David Foster Wallace hanged himself on September 12th of this year. He was 46 years old. The news of his death was unexpectedly jarring, a shot to the gut. He was obviously much too young. I was just getting to know him, it seemed. I'd tried reading Broom of the System when I was 23 but couldn't get through it. But I've been reading his non fiction and short stories over the past few years and I realized he was one of those rare authors who speak to something essential yet inarticulated inside me, like Hemingway and Salinger and Chekhov did. He was truly one of our best contemporary writers. Really, he was. For some reason I read his musings on the concept of Infinity while on our honeymoon vacation. What kind of fiction writer/creative writing professor writes full length books about complicated mathematical notions? Currently, I'm plowing through the essays in Consider the Lobster. (My god the piece he wrote for Rolling Stone in 2000 about the John McCain primary campaign (Up, Simba) simply won't get out of my head it's the best thing in New Journalism since that Gay Talese wrote about Frank Sinatra's cold.) Infinite Jest is next. DFW wrote with an energy and originality unmatched by practitioners of modern fiction. And he was cool. He was cool guy. The kind of dude you wish you were friends with or at least a guy who would meet up for beers every once in a while. He wrote about Roger Federer and Tracy Austin and Lobster Festivals and even the National Academy Awards of Porn without fawning or seeming patronizing or smarmy toward the subject matter. He was curious about the world. Things he didn't understand, he simply read and researched them. Because of his youth and edgy style, he brought a cloak of hipness to what was essentially an extremely intellectual and sophisticated mind.
One constant theme running through his work is this entire post-modern angst predicated on self doubt and the tenuousness of a consciousness liberated from historical constraints. It gets away from us, though. We stop being I. We are the voice who watches the I acting in an entirely predictable, banal fashion. And it's supposed to be funny but more than anything else it's frightening as hell...Let me clarify a few things. First of all, this isn't going to be a typical Buckeye Surgeon blog post about dead stomachs or crazy gallbladders or some injustice toward physicians I read about on the NY Times online. This one is going to be long and rambling and it may not be in your taste. Stopping right here may be in your best interest. I'm going to write about things that I don't usually address on this blog. I'm going to open myself up a bit more than I usually would.
Let's start off with this whole concept of Post Modernism. Everyone has heard the phrase. We're in a 'post modernist' era. Deconstructionists and Derrida and Foucault and Lyotard. Those are the names you usually see attached somewhere in a piece about post modernism. It's like if you are writing about "Communism", you're going to see the names Stalin and Lenin and Trotsky scattered throughtout. The difference is that everyone seems to have a solid grasp of what "communism" means: collectivization of resources/wealth, proletariat movement, centralization of power, Gulags, state police, totalitarianism, mass graves, crushing of the human spirit, etc. But post modernism is just a word for most of us. And Foucault and Derrida are just names. We've all come across them at some point and we might be able to answer one of those simplistic Jeopardy questions where the category is "Names that start with F" and the answer is 'this bald guy was a philosopher of the post modernist school' and you can give the question who is Foucault not because of any real knowledge of Foucault or what he wrote about but merely because the Jeopardy game is contrived in such a way that rewards rote trivia retention over true intellect. Anyway. And I don't think it's anything to be ashamed of, not knowing what the hell these guys were talking about. The school of post modernist thought is vague and esoteric and downright unitelligible at times. Here's Noam Chomsky:
There are lots of things I don't understand -- say, the latest debates over whether neutrinos have mass or the way that Fermat's last theorem was (apparently) proven recently. But from 50 years in this game, I have learned two things: (1) I can ask friends who work in these areas to explain it to me at a level that I can understand, and they can do so, without particular difficulty; (2) if I'm interested, I can proceed to learn more so that I will come to understand it. Now Derrida, Lacan, Lyotard, Kristeva, etc. --- even Foucault, whom I knew and liked, and who was somewhat different from the rest --- write things that I also don't understand, but (1) and (2) don't hold: no one who says they do understand can explain it to me and I haven't a clue as to how to proceed to overcome my failures. That leaves one of two possibilities: (a) some new advance in intellectual life has been made, perhaps some sudden genetic mutation, which has created a form of "theory" that is beyond quantum theory, topology, etc., in depth and profundity; or (b) ... I won't spell it out.
