense against anxiety and despair, but that the risk is that dehumanizing the other "dehumanizes the dehumanizer," (Stoller, Observing the Erotic Imagination, 32). Stoller writes that this is a prior step that precedes the dehumanization of the other, "we seal ourselves off...a process that dehumanizes us. Then, to be doubly safe, we dehumanize them," (Stoller, 29). Thus, dehumanization is a two-way process; one cannot dehumanize another without losing something integral in oneself. This is what appears to occur when Roy begins to identify with the gomers' absence of feeling.

The Idealized Medical Self

While Roy initially wants to help people and be a good doctor, once he begins to enter into the language and milieu of dehumanization this ideal fades. His horizon shrinks down to include only himself, but as longs as he dehumanizes the other, he himself is beyond saving. This cost of dehumanization is what eventually threatens Roy's sense of self and distances him from patients and eventually friends and loved ones.

Sex, alcohol, and dehumanizing the patient and staff, all these had failed him. Again threatened and without defense, Roy tries another maneuver to save the self. He is overrun by feelings of hopelessness and despair, so he rejects those human feelings. He embraces the idealized medical self and the illusion of omnipotence and certainty. As Roy puts it, one "side of me was filled with the horror of human misery and helplessness; the other was exhilarated, king in an erotic diseased kingdom, competent to run machines," (Shem, 341). The threatening possibility of empathy for the suffering of the other, and the corresponding empathy toward the suffering part of oneself, is discarded. Roy describes this process when confronted with an emotional crisis. "For a few minutes I felt as if I were on the edge of some disaster, some abyss that seemed familiar from a nightmare. Then it passed, and again I felt calm," (Shem, 353). Roy decides that this new found sense of calm is so important that he refuses to allow himself to feel any of the turmoil of human emotions brought up in the hospital or in his relationship with Berry. "As if from far off, I heard myself saying, 'Better ROR [an acronym for Relationship On the Rocks] than anxiety, Berry. Better that than Type A...At this point in time,' I said, trying to remain calm in the face of all this turmoil of emotion and stress, 'that's all I have to say'" (Shem, 349-350). Berry replies to this, '"You're not a jerk, Roy. You're a machine.'" To which Roy responds, "A machine? So what," (Shem, 350).

Roy has become "competent to run machines," and now he has become a machine himself which operates calmly and without doubt. The embrace of the idealized medical self has become complete. Although this initially seems like it could be a positive development, a consolidation of the professional self, it cuts Roy off from what is important in himself and others. He chooses the idealized medical self over the non-medical self to avoid the anxiety and distress which come with dealing honestly with death. He ceases to struggle to save his human self and gives it up for lost. Roy's previous cynicism offered no solid way of addressing the fear and doubt which confronted him daily in his dealings with suffering and death. When cynicism began to slip into nihilism, Roy embraced the idealized medical self as a way of alleviating his own fear and doubt. The idealized medical self has characteristics of omnipotence, objectivity, certainty and an absence of anxiety, despair, and fear. It is a state beyond the "subjective" emotions of the lay person.

Roy completely identifies with the idealized medical self, in which the physician is free of anxiety or fear of death, to the point that the human reality of death is distorted and denied. Lifton, in his discussion of nazi doctors, has described the process of formation of the "medical self, which enables one not only to be relatively inured to death but to function reasonably efficiently in relation to the many sided demands of the work," (Lifton, The Future of Immortality, 205). Lifton seems to imply that some degree of "doubling" in this sense is necessary for a physician to function, but warns that it must be kept in check. The risk of unchecked denial of death through the embrace of the idealized medical self can be seen to be harmful not only to the well-being of the physician, but also to patients who are not allowed to die in peace, but instead must go down fighting in a high-tech flourish of medical technology.

Is it necessary that the physician have the capacity to isolate or override his or her own emotions when caring for another? What if the physician learns this task of doubling too well and the idealized medical self becomes the dominant self? We could imagine a conflict arising between these two modes of being and relating. On the one hand is the idealized medical self - objective, rational, certain and in control. On the other hand is the human, non-medical self - subjective, emotional, uncertain and subject to anxiety and despair. If this self is seen as a hindrance to functioning as a physician, there will be a great temptation to get rid of it, deny it, lock it away. If this is done, then the dehumanization of self and other is complete and the dehumanize becomes dehumanized. The physician's own emotions are denied as much as the emotions of the patient. Looking back on this position, Roy describes feeling as if "Something in me had died...My calm had been the calm of death," (Shem, 359).

Truly Saving the Self

Roy is lucky enough to be rescued from this protective prison of the idealized medical self through the caring of others. One night when he is not on duty, he decides that he would feel more comfortable if he slept in the hospital. However, Berry and two friendly policemen forcibly remove Roy from the hospital and take him to see a comedian perform. As Roy loses himself in this performance, he has a sudden rebirth of emotions. "All of a sudden I felt as if a hearing aid for all my senses had been turned on. I was flooded with feeling. I roared. And along with this burst of feeling came a plunging, a desperate clawing plunge down an acrid chasm toward despair. What the hell had happened to me? Something in me had died. Sadness welled up in my gut and burned out through slits in my eyes...Awakening, I began to thaw. I began to feel a trickle, then a rush of feeling that was scary and overwhelming...My calm had been the calm of death," (Shem, 359-360).

