Doctors, Mothers And Daughters, Death and Caring, Writing

This essay is also available at: https://medium.com/@buddshenkin/mothers-and-daughters-doctors-and-death-4be81ebf460f This isn’t a confession of matricide, but technically speaking, I did kill my mom. Both JAMA and the New England Journal of Medicine have one 1,200 word personal essay per issue. I used to avoid them. I thought, probably unfairly, that they were written by stuffy older men dispensing what they considered their wisdom, as some of my self-satisfied Harvard Medical School (HMS) teachers used to do. I think that opinion said more about me than it did about them. It also reflected the press of time and the relentless appearance of the journals in the mail every week. You took the journals in the hope that you wouldn't miss important things. You also hoped that each issue had nothing important so you could accomplish your self-assigned task expeditiously and just discard it – triaging limited time. But that has changed. I still hope for articles without interest so I can clear the kitchen table more easily. Accomplishing tasks quickly will probably be a life-constant until I die – well, that's hopeful, isn't it? Still functional until the very end? Here's hoping. But now, instead of dismissing the essay, I look forward to them. I know that I have changed, but have the articles changed? Maybe. For one thing, a lot of them are now written by women. Women in medicine! Thank God for the women in medicine! Like it or not, women write differently from men, because like it or not, women are different from men. Talk about adding needed balance. Every patient should have a choice between a woman or a man for their doctor, because they're just different, not all the time, but lots of times. And we medical readers should have the same choice. So in this current NEJM issue, Stanford woman neurologist and palliative care researcher , Hannah Kirsch, writes about killing her mother. See My Mother's Choices – https://www.nejm.org/doi/full/10.1056/NEJMp2410639. She a hell of a writer, this one. So many of the 1,200 words writers now are really good – the liberal arts persist in medicine. Good words, punchy, each sentence counts. Great introductory sentence: This isn’t a confession of matricide, but technically speaking, I did kill my mom. Men can and do write like that, of course, and sensibilities are not segregated by sex. But one thing is segregated by sex. That thing is the relationship between mother and daughter. There's just something about that relationship that's different. I read two books in the last couple of years that if you haven't read, you should, especially since they're not only great, they're short. One is Annie Ernaux's remembrance of her mother on the occasion of her death, A Woman's Story. She is raised by her ambitious mother in the working class of Yvetot, Normandy. Annie replaces a sister who died at age six. What is the effect of replacement? We don't know, but it affects all of them. We'll try again. They're trying again with me. Most of us carry the burden of expectations, they propel us forward, they give us a sense of mission that comes not just from us. I titled the book that one of my characters wrote in my unpublishable French novel, “Amour, Cadeau ou Fardeau ?” Love, gift or burden? My character, Juliette, means it in romantic love, but clearly, that's not the only love nor the only gift nor the only burden. Annie turns out to be very, very smart, and grows up to write books I love, books of genius, books worthy of the 2022 Nobel Prize for literature. But along the way, inevitably, her growth and excellence, fueled by her mother, draws her away from her mother. Her sensibilities change. Her social class changes. Her interests widen. Her conversation is at a higher level. Annie is bored at the narrow working class conversation around the family table when she returns from Rouen or other place of residence. It is the gulf her mother hopes for and then suffers from. Annie is dutiful. After her father dies and Annie is living in eastern France, her mother comes to live with her and her husband and her two sons. Grandmother takes care of the grandsons, meets some people, and it is one of the happiest times of her life, maybe her happiest time. When Annie moves to an anonymous Paris suburb around the Boulevard Périphérique, known as the Périph, that time is over. There are no friends to make here. So her mother moves away, back to Yvetot I think, and then she dies of Alzheimer's, and Annie reevaluates the long course of mother-daughter love. The closeness, the identification, the irritations, the impatience, the guilt, the duties, the rupture. Growing up. Love is such a mixture of contending feelings sometimes. Father and sons have it, sure, but not like mothers and daughters, I think. The other book you have to read is Simone de Beauvoir's A Very Easy Death, another short book that is easily read. “Easy Death” is what someone says in all sincerity after her mom dies, but after what we've read, we understand it as an ironic title. I've come to think – is any death “easy?” Simone gets more of her ambition