Now you're thinking, who does this marginally educated general surgeon in Ohio think he is, proposing to explain post modernism after going to great lengths to portray it as an imprecise, borderline nonsensical fraud, a charade that a legitimate intellectual like Noam Chomsky exposed years ago. And what does post modernism have to do with surgery in general and badly toupeed elderly men specifically? Well I'm not going to explain anything, in the scholarly, professorial sense. I can only simplify a few of the key notions that I have been able to digest. One way to look at post modernism is in contrast to its precursor, Modernism. Modernism is a little more manageable. It's less obscure. You won't find as many sentences like this: (from the scholarly journal Diacritics in 1997) "The move from a structuralist account in which capital is understood to structure social relations in relatively homologous ways to a view of hegemony in which power relations are subject to repetition, convergence, and rearticulation brought the question of temporality into the thinking of structure, and marked a shift from a form of Althusserian theory that takes structural totalities as theoretical objects to one in which the insights into the contingent possibility of structure inaugurate a renewed conception of hegemony as bound up with the contingent sites and strategies of the rearticulation of power." Modernism, for the most part, can be articulated more lucidly. After WWI and the killing fields of the Somme, it dawned on the intellectual elite that maybe universalism and pan-humanistic ideologies and nationalistic fervors weren't such wonderful things. That perhaps it would be better to promote individual perspectives over unyielding previous authorities. It represented a break from the old historical dogmatic shackles, a rejection of previously unquestioned traditions. Institutions such as the church, government, philosophy, and art, were subjected to a reappraisal and were redefined in terms that acknowledged the predominance of the individual. This is probably best represented by the arts of the early Modernist period. Stream of consciousness writing and shifting perspectives, as practitioned by James Joyce in Ulysses and Virginia Woolf in To the Lighthouse, challenged the prevailing literary tradition of having a consistent, chronological narration. The Impressionist school of painting emphasized the ephemeral and the fleeting nature of beauty in the world as opposed to the perpetual exactness of previous art. (Think of the contrast between a series of Monet paintings of the same haystacks but in different seasons versus the austerity and perfect lines and perspective of a Rembrandt portrait.) Basically what we're talking about is the undermining of external authority and preconceived notions of reality by an insurgent individualism. In so doing, two thousand years of foundational standing ground were smashed to bits. Questioning religious dogma was no longer considered "heresy". Protesting authoritarian government did not necessarily make you a rebel or an insurrectionist. According to the precepts of modernism, one has to participate in such fractiousness in order to more fully realize one's individualist potential.
But there's a price to be paid for the destruction of old authoritarian constructs. Suddenly, we're cast adrift, free as can be, but without a net. That can be fun and also not so fun. It can be downright terrifying when someone rips the ground out right from under your feet and all of a sudden you have to tread water or ether or whatever subjective reality it is that we've decided to suspend ourselves in for the rest of our lives. Because that ether is entirely self contingent. You can't take a day off from believing truly in what your mind projects as consciousness. It's all yours, baby. You asked for it and now you have to live with it for the rest of your life no turning back. From TS Eliot's The Hollow Men:
This is the dead land
This is cactus land
Here the stone images
Are raised, here they receive
The supplication of a dead man’s hand
Under the twinkle of a fading star.
Is it like this
In death’s other kingdom
At the hour when we are
Trembling with tenderness
Lips that would kiss
Form prayers to broken stone.
Broken stones are all that's left around us now. Post modernism, then, is modernism turned back on itself. If it's ok to question external forces of authority (church, state, traditional art, etc) then why can't we likewise impugn the veracity and validity of internal sources of authority? Namely, how are we supposed to trust and/or verify that ubiquitous running monologue within our own heads? How do we know it's speaking from a vantage point of objective limpidity? How do we know that what we're feeling or thinking at any one time corresponds even slightly to the actual world or to what 100 other sentient beings would be thinking/feeling under similar circumstances and whether those thoughts/feelings we have are contingent on external forces to varying degrees depending on our education level, our upbringing, our physical environement. Troubling, no? It's like Plato's men in the cave; they didn't realize they were in a cave. The shadows on the walls were a sufficient reality to them because they didn't know any better. So even though shadows on mildewy cave walls are poor substitutes for the lush colors and pungent smells of "reality" as we know it, the truth is, it doesn't matter. Those men aren't coming up out of that cave anytime soon to find out what they've been missing. Post modernism, however, impels one to reconsider one's own self, not just external forces and institutions. It would be like old Socrates yelling down into the cave one night that the cave people were a bunch of idiots because there was a whole different ( i.e. better) reality up with him, only he doesn't tell them how to get there. Not so nice, right? And that's the prick of the post-modernist thorn. We're aware that our own identity/consciousness may very well be arbitrary and foundationless. As a defense mechanism we adopt a mindset of detached irony and amuse ourselves with a knowing cynicism, funnier all the more because we're totally aware that what we're belittling is the same thing that gives rise to our disparaging commentary. Confusing and circular, I know. Makes you want to tear your hair out.
