Between Poetry And Medicine, Personal Communication

My first impression of surgery was incredible. I was assisting my father, a surgeon, one night, during an emergency operation for bowel intussusception, which is basically a formation of a tight knot by the bowel loops that will not allow normal passage and movements of the bowel. If surgery is not performed in time, the results are devastating, causing the development of dead segments of the bowel and, eventually, death. The trick and sign of surgeon’s art is to catch this in time and to remove the entangled part of the bowel and reestablish the passage through bowel and normal movements. So, usually, these operations are performed on an emergency basis. That night, in front of my eyes (I was standing by and holding some instruments; I don’t even remember exactly what I was allowed to do), a middle-aged mechanic, father of three was on the operation table. The mechanic was conscious and talking to my father, his belly opened, bowel loops exposed, and my father manipulating them, injecting more and more Novocain (similar to lidocaine) deeper and deeper into the root of the mesentery, where most of the nerves pass to the bowel.

My father was one of the beloved students and associates of the famous Russian surgeon Aleksandr Vishnevsky, one of the main founders of the method of advanced local anesthesia given for major operations. As one of his main associates, my father was very skillful, even in performing removal of a lung or breast operations and such without general anesthesia, just with minor premedication.

This was all heroic and very impressive, but as I mentioned before, I took another turn. One of the problems I had with surgery is the tedious part of it, hours of holding something, tying the knots, staying on one spot…Medicine is very much like art. An excellent pianist can’t be an equally good painter. Medical specialty requires a certain personality, and development of a certain personality goes along with the development of a specialist. A surgeon who is not aggressive enough is a bad surgeon. An obstetrician who likes to go to bed at regular times and sleep all night can’t be an efficient obstetrician. I was thinking of becoming a surgeon based on my father’s advice and his taking me to assist him with operations in the middle of the night. My mother was a pathologist, well-known in the area of rheumatic diseases. So, I have become a pathologist. At that time I felt that I would be a central figure in the decision-making process related to a patient. As a 20-year-old guy I felt I would be a sort of guru—the go-to guy. Pathology, I thought, was a very scientifically related discipline, and I wanted to do science and felt that pathology was the most intellectual of all of medical specialties. Actually, I still feel the same way. I have had long periods of frustration, fearing that, with my aggressive personality, I would do better having more immediate contact with patients, exercising full control and having an ability to fix problems with my own hands.

***

This was the time of great genetic discoveries and the rapidly developing field of immunology, transplantation, and cancer immunology. Still at high school, I bought an amazing book by Sir Macfarlane Burnet, Nobel laureate, on clonal selection theory of cellular development. I felt that this was amazingly interesting and this is where the nucleus of problems related to cancer, transplantation, and such was located. My father, who himself knew immunology quite well and was a specialist on treating chronic infections with some ideas about resistance of organism, was strongly against my growing interest. The thing was that he belonged to a generation of people who suffered under Stalin. Many of his friends, some of our relatives, went through Stalin camps; some perished. I was part of the so-called “Khrushchev Generation,” so-called period of “thaw.” Solzhenitsyn had just published his famous short novel, One Day in the Life of Ivan Denisovich, and some short stories. There was a lot of literature coming out describing the sufferings under Stalin, and a lot of nonconformist art was emerging. But my father, as many people of his generation, was very cautious about it and afraid that it might turn backward, and then everybody who exposed themselves would suffer. Therefore, he was very concerned that I would go to get my education in chemistry or biology at Moscow University and become one of the scientists. His rationale was that in case of big trouble in the country, I would find myself either without bread or even imprisoned in the camp and unable to survive. Despite the relatively good times, early- to mid-sixties (life was getting better; we had a car and a co-op apartment) my father was saying to me, “You never know. God forbid you get to a camp, if you are a physician—you survive. You know something that other people don’t. This is the survival of the fittest—horrible Darwinian law.”