from her rather unsuccessful father, I think, and from her inborn indomitable will – as a toddler she lies on her back on the floor and screams from frustration and no one can stop her – than from her very religious mother who easily accepts her place in a man's bourgeois world. When Simone loses her faith, she becomes a lost soul to her mother's anguish. When she grows into her life as perhaps the most notable woman of the 20th century – I think I love Simone – I think her mother gradually accepts her new status, but the bitterness of the gulf remains. I have to read the second volume of her memoir to really know what happened to them, but the first volume is striking and even lacerating. It must be hard to talk when you come to such different stations in life. But then her mother gets cancer and is going to die, and gradually does just that, Simone and her younger sister Poupette tending to her together. A dying mother, a mother who raised you, who you were so close to, who facilitated your rise in life, and who you left behind perhaps bitterly, who pissed you off, but a relationship of love you can't leave behind, it just sneaks around another corner. Her mother is not told she has terminal cancer, the doctors won't listen to slowing down their fruitless pursuit of cure, but then she must accept it even if unspoken. She sits in bed with one arm around Poupette and one arm around Simone and she says, “My girls. That's all I really want, my girls.” And I cry. So now we have women in medicine, and they can write about their mothers. I heard about this one incident from a friend who hasn't written about it. A woman doctor friend of mine at HMS lost her mother last year to cancer. As her mother got sick, she needed tending to back home in the Southwest.. Their relationship had been fraught, especially as her mom had divorced and become a single mom with all the intimacy with a daughter that that can entail. Do you drop everything to tend to a mother with whom you have had a tenuous relationship? My friend did; she took leave and went back and tend to her mom, she was glad she did, but it was never easy. But she did what a daughter has to do. I'm not sure it brought resolution to their relationship; I suspect it didn't. But she did what was right, and I'm sure she did it with great compassion, because that's who she is. Hannah's relationship with her mother was similarly fraught, and as part of her reflection, not to say resolution, she writes about the death by assisted suicide, movingly and beautifully. As for all of us who are doctors, when our parents or our wives or our husbands die, we are both daughters and doctors, husbands and doctors, and sometimes we are parents and doctors. Our HMS classmate Gerry Rogell presented us, his HMS classmates, just recently, this very same ambiguity and dilemma when his wife was ill with Covid. We are sons and daughters and husbands wives with special powers. As doctors we struggle with how close to get with our patients, how close we can afford to get, how apart we need to stay. We struggle each in our own way. I wonder if the special power, knowledge, makes it easier or harder. I think it made it easier for me when my wife was sick and dying – I was oriented to the field, and I did adapt to being instructed and leaning on caregivers and nurses, because as a pediatrician, we could all accept that I knew things as a doctor but didn't know things as a child's doctor. In my friend Gerry's case, it was a little harder, because he had to decide whether or not to press for a medical course that he thought might be indicated, and didn't know at that point whether to act as a doctor or a husband, and was tortured by that choice. But in Hannah's case, dealing with a difficult mother with strong independence needs, just like Annie and Simone and Gerry, was it easier or harder? Actually, it seems to me that it was easier. She knew medical expectations. She knew endpoints. She had seen many courses that patients had taken. She could navigate the mother-daughter relationship with that information giving her perspective. As a doctor she knew how to talk, so instead of rejecting her mother's request instantly as impossible, she takes a minute and says, “What makes you ask that now?” And she continues, until the end, when her mother chooses not to surrender to decay but to choose herself when and how to go, and Hannah mixes the deadly elixir and gives it to her mother to drink. I never let her, or any of the other people at her deathbed, perceive what roiled between my agonized detachment. I wanted someone else to be in charge, even though I couldn't let go of the iron control of the 'primary caregiver.' I wanted to inhale the dregs of the mixture in the hope of sleeping, not forever, but long enough to resolve the conflict between my personal desires and my professional commitment. I wanted to curl up in her lap, just the two of us in the room, and weep, begging her not to do this, telling her that I need her to tell me I'm her special girl, that I'm scared and need my mom. And I cry. Maybe you see why I'm not skipping the little personal essays anymore. Budd Shenkin