Now Roy realizes that he was not even able to save himself. Earlier in the book, Roy had stated "I realized with alarm that I hadn't learned how to save anyone at all, not Dr. Sanders or Lazarus or Jimmy or Saul or Anna O., and that what I was thrilled about learning was how to save myself," (Shem, 140)." He now realizes that in his defensive attempts to save himself, he was actually deadening himself. He learns this through allowing himself to experience his own feelings and reconnecting with others. In a sense, he has to deprogram himself, to reverse the objectification and dehumanization of the internship. He struggles to reconnect with others. Ultimately, he rejects medical training as being incompatible with this goal. He decides to enter psychiatry in hopes of learning how to be with his own emotions and those with others. To save the self, he must preserve its uncertainties and its chaotic collage of emotions.

The Doctor's Disease

Throughout the book, the process of becoming a doctor is described as itself being a disease. One of Roy's fellow interns is described as having two traits "which would prove useful to him in medicine: unawareness of self, and unawareness of others," (Shem, 84). Not all the interns were "blessed" with these attributes to begin with, they had to be learned. The Fat Man is the principle spokesman for this view that the "profession is a disease," (Shem, 106). Later in the book, Fats is often the voice of humanism over dehumanization. In the following quote he admonishes Roy to be skeptical of the educational process and those techniques of academic medicine which are based on dehumanization and objectification. "I'm telling you that the cure is the disease. The main source of illness in this world is the doctor's own illness: his compulsion to try and cure and his fraudulent belief that he can...With me, [the patients] feel they're still part of the human race," (Shem, 214-215).

Roy eventually comes to take the Fat Man's view on the system of education. "Lethal, this becoming a doctor! Denying hope and fear, ritualized defenses pulled up around ears like turtlenecks, these doctors, to survive, had become machines, sealed off from humans - wives, kids, parents - from the warmth of compassion and the thrill of love...This internship - this whole training - it destroys people," (Shem, 361-362).

Although he makes the decision to leave academic medicine, Roy still must face his own emotional wounds and attempt to repair the damage of the year. One aspect of this project is to reconnect with others, particularly Berry. But Roy cannot erase the past. He retains within himself the potential of the idealized medical self, even while on a beach in France with his girlfriend. He carries within himself the taint of his experiences, the potential for a parallel objectified commentary on experience.

As Shem writes in the introduction to the book, recovery from this objectification and dehumanization takes years. While the narrative is told from Roy's perspective, Shem assures us that much of the tale is true. We can assume that this truth is expressed through the fictional character, Roy. Further complicating this truth is that Samuel Shem is also a fictional being, the pseudonym of Stephen Bergman. In the introduction, Shem writes that "I wrote the book because I could not not write it, I had to report back on what still seems like the worst year of my life," (Shem, 6). Shem's book, as told through Roy's narrative is an attempt to bear witness to the dehumanization experienced from the intrinsic and extrinsic traumas of medical training. He creates a narrative that is moral and political in nature, in addition to semi-autobiographical. It is an indictment of the power structure and dehumanizing ideology of academic medicine. The narrative is also an opportunity to re-create the past, giving the human self an opportunity to counterbalance and address the excesses of cynicism, dehumanization, and the idealized medical self. The book is not only a warning to others, but also an atonement for his own "crimes against humanity."

If Roy's narrative of his own struggle to save his sense of self is considered to be "typical," in the sense of being similar to other physicians' experience, one can extrapolate to consider the role dehumanization plays in medical education. Shem encourages this reading in his introduction. He warns that this element of dehumanization as a response to the potentially traumatic exposure of medical education carries not only a risk to the well-being of the physician, but also could affect the entire institutionalized nature of the doctor-patient relationship. While it is true that traumatic exposure cannot be avoided in medical education, what can be changed is the institutionalized response to death and illness.

The lesson that Roy learns is that in order to save the self, we must avoid dehumanization of ourselves and others. This, however, is not as simple as it may seem. The exposure to death, illness, and other traumas can be very difficult to bear without resorting to these defenses. Also, the medical education process often encourages dehumanization as a mistaken form of professionalism. To save the self, one must be willing to let the self be threatened with overwhelming emotions and must be willing to speak up for what is good and human. One must preserve connections with others as if they were a life-line, this includes the relationship with the patient if one is going to have any chance of easing suffering. The self cannot be saved in isolation. One must avoid the temptation of omnipotence and certainty promised by the role of the ideal physician. One must listen to others and rely on their human frailty.

Roy realizes what the cost is of dealing dishonestly with death (which, ultimately, means living dishonestly). It not only leaves those suffering alone in their pain, it also seals the physician off from his or her own emotions and humanity. It is as if one must honestly confront death in order to fully live. This lesson is taught to Roy by Doctor Sanders, a dying physician whom Roy is caring for. Doctor Sanders tells Roy, "I went through the same cynicism - all that training and then this helplessness. And yet in spite of all our doubt, we can give something. Not cure, no. What sustains us is when we find a way to be compassionate to love. And the most loving thing we do is to be with a patient, like you are being with me," (Shem, 175).


References:
Caruth, Cathy: “An Interview with Robert Jay Lifton,” in Trauma: Explorations in Memory, Baltimore: Johns Hopkins University Press, 1995.
Des Pres, Terrence: The Survivor, Oxford University Press, 1980
Lifton, Robert Jay, The Future of Immortality, New York: Basic Books, 1987.
Shem, Samuel: The House of God, New York: Dell Books, 1980.
Stoller, Robert: Observing the Erotic Imagination, New Haven: Yale University Press, 1992.


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