So I did go to medical school and was very happy there, after several dull years of high school education. I felt at home there. I felt that I understood the structures—feeling of texture, anatomy and histology, this all was close to me. I felt that I was in the right specialty because I could feel, sense that matter of life. Not in an abstract way, not in an indirect way, but in a very simple and direct way: Heart beating, the tuberosities of the temporal bone, vacuoles in the cells, all those real structures and phenomena, not imaginary or mathematical models. That is why out of all “exact sciences,” chemistry, “semi-exact science,” so to speak, appealed the most to me. I remember when I was visiting the chemistry department of Moscow State University at the open house and a professor showed how mixing a few liquid, semitransparent solutions created a quickly solidifying gel. I knew that this was simply a chemical formula based on mathematical data, electrons, positive and negative charges, etc., but the physical reality of transformation into a different state of matter really struck me. So I was pretty good at chemistry and earned the highest score at the entrance exams and got into the long-desired premiere First Moscow Medical Setchenov Institute. I was the third generation there. It was a nice feeling to follow in the footsteps of my parents, since a lot of professors and instructors recognized my name and many of them were my parents’ classmates and alumni. There was a comfortable feeling in Moscow all along, to be from a well-known medical family, even after I finished medical school and went for my internship, residency combined with Ph.D. training. I went through the equivalent of an American M.D. – Ph.D. program. My immunopathology and immunology training and experience and some publications certainly helped me during the hard period of adjustment in the United States, but it was a rude awakening.

There is a good old Russian saying: “Moscow doesn’t believe in tears.” It means that a lot of people coming from the periphery to Moscow should shed at the entrance all their achievements, hierarchical positions, etc. and play by the rules of this tough, big city. Similar things happen here in the United States when people come from around the world—well-groomed children from the Middle East, Russian Jews from well-educated families of professorial or artistic background, people from India from the upper castes. And one of the best ways to shape up, certainly, was residency in the American training program.

***

After two years waiting for the exit visa in the Soviet Union, I still managed to retain that professional and family-related feeling of being a physician, being somebody who had a certain professional and social position. We got off the plane at the JFK airport on May 21, 1981, coming from Italy after waiting there for two months, with two little children, five and eight years of age, four suitcases, and $524 in my pocket. That was all. We were a nuclear family. The whole network of relatives, parents, friends, connections, alumni from my medical school, everything was left behind. The preceding two years were hard. We applied for emigration in the spring of 1979 and were hoping for about eight to ten months of wait, studying English and, for me, preparing for the medical entrance exam (at that time ECFMG). That would confirm my medical school education and allow me to enter postgraduate medical training in the United States. December 1979 the Afghan war erupted. For some, even now, not-quite-explained reasons, Soviets decided to take matters into their own hands. I believe some internal struggle in the Kremlin between “hawks” and “doves,” if this may be applicable to the Soviet leaders. The bloody coup ensued; Soviet paratroopers took over the presidential palace (typical style!) and the longstanding horrible war against Afghan mujahideen and soldiers of the international jihad against infidels, in part led by Osama Bin Laden, unraveled.

During all this time, the immigration of Soviet Jews or anybody else to anywhere else was completely shut down. So, I was out of work for two years and eventually had to spend the summer months of 1980 doing hard labor in the country, about 12 hours a day in southern Russia to make some money to support my young family. The spirit was still there, and I kept reading literature and preparing for the medical exam in the United States. I remember lonely mornings, after early-morning work was over (I was working as a beekeeper, deep in some grove, far away from the closest town) and sometime in the evening, walking the woods of southern Russia (Voronezh region). I was conducting imaginary dialogues with myself, using newly learned words and also rereading chapters from The Merck Manual and copied pages from Harrison’s Principles of Internal Medicine. I clearly realized that there was very little hope for me to ever use this fragmented knowledge in the near future or ever. Nevertheless, this was one of the few things that were keeping me from depression, insanity—giving up and crawling into some totally different pocket of life. In other words, giving up hope to live in the free world and to be who I always have been—a physician. I remember the sound of trees being cut by the local loggers, deep in the woods as I was walking among the trees, memorizing and repeating and memorizing typical medical discussions during morning rounds at an American hospital.

Another core of my life that kept me straight was poetry. I had been writing in earnest for several years by then (1980). I had a typewritten collection made on a mechanical typewriter, as people of my generation did at the time; even self-publishing was impossible. As a matter of fact, it was very dangerous because it was against the law and could be considered anti-Soviet propaganda. So we read poems to each other in small groups or just to friends and did some typewritten copies. Unfortunately, because of my preoccupation with medicine and studying English and making money for my family, poetry was not coming to me easily during this period. Still, I was walking in those woods, trying to put some lines together, trying to overhear some fragments of sounds, process metaphorically what was happening. I was trying to seize time in flight. Interestingly, those feelings and images resurfaced later on in some poems, in both languages, 20 to 30 years later.

In medicine experience is enormously important. But also in poetry. Life is the process of accumulation of material for artistic expression, as long as the artist is not afraid to look into the depths of his own life, weaknesses, fears but also register wonderful moments that passed forever, still always available to be burned in art’s oven, giving some light and sending the shadows of the past to move through your room.