In medicine, we as physicians are privileged to encounter other human beings at their most vulnerable. Illness and pain and suffering break down a lot of the barriers we erect to ensconce us from being exposed. We erect a persona or an ideological front that protects us from the prying gaze of the Other. We can control the projection of an identity. You simply proclaim yourself as doctor, engineer, fireman, vice president of sales. Husband, father. Philanthropist. Criminal. Bad ass. We can spin things so that the message received by most people we encounter is a message we're comfortable with. Image is a powerful force in modern. That's why advertising and public relations are billion dollar industries. But there's no spinning of the truth when you're ill and laced up in an ass hanging out gown, sharing a tiny room on a lousy bed in the hospital. All your cards are pretty much out on the table at that point. There's nothing phony or disingenuous about your situation. And then a well dressed human being in a white coat walks in and starts asking you questions about everything private and embarassing, everything you normally try to avoid thinking about, things your spouse doesn't even know, and then he/she starts examining you, probing you with clinical detachment. A specimen to be evaluated and contemplated.
For doctors, the onus of responsibility in such situations is enormous. Another person is granting you a glimpse of his/her essential being, if only for a few moments. There is an unspoken trust that keeps the whole potentially awkward encounter from going to pieces. Trust that the patient will not lie about his/her symptoms or medical history and trust that that the doctor will act in the patient's best interest. It ought to be as simple as that. But there's more to it. There's more to being a doctor than just an honest exchange of information. Otherwise, it's not such an appealing gig. Although we do occasionally have automaton tendencies, we are also fallible human beings. There's a pay-off that goes unvoiced. We don't like to talk about it but there's something powerfully edifying about being able to assuage a patient's suffering. It's a rush. To help someone. To use a lifetime of study and hard work for the benefit of a stranger. I saw an old lady the other day whom I had operated on several months prior for peritonitis. She was in the hospital for something unrelated and seemed in good spirits. I stopped by just to say hello, recognizing her name on the patient board. She beamed at me when I walked in and grasped my hand. Her daughter was there and they seemed genuinely happy to see me (she'd been lost in the maze of rehab hospitals and long term care facilities). And right as I was leaving the room, the daughter said "Doctor, things moved so fast back then; we never had a chance to say how grateful we all are for what you did." It was heartfelt and real and all I could do was mumble something half way gracious all embarassed as I left. It happens all the time in general surgery. We enter a patient's life at times of great threat and change. With a good outcome, patients are extraordinarily grateful. I always call patients after a breast biopsy to tell them that the pathology is negative for cancer. There's always a half beat silence as it sinks in. And then the warmth suffuses over the phone as they express thanks. You can almost see that death grip on the phone relax as it becomes clear that no, they do not have cancer. Then there was this old lady recently who came in with an incarcerated ventral hernia. I saw her in the ER and made OR arrangements. Before the surgery I met her in the holding area to answer any last questions. I pulled back the drape and had to take a step back. She was surrounded by several large men (all at least 6'3") all talking volubly. She had five grown sons and her husband was hunched over her, holding her hand. Her boys were trying to keep it light, laughing and joking, talking about the Cavs. And then the husband stood and approached me, and he grabbed my hand tight and looked me in the eye hard and forthright and said "I just wanted to thank you so much for taking care of my wife, I love her so much" and his eyes were moist and red splotched and his face was flushed and he was one of those big bears of an old man, white bushy eyebrows and a big paunch and he towered over me with his trembly voice and I noticed his toupee was maybe a little too wooly, didn't quite match the rim of hoary white around his ears and that it wasn't on quite right, tilted forward a bit too much, like he had put it on haphazardly, too quickly, as he rushed to get to the hospital to see his sick wife.
And as the six giant men left, the CRNA whispered to me "you must love that", meaning that it must be such a thrill to be able to be almost a hero for these random strangers who wander into an emergency room. Yeah, I said. It's something. And I really want to believe that it's that simple. It's paramount that what I'm feeling and why I'm feeling it are contingent on human compassion and a simple desire to do a good deed for someone besides myself. Otherwise the the whole system falls apart.
