after my first medical school class

Good evening! If you have the option of staying inside your house today, please do so, the weather outside is something Dean Martin might sing about around Christmastime. Renege on your Faustian bargain with coffee, and consider having a lovely cup of tea instead. Thank you for reading, I love you!

When they announced the score profile for our final block exam – the mean was 82, the high 100 – there was a flutter of something like approval and excitement in the ‘oohs’ and ‘ah’s’ everyone made. I liked that – the fact that someone else’s excellence was something to approve of, as if whoever got the 100 confirmed that the excellence we all sought was possible. There was a girl who finished the exam 30 minutes into the 2 hours we were given – I remembered that she was the first one to finish the first exam too, which she also completed in 30 minutes. It brought me some strange joy, seeing her perform at that level with such ease. She reminded me of how Dr. Atul Gawande talked about competence in one of his books – he said that doing your job, and doing it well, constituted the highest level of human performance.

I am often reminded of how mechanical medicine can be – you must know each moving part so intimately, and have such command of its mechanisms, that when they begin to glitch and steam, you must know exactly how to get those parts moving again. It is about performance, and the excellent execution of that performance. Perhaps in rebellion against this inherently mechanical design, I used to detest the attestation that there was no room for creativity in medicine. What little I have in the way of creative impulses still occupies very important spaces in my life – dreams of reading and writing, viewing art, having drifting conversations about media and our involvement in the things we create. These enterprises remind me of who I am. Only now do I recognize that even such creative endeavors are necessarily subject to discipline and mechanics. I have learned that when I write, I cannot conjure up catharsis at will. When I try to write with no feeling, or no god-sent image in my head, what comes out is near rubbish. Although she was talking about sharing intimacies with a lover, Sylvia Path once said something that speaks to this difficulty –

“And when at last you find someone to whom you feel you can pour out your soul, you stop in shock at the words you utter— they are so rusty, so ugly, so meaningless and feeble from being kept in the small, cramped dark inside you so long.”

This is what writing is like when it isn’t sent from above, or isn’t brought to you on wings, the way it usually arrives when it’s good. But perhaps this transcendence in writing can be achieved by competence rather than by catharsis, the way one does with medicine. The skilled physician must be competent – any dip in performance, otherwise, may be reflected in the survival of a patient. That is a heavy injunction to hold over a physician’s head. There is no room for charismatic invention, or being a dilettante, in a hospital. But being a dilettante is encouraged, even praised, in literature and art. Being such a one in medicine is ridiculous. The girl who finishes her exam in 30 minutes is not achieving by catharsis, or by some spiritual transcendence – such things are too transient for consistent excellence. She is achieving by some glorious feat of competence. Murakami sticks to a rigorous schedule that even a physician would envy - wake up at 4 a.m. to run, write until noon, listen to music, and be in bed by 9 p.m. Doesn’t this show that art can be constructed through sheer discipline and force of competence, the way medical skill can?

[Image description: Oil painting titled I, With My Alter Ego, by Ebenezer Sunder Singh, oil on canvas, 1991, 70 1/4 x 43 in. Signed and dated 'Ebenezer / 91' lower left.]

Simon Critchley and Daniel Mendelsohn, in this talk at BAM I just re-watched, have a spectacular discussion about myth and tragedy and how we need myths as mediators to get at the essence of the problems we have. They cite political dynasties like the Kennedys, or vessels like the Titanic, as examples of modern myths we have made about things we don’t understand fully – like cursed families (for the Kennedys), or the idea that something is ‘too big to fail’ (like the Titanic). Critchley said we use myth to achieve catharsis, and that catharsis is a ‘purification of emotion’. Mendelsohn says that catharsis isn’t so elevated, and that it’s ‘actually quite low’ - it might actually be like a rude, mechanical thing. I don’t think pure, artistic impulses or ‘myth creation’ are the only sources of catharsis. There are other, more rude skills that can engender that experience.

See, I feel this odd sense of purification walking out of the library 9 hours after entering it. Suddenly this mechanical, rote exercise in medical study feels cathartic - it is very close to the feeling of writing a god-sent, successful sentence. Both writing and medicine seem to have such disparate origins and such diverging paths, but both contribute to the myth I have covered my life in. The way I have invented my life (I aspire to literary creation, and I also aspire to medical skill) is now clear to me – the myth itself is clear. There is, of course, no inherent meaning to this life, this “tissue of negligible detail”. There are the mechanics of nature, the phospholipids in our cells, the ventricular rhythms of our hearts and the electricity burning through our neurons. Yet the invented myths I shroud my life in is critical to how I live. Perhaps people suffering from depression have lost this ability to sustain constructive illusions, or myths, in their lives – because it is constructive. If I were constantly reminded of the futility of my existence, and that any myth I lay over it is not a source of catharsis but rather a funny little trick to make me forget all my phospholipids, cardiomyocytes, and neurotransmitters, I wouldn’t last a week.

So, I need to write, and read, and have drifting conversations about art and why we create it. But I also know that that alone is not sustainable for me. The discipline of mechanics, the competence that medicine demands from me, can teach me how to invent my life better. It teaches me that I am this kind of person, with these weaknesses and strengths, this capacity for excellence and consistency.  It asks that I balance the pull of illusion, the desire for myth and catharsis, with the mechanical skill of negotiating reality, of building competence. Murakami writes for five hours every morning pre-dawn, runs 10 kilometers, then proceeds to listen to jazz music for the remainder of the day and is in bed by 9 pm. All these disparate elements of life are helping each other, actively constructing the myth through sheer force of competence. For him, it seems it is jazz and running. For me, I think, it will be medicine.