The Left Atrium · De l'Oreille Gauche
CMAJ 1999;161:418-21
Suicide and survival
After Daniel: a suicide survivor's tale
Moira Farr
HarperFlamingo Canada; 1999
224 pp. $25 ISBN 0-00-255725-8
"Suicide kills everyone," author Moira Farr writes in After Daniel: A Suicide Survivor's Tale, drawing on the reflections of English essayist G.K. Chesterton. This is a realization that all physicians must come to terms with as they care for those in melancholy and those in mourning. In a recent survey conducted through the Canadian Psychiatric Association's Practice Research Network, 27% of responding psychiatrists had lost a patient to suicide in the last year. In several instances, these psychiatrists reported profound changes in their professional lives that had resulted from the suicide. An award-winning journalist, Farr writes about her recognition of suicide and survival following the loss of her partner, Daniel Jones. Farr explains that the impetus for writing this book was not simply her lover's death, but "a combination of events and circumstances in the wake of Daniel's suicide that made me feel I was somehow called upon — in the right or wrong place at the right or wrong time, I think — to begin seeing the world in a different light. I know I could never go back to the old way of seeing, or not seeing." Farr's journey of understanding uncloaks the impact of suicide on survivors and publicly unmasks the pain and suffering of those left behind.
The book follows the author's grief from Valentine's Day 1994, when Daniel took his life, to the point of her durable recovery from the trauma four years later. The chapter entitled "A Closed Door" recounts the raw, disorienting discovery of Daniel's handwritten note on the locked living room door: "Do not come in. Please call the police." Farr's recollection is chest-grippingly painful. She reflects that perhaps it was "that cruel quality of Daniel's" that she recognized as she stood at the closed door, "a quality that might have made him fashion some horrible tableau for the living to find. 'An act like this is prepared within the silence of the heart, as is a great work of art,' writes Camus of suicide in The Myth of Sisyphus. And what artful death, I could hardly have dared ask myself, had Daniel silently prepared?" This chilling account will remind physicians that the suicide survivor's response is often a complex combination of posttraumatic features and guilt-laden grief. Both aspects must be worked through during the process of recovery.
Through the middle four chapters, Farr examines how the rest of society copes with the reality of suicide. She describes our current scientific knowledge about suicide with a depth of understanding and considers contemporary society's sensationalism of suicide. And she uncovers the Internet's exploitation of suicide. In particular, Farr highlights the cultural overkill of the theme of suicide that numbs our sensitivity to this tragedy. She notes how many recent movies use suicide as a plot device much as they would a car chase or an exploding building. Farr concludes, "This multiple-personality Media can be a breezy, entertaining buddy, a concerned and thorough teacher bent on enlightening and informing, a shameless manipulator, a brainless twit, an overbearing nuisance, and worse, an insensitive, torturing bully."
What role should we insist that the media play? I feel that Farr is not critical enough of her media colleagues. Writers and journalists have a profound professional responsibility to deal with suicide in ways that prevent contagion. The potential for vulnerable individuals to carry out copycat suicides in response to fictional or nonfictional accounts is well documented. Too many times in my professional role I have had to remind journalists about the existence of media guidelines for the reporting of suicide. The portrayal of suicide in the popular media has an impact on the health of the community. We as health professionals must insist on greater professionalism from the media in this regard. Journalists, just as physicians, must be aware of the side effects of their interventions.
Although Daniel Jones was a writer of some notoriety, this book is not a tell-all story of the Toronto artistic scene. It is not an academic recounting of current scientific formulations of suicide. It is not a prescription for the self-directed recovery from grief. Rather, it is an offer of hope, a beautifully written journey of reclamation, and simply a very personal account of the author's own grief. I was very moved by After Daniel. Many physicians have and will, in the future, encounter suicide in their professional and personal lives. Many of our patients will be survivors of suicide. I recommend we all take up and read Moira Farr's account of death, life, and humanity.
Paul S. Links, MD
Dr. Links holds the Arthur Sommer Rotenberg Chair in Suicide Studies at the University of Toronto.
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[Contents]
Room for a view
Fear and loathing in residency
[See also: The walnut manoeuvre]
If you have to choose between the two,
it is better to be feared than loved, for fear
preserves you by a dread of punishment, which
never fails.
Machiavelli, The Prince
"So why didn't you order potassium in the IV?"
Coming from a medical student, the question was innocent enough. For us three clinical clerks, it was day one of the surgical rotation. Keen and eager, we had just met our preceptor as he exited the OR to write postoperative orders. Now a curious and fertile young mind was seeking a little knowledge — some enlightenment from the master. It was the perfect moment to teach. Or to destroy.