I don’t know exactly what influenced the authority’s decision to let us go along with a few hundred other Moscow families in the winter of 1981. It was a miracle, a very narrow window of opportunity, and we used it. We didn’t enjoy Vienna at the time, since it was right after another Palestinian terrorist attempt on the life of Soviet Jews bound to Israel at the Vienna airport. So, we were escorted by the Viennese police, along with plainclothed Israeli agents, to the big, heavily guarded castle formerly of some nobleman and then belonging to the Red Cross and then to the Sochnut, the Jewish Agency for Israel. We made a conscious decision to go to the United States. Both my wife and I felt very Western-oriented, very interested in the idea of America, and I simply felt that I wanted to have more opportunities. We were transported to Rome, where I continued studying and began writing letters of application to obtain a job in the United States, somewhere on the East Coast between Washington and New York, where we had friends and where we felt the culture was closer to ours.

From then on one can consider this a success story. Some of my friends from the medical school were already at the NIH, working in NCI, fellows or researchers. I had some publications, and the Associate Director of the NCI, Dr. Bruce Chabner, knew some of my mentors on the other side, from the Soviet Union, by publications and occasional meetings in Russia. I received a Fogarty International Fellowship in medical science and spent an exciting year in the Division of Cancer Treatment at the National Cancer Institute. My immunology background and clinical pathology training helped a lot; I felt very much at home, gave a few talks, and even managed to publish a paper in the first few months after arriving there. I did not even realize how important this was for my future career, experience with research and being a fellow at the National Cancer Institute. My boss then, Dr. Paul Bunn, currently President of ASCO, explained to me in very simple terms: “Andrey, if you want to pursue a scientific career, you have to hang around me at the NCI for about five years to confirm your Russian Ph.D. If you want to go and become an American physician, it is okay with me; you can leave as soon as you are ready, but remember you will have to give up real science. Because for several years of very, very hard work, you are going to be in the process of being shaped up by a very tough system of postgraduate training.” But I had already made up my mind in the deep woods of southern Russia a couple of years prior to this.

Pathology residency was a natural path for me, since I already had had pathology training in Russia and was very much involved with research. Frankly, several times later on, I had second thoughts in the course of my training. I was afraid to become secondary in the medical system, not being in control, not having my own patients, making decisions, and dealing directly with people. I almost made the decision to leave pathology and sign up for an internal medicine residency at the VA Medical Center in Washington, D.C., where I had my rotations at that time. I was enrolled in the program at the George Washington University Medical Center and the VA Medical Center.

My first job in the US
was at the VA Medical Center:
Nights of the boxed breath
and the smell of stale piss;
chain-smokers, the collapsed lobes
overgrown by the relentless pink matter;
laryngless vets, talking in robot voices;
emaciated black guys in the men’s room,
puffing through the tracheostomy tubes;
a burn unit survivor
hit by a Kamikaze
at the very end.

The young, Jewish doctors
were rotating for a year or two,
running around with syringes,
dispensing chemotherapy, then
disappearing into the green sponge
of the suburban universe.

My way back to the newly rented home
was graced by a sunset that touched
crosses on the descending lawn
by the soldiers’ home, lit up
Rock Creek for a few minutes,
lingered pensively in the tree crowns
over the mansions at Connecticut Avenue,
then went underground somewhere
in Pennsylvania.

Around was the darkness,
punctuated by a dialogue
between the towers on the flagships:

The Naval Hospital and the Mormon Temple,
guiding the large cargo planes,
gliding through the black milk
of the night breath toward
Andrews Air Force Base.

But I stayed in pathology, and after years of becoming a very experienced cancer diagnostician, I never regretted this again. I also become a cytopathologist, performing a lot of fine needle aspirations on patients and have become an expert at this. Because of my clinical and research experience, I was approached several times by commercial medical companies to acquire a directorship and to run the medical branch of such a company. I always turned this down. I love the feeling of coming to the hospital in the morning, joking with technicians, nurses whom I know from my work in the OR (in my scrubs, doing frozen sections). The so-called “frozen section room” is right in the operating block, and surgeons often come by to look at the specimen, rub shoulders, to look into the microscope with us and make a decision together. This is what I enjoy. Pile of consults on my desk, each slide is somebody’s life (or death…) story. Sometimes patients come by to ask a question. People refer a lot of patients to me, with thyroid or breast masses to perform fine needle aspiration on, to advise, to help make a decision whether the patient should be operated on or not.

