By John Shea
The poem, simply titled “Journey,” begins quietly: “Sixteen blocks to the hospital from home / at 47th and Pine.” As someone who has lived and worked in West Philadelphia – and who even had an apartment at 47th and Pine streets for a couple of years – I was immediately hooked. But no doubt there are other cities that have such numbered and named streets. A few lines later, however, another tip appeared: “44th and Spruce.” This was going to prove a journey within a city, then. When the narrator arrives at 34th Street, however, it is clear that Jack Coulehan, M.D., G.M.E. ’70, M.P.H., is writing about Philadelphia and his daily walk to HUP. And what a journey it is, full of surprising and sometimes amusing juxtapositions. In the poet’s imagination, yaks clang in the Himalayan mountains of Bhutan, while he dismisses from his mind a “Chevy Impala on concrete blocks.” The reader also encounters the rivers of exotic Sarawak, a Malaysian state thousands of miles away, as the walker does his best to ignore dog turds on the city street. Finally, he arrives at the “lair” of the “wolves of compassion,” apparently the HUP physicians. The narrator is not yet a full-fledged member of this pack but is, instead, “an adopted son.”
More than a touch of ambivalence and uncertainty on this early morning walk: “my mind blocks the reality of row houses, muffler shops, / and work.” At the same time, his imagination seems boundless.
“Journey” was published in the December 1, 2015, issue of JAMA. Coming upon it, I recognized the poet’s name at once. In fact, I had covered a visit Coulehan made to the Penn campus many years after his time here as an intern (Penn Medicine, Summer 2006). He was part of a group of distinguished guests who spoke to medical students and faculty on the vital topic of professionalism. Back then, Coulehan was a professor of preventive medicine at the State University of New York at Stony Brook, where he served as director of the Institute for Medicine in Contemporary Society. At Stony Brook, he also directed the medical school’s required four-year curriculum in ethics and social issues in medicine. A co-author of The Medical Interview: Mastering Skills for Clinical Practice (5th edition, 2006), he had also received the Humanities Award of the American Academy of Hospice and Palliative Medicine.
At the Penn symposium, Coulehan noted that many students enter medical school determined to be activists and “complete physicians.” In the course of their four years of study, however, some become cynical as they recognize a disparity between the school’s explicit curriculum and what he called “the informal curriculum” and what others have called “the hidden curriculum,” the influences exerted by an organizational culture. Some students continue to believe that “the patient comes first,” but they remain somewhat detached from the patient. One of the ways to foster professionalism, Coulehan suggested, was for medical schools to include more role models in their clinical departments who would “demonstrate the qualities we want to inculcate.”
At that time, I did not realize that Coulehan was also a poet who often used his experiences as a physician in his writing. Looking back, I find another of his suggestions for fostering professionalism especially relevant: to teach students to make use of “narrative,” not in the patients’ charts but “in our minds, in our relationships.” It seems a small step to a different kind of creative writing that can also be a way of making deeper personal connections – poetry.
In a lecture Coulehan gave at a plenary session of the American College of Physicians meeting in 2012, he summarized his beliefs about the connections between medicine and poetry. One of his patients many years earlier at a community health center in Pittsburgh was a “chronically dissatisfied” woman who made it clear that “I was too young to know what the hell I was doing.” But one day she – “Celia