"Don't you know anything about electrolytes?!" snarled the surgeon. There followed a flurry of questions, each more difficult than the last, a rapid-fire grilling about intra- and extracellular anions and cations, cell physiology and renal function. Now totally rattled, the student could only respond, "I don't know, I don't know" until, humiliated in front of her peers, she broke down and began to cry. The surgeon sneered and stomped off without a backward glance.
None of us ever asked him a question again.
Instructors in medical schools and residency programs usually have no formal training in education; anyone who has made it through the system is deemed capable of teaching. As a result, the quality of teaching in our academic centres varies tremendously. While some preceptors are exemplary, others are mediocre, inept or just plain uninterested.
And a few are bullies who use their position in the medical hierarchy to intimidate and browbeat. The same feeble pretexts for this churlish behaviour surface time and again: "I'm doing this for your own good," or "That's the way I was treated when I was a resident." Weak excuses that fail to cover what is really an abuse of power.
A sure sign of a bully is the habit of making an enormous commotion over a minor incident. One of my more memorable moments as a surgical resident involved a bowl of soup. In our last case of the morning the surgeon scrubbed out early and strolled away for a leisurely lunch. In the meantime, I closed the incision, dressed the wound, waited for the patient to wake up, helped transfer him to a stretcher, jotted down an operative note, wrote the post-op orders, dictated the case, and answered some questions from a medical student. I then grabbed a bowl of soup from the food cart in the OR lounge. I had just raised the spoon to my mouth when the intercom crackled: our next patient was in the operating room. The well-fed surgeon, hearing the announcement and seeing me with spoon in hand, went ballistic. An observer would have thought that I had been caught red-handed stealing nuclear weapons secrets.
"How dare you," he spluttered, so choked with rage that he could scarcely enunciate. "How dare you sit there and eat soup while my patient is in the room? What kind of resident are you? Where are your priorities?" And on it went. Apparently the surgeon believed that public chastisement was an effective teaching tool. Dire predictions of my failing career continued at full volume, in easy earshot of others, while I put down the spoon and scrubbed up.
Bullies may create the illusion that technical prowess compensates for personality disorders. Recently I ran into a family doctor who was a medical student on service when I was a resident. I asked him about his most vivid memory from his surgical rotation. Without hesitation, he replied: "There was this one surgeon, he was all over us all the time, even at three in the morning. Nothing we did satisfied him. And he would belittle the OR nurses until they ran out of the room crying." Then, almost apologetically, he added, "But he was a helluva surgeon."
A physician can possess great operative dexterity or encyclopedic knowledge but still be a failure as a teacher and an overall liability. In The Dilbert Principle, Scott Adams advises that nothing can "drain the life-force" out of an organization like the few bullies who are bent on making life hard for others. These employees may have important skills, Adams writes, but the trade-off is never worth it.1
Now that the formal portion of my training is complete, I look back on the experience with many fond memories. I had scores of preceptors throughout medical school, internship, residency and fellowship who were fair and had a genuine interest in helping students succeed. An unfortunate few failed to recognize that residents are mature, accomplished adults, not raw recruits in a Marine boot camp. I look forward to the day when this type of behaviour, which is not tolerated in most other workplaces, will be out of favour in our medical teaching institutions.
Robert Patterson, MD
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Reference
[Contents]
Lifeworks
Anomalies and anonymity
Face to Face: Four Centuries of Portraits, a major exhibition on view at the Vancouver Art Gallery until September 26, traces the aesthetic and social conventions of Western portraiture from Renaissance painting to 20th-century photography. The two images reproduced here demonstrate how, by its very nature, photography opened new horizons for the creation of "likenesses" — a capability that naturally served the ends of scientific medicine. Photography was quickly embraced by physicians to meet a need for realistic illustration and to provide evidence of cures. But the ways in which medical phenomena are recorded are determined not only by technology but also by the social framework within which we see — or are willing to see — them. A documentary urge sometimes collides with propriety in interesting ways.
The photograph attributed to Philadelphia photographer William Bell (18301910) of a man with a gunshot wound incurred in the Civil War appears to be one that Bell took while he was working for the Army Medical Museum in Washington, DC. The museum was founded in 1862 by the US Surgeon General's office to collect "specimens of morbid anatomy, surgical and medical, which may be regarded as valuable; together with projectiles and foreign bodies removed, and such other matters as may prove of interest in the study of military medicine or surgery."1 In this photograph the norms of the studio portrait prevail. The photographer's chair, with its Victorian fringe, seems a ludicrously conventional prop in view of the subject matter. The man has disrobed only to the minimum extent necessary, and the use of the mirror, as well as showing the bullet's entry and exit, allows him to confront the camera directly. There he stands, a human being entire. A modern clinical photograph would only show a piece of him.