But you wonder sometimes. Post modernist self-doubt compels you. Am I sure that's why I do this work? Am I sure that my motivations are always derived from purely benevolent impulses? I mean, how do I know that the real reason I like being a doctor isn't because I like having people think I'm some kind of amazing hero? Or maybe I just like having people think I'm the kind of person who does good deeds. Or maybe I find compliments self-affirming. Or perhaps I just enjoy the sense of power and control a physician can exert over a vulnerable patient. How do I really know for sure? How do I really know if I'm doing this because I'm such a grand and altruistic guy or if maybe I just like having people be proud of me and impressed by what I do and old guys shaking my hand with reverence and awe. Maybe I just tell myself that I'm acting from humanitarian impulses in order to obscure the true, unacknowledged selfish reasons. And does it matter? Pragmatically speaking, as long as a good deed is performed, the etiology of such action ought not to matter. But I can't let it go. It matters to me. I can't help it.
We've opened this Pandora's Box of ironic detachment and self awareness and life can be analyzed like a plot from an episode of Scooby Doo and it's funny and amusing at first. But eventually, if you follow it through to its logical conclusion, it all just makes your stomach ache your palms sweat your mind spins at night you can't get any rest and it's all, finally, just sort of sad and mournful. Fundamental assumptions like the ineluctability of self identity are suddenly cast into doubt. We begin to doubt whether we can rightly trust our initial emotional responses to situations. Can the uplifting sentiments I'm experiencing rather be explained by something dark and nefarious? We've tossed earnestness to the curb in exchange for unctuousness.
Near the end of Up, Simba, DFW writes about the conflicting feelings he has about John McCain. On the one hand he's impressed by John McCain, the POW and his obvious love of country and the credibility he brings to what would normally be a half-assed campaign exhortation like "to inspire young Americans to devote themselves to causes greater than their own self-interest", but John McCain being a man who repeatedly turned down a chance at early release from a prison camp where he was starved and tortured because "it wouldn't be right, it violated my Code", that John McCain brings a lot of moral weight to a potentially vapid, meaningless slogan. On the other hand, there's all the phony b.s. that a candidate has to subject himself to in order to get into a position where he's a viable contender for the presidential nomination. The same speech he repeats day after day at town hall meetings. The broken promise not to run negative ads. The sleekness and controlled professional verve of an organization that is ostensibly promoting the anti-candidate in such a fashion that makes him look like any other typical candidate for office. It's all so confusing, the conflicting messages. Eventually, the battle between what you want to believe and what your inner, cynical voice is saying you ought to believe becomes more important than what's actually going on in McCain's head. Whether or not McCain is a potentially great leader or just a slick salesman ultimately is irrelevant compared to what's happening in your own heart.
Now I realize David Foster Wallace suffered from depression for over 20 years and I won't presume to know everything that was going on in his head leading up to that fateful day two months ago. But I think DFW woke up every day struggling to overcome this conflict within his heart; whether to trust those warm and fuzzy first impressions, or to succumb to the cynical doubts that crept in with enough introspection. Every day he mounted an effort to ignore that doubting voice that questions our feelings and emotions and casts a pall over anything heretofore thought of as an "authentic" response to a life event. I think DFW exhausted himself mounting that effort day after day. It wore him out. He expended so much energy looking at everything from both sides, trying to be reasonable, giving every point of view it's due (inescapable, from a PM perspective), that he lost his drive to have to constantly redefine and justify himself every morning. He got tired. And then one day in September he hung himself.
I've been thinking about that old guy with the off-kilter toupe and the hearty handshake and the glistening eyes a lot lately. I think about him more than his wife, the actual patient. She did fine but I don't even remember much about the operation. Hernia repair, bowel resection, etc, etc. Presumably, she'll be enjoying another Thanksgiving dinner very soon with her brood of boys. Everything worked out for the best and that ought to be all that matters. But I want there to be more to it than good outcomes and high patient satisfaction scores. There has to be something irrefutably genuine that occurs during encounters between patients and physicians. There will be complications and unfortunate outcomes and mistakes are going to be made and I can handle all that; this surgery business isn't an easy gig sometimes and I knew that going in. I can handle complications. Overcoming external adversity often isn't nearly as daunting as reconciling the internal battles that rage inside our hearts. Somehow we have to quell the rise of this creeping cynicism that threatens to poison everything good and noble we do.....
"There are no choices without personal freedom, Buckeroo. It's not us who are dead inside. These things you find so weak and contemptible in us---these are just the hazards of being free."
"Postmodern irony and cynicism's become an end in itself, a measure of hip sophistication and literary savvy. Few artists dare to try to talk about ways of working toward redeeming what's wrong, because they'll look sentimental and naive to all the weary ironists. Irony's gone from liberating to enslaving. There's some great essay somewhere that has a line about irony being the song of the prisoner who's come to love his cage… The postmodern founders' patricidal work was great, but patricide produces orphans, and no amount of revelry can make up for the fact that writers my age have been literary orphans throughout our formative years."
R.I.P. Mr. Wallace