***

Over the years I realized that I created my own philosophy of what I was doing in medicine. A physician should have an idea of what he/she is doing. Not simply being good at what you do, making good money, and following your training and skills. So, despite the fact that I was very well-trained in regimens, protocols, policies, knowing closely all those magical terms and notions, I always had my own philosophy about my place in the process. As a diagnostic clinical pathologist, I have always felt that the main idea is to prevent any harm to the patient: By unnecessary surgery, excessive, broader operation; by hopeless chemotherapy, based on some approach, statistically prolonging the life of a patient from six months to seven and a half months; and a variety of unnecessary tests and sometimes dangerous procedures. The latter factors are directly related to the main disease of American medicine—its defensive malaise, attempt to protect from the devastating, humiliating, and demoralizing malpractice lawsuits, of which I myself have been a victim several times. As I mentioned before I am a breast specialist and a specialist in cancer diagnosis. One of the hardest memories of my medical career was being frivolously sued for a breast cancer case (I was completely cleared by the jury). An experienced, cynical, cold-blooded plaintiff’s attorney was accusing me of an attempted murder of a patient, who was sitting on a bench with her family nearby, the lawyer reading lines from John Donne: “For whom the bells tolls; it tolls for thee.”

***

At the beginning of the new millennium, I realized that my choice of diagnostic medicine (cancer diagnostic pathology) was even more unincidental than I had thought. I am talking about rapid development of molecular medicine, identification of abnormalities, diagnosis of diseases based not only on chemical tests of blood compounds or examination of patterns in the tissue, but on detecting molecular abnormalities germane to a certain condition or disease. This is a fascinating area of modern medicine related to dissecting nucleic acids in the tissue and the ability to actually visualize the changes (fluorescence in situ hybridization, immunocytochemical methods, and such). I remember my high school fascination with the gel formation by mixing two chemical substances, creating a new texture of the matter. “Metaphysically,” this is the same thing.

***

My father was a great surgeon, came to visit me once in the United States and was very warmly received by the American surgeons in my hospital (at the time, Lenox Hill Hospital in Manhattan) who knew his name and his innovations in stapling surgery. He died at the age of 73 in 1994 of a malignant brain tumor. I went to Moscow to be with my father when he was diagnosed and review, myself, the pathology specimens. It was still the same old Russia: Good, skillful surgeons, some very dedicated and kind nurses, few medications, horrible conditions. My father was an in-patient in the Neurosurgery Institute, a very prestigious, highly desirable institution. He was lying in a small bed, three other men in the same room, after craniotomy and brain surgery. Those were privileged people, some leaders and administrators from the provincial cities. Their wives came there to live with them in the same room since there were not enough nursing help and nurses’ aides. There was no place to stay in Moscow at the time, or they didn’t have enough money for that, so the wives slept, feet to head, in the same bed with their husbands, who were also recovering after craniotomy and brain surgery. I would bring my father, a few days after brain biopsy, to the communal toilet on the floor, with broken windows in the late fall, old newspapers instead of toilet paper, several diehard smokers with their heads bandaged, puffing heavy, unfiltered cigarettes.

My father had been buried in Moscow at the “German Cemetery” in the Lefortovo district of Moscow. This is an old neighborhood, established in the early 18th century at the time of Peter the Great by German craftsmen, builders, and military men invited by tsar to Russia. Later on it was the “cemetery of choice” for the upper layer of the Moscow society: Professors, military men and later by the Soviet upper middle class (the academic, artistic, and military elite). My grandfather, a hero of World War II, was buried there. So my father joined him. A year later, my grandmother. This place has become my real home in Moscow after so much changed in the central part of the city due to a distasteful excess of money, oil, and gas. Everything stays the same in this part of the world: The wrought iron gate, the overgrown paths, small mausoleums, little chapel. In June everything is covered by ever-flying fluff from everlasting Moscow poplars. It’s a summer snowfall all around the city, especially in this area because of the abundance of mature poplars. In June the place looks like it is covered by silent, heavy snowfall.

I almost knew by heart all those med-school books
piled on my chest: Hencke und Lubarsh, Abrikosoff,
the books filled with dust of the anatomy museums
still guarded by the infants floating in the liquid,
long-desired drink of our victorious infantry.
Then: Merck, Harrison, their principles as heavy
as the New England snow sheets.