 Attributed to William Bell. Civil War veteran: gunshot fracture of the upper third of the left femur united with slight deformity, c. 1865. Albumin silver print. National Gallery of Canada |
 Charles Eisenmann. Woman with a hydrocephalic baby, c. 1875. Albumin silver print. National Gallery of Canada |
The illustration of gross abnormalities and pathologies was an area in which early medical photography rapidly took hold. That being said, the motivations of New York photographer Charles Eisenmann appear not to have been scientific; he made a successful career photographing the human exhibits of the "freak shows" and dime museums of the Bowery district of New York City, satisfying the Victorian taste for the grotesque with P.T. Barnum-style showmanship.2 The sitters for his portraits had a harrowing range of congenital and metabolic abnomalities; many made a living presenting themselves to the public as the "Lobster Boy," "Elastic Skin Man," "The Living Skeleton," "The Four-Legged Woman," and so on. This photograph of a woman with a hydrocephalic baby is by no means the most unsettling of Eisenmann's portraits but is one of the most haunting. From the beginning of clinical photography, the medical establishment was uneasy about the voyeurism it made possible, a voyeurism demeaning both to the subject and the viewer.3 But, as exploitative as they are, Eisenmann's photographs have the effect of making us wonder what the quality of his subjects' existence must have been like. Inadvertently or not, they raise the problem posed much later by the photography of Diane Arbus (19231971), who famously remarked that "It's impossible to get out of your skin into somebody else's. ... Somebody else's tragedy is not your own." These days medical photography neatly avoids the problem by taking a more technical, fragmentary and anonymous view of the body, one that, with new standards of propriety, leaves the person behind.
Anne Marie Todkill
Editor, The Left Atrium
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References
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Hammond AH. Circular no 2. Washington, DC; Surgeon General's Office, May 21, 1862. Cited in Pitts TR. William Bell: Philadelphia photographer [Master's thesis]. Tucson (AZ): University of Arizona; 1987. p. 13.
Mitchell M. Monsters of the gilded age: the photographs of Charles Eisenmann. Toronto: Gage; 1979.
Kemp M. "A perfect and faithful record": mind and body in medical photography before 1900. In: Thomas A, editor. Beauty of another order: photography in science. New Haven and London: Yale University Press; 1997. p. 125-6.
[Contents]
Image of the profession
Dr. Eisenbarth
At the Council of Tours in 1163 the Church forbade physicians to practise surgery. Because many physicians were men of the cloth, surgery fast became a paramedical, then an extramedical, pursuit. In Germany and northern France, quacks and charlatans of all kinds recognized the potential market and quickly added surgical services to miracle cures and the pulling of teeth at country fairs. The principal acts performed were the removal of clouded lenses and of bladder stones, true or virtual.
It was evidently not good even for an itinerant healer to lose too many patients, and some of the procedures need not be considered primitive. Immense bladder calculi were removed, from the 16th century on, through sectio alta, that is, a horizontal cut just above the symphysis. An incision through the perineum, recommended by Ambroise Paré, was avoided because of the increased risk of infection. The prudent operator had the patient drink a lot of water beforehand, to make sure the intestines were pushed up and out of the way.
With the passing of time, techniques improved and some of the itinerant surgeons became famous. The story of Johann Andreas Eisenbarth (16611727) is particularly interesting because we have some of the leaflets he had distributed before his arrival in town. He advertised cures for calculi, scurvy, catarrh, fever, tinnitus, caries, dropsy, "the French disease" (syphilis) and memory lapses, and he peddled medicines produced in his factory in Magdeburg, near Berlin. Eisenbarth was well rewarded with appointments to the courts of Saxony and Prussia and with a load of money. German medical students still sing of his technique, his sleight of hand and his brazen self-glorification.
Wolf Seufert, MD, DSc
Université de Sherbrooke
Engraving by Pieter van der Heijden after Pieter Brueghel's De heks van Mallegem. The witch of Mallegem comes to the country fair to be cured of the buzzing in her ears (the "wasp in her head"). Meester Ian, the "doctor," shows a stone he pretends to have removed from the head of the patient leaning on the bench in front of him. In the collection of the Rijksmuseum-Stichting, Amsterdam, The Netherlands.
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© 1999 Canadian Medical Association