We know a disease has its own time structure:
After the torpid phase—explosion at some point,
creating a palpable image that we have to study
and study until it’s hard to breathe.

Night opens all the books, and the gray wind turns the pages.
I studied them; I ate them
until my brain was turned
into a cracked stone with lengthy lines of convolutions.
Who would remember now all those stories of destruction,
the voyages of fever across the world’s ocean?
The Papatacci fever. Who would know?
I know you would.

You knew all the answers.
You wanted me to study in order
to survive this life.
It does not matter anymore.
What matters is that the air vanishes.
This very air that feeds the cells, their cytoplasm,
those wonderful, convex membranes, and to give the air of presence,
to project the gesture, to make us exclaim the words
when we are not asked, that is
our ethnic trait.

It’s getting closer, and I still can’t find
the subject in all those books.
Where is that page, this line in the subject matter,
that would classify the void,
this wide, black hole growing on me
as you grow smaller and smaller?

During periods of hardship in my life (my father’s death in Russia, mother’s stroke in New Jersey, two divorces [artists occupational hazard?], my daughter’s dramatic divorce from my younger friend-poet), medical work and coming to the hospital every morning helped. Habitual stress, hard routine, intellectual challenge, all this kept me going more than any psychiatrist, Prozac, and such. Putting on a clean shirt, tie, and white coat has been like a sacred moment of putting on the uniform and a weapon for a military officer.

My daughter, then an internal medicine intern at Columbia-Presbyterian in New York, stayed at my house after her dramatic exit from her husband’s madhouse, and I was with her, a fourth generation of physicians in the family—three at the First Moscow Medical School and her, graduate of the NYU Medical School. I thought, at the time, that if my grandparents, during their around-the-world trip, escaping the Civil War in Russia, did not decide to return to Moscow from the war-torn Odessa, my life would have been different. They could have relatively easily taken
the other direction, sail to New York, where my father would have been born and become who he was, a great surgeon in that great city. I (or whoever I would be) would become one of the fortunate doctor’s family children, probably going to NYU as well. I never regretted that my grandparents took that turn—to the North, not to the West. That gave birth to my bilingual, dual life. My poetry, probably, would have been very different and would not live its own life in intercultural, interlingual space between poetry and medicine, between rock and a hard place.

Many laypeople, even physicians, don’t understand that being a physician implies a certain type of thought process, an almost subconscious feeling of clinical situation. It’s like a police officer, a military man. You either are or are not. It’s a certain type of personality. Like a credit card with unique password—“not transferable.” The key part of being a pathologist is ability (or talent) of recognizing a pattern of abnormality. Same as a radiologist. A radiation oncologist uses radiation and does not cut anything. A doctor nutritionist or a psychiatrist look at some tests, talk to the patient and give recommendations. In all those situations a physician makes a diagnostic or treatment decision based on vast knowledge but, very importantly, on an inborn natural intuition, matured over the years of experience. When I discuss a breast cancer case with a surgeon, radiologist, or oncologist, I discuss actual circumstance of the case (history, clinical situation, possible consequences of treatment) as much as morphological diagnostic pattern visualized under the microscope.

Once, residents in pathology showed me a photo of a specimen: Extrauterine tubal pregnancy, with a formed embryo looking out from the opened tube, like an astronaut looking out of a small spaceship. I sensed a beauty in this picture, beauty of nature, similar to a beauty of trees (do they know how wonderful they are?), cats, etc. It is an aesthetic beauty of life. Being very much pro women’s rights, emancipation, and such, I did not realize how negatively and erroneously this poem would be understood at the poetry seminars and workshops.

The world was glistening inside my soft universe
in the filigreed web of warmth,
pulsating and feeding my unborn hopes,
tentacles of attachments, frustrations, death.

I could have been a father, a sister,
carpenter, savior, the judge, an executioner.
My actuarial survival
was not yet registered.
The winds of unknowing
caressed my mother’s skin.
And the pain was vanishing

because I did not exist anymore.
I was not accounted for.
And still, brothers and sisters,
we were bonded and floating together
in the shared hardship.
For only you could appreciate
My gift to you:
My silent grace, the gentle beauty, dignity,
and what I would not have done to the world.

And remember, there are others
for whom not only I,
but also you
are a mistake.

And this only confirmed my feeling of autonomy of poetry, art’s irrelevance to the specific historical and political circumstances and of artistic nature and beauty of medicine. The aesthetic and metaphysical sides of medicine have as much immediate relevance to some patient’s life (not just another case) and are what makes medicine a life’s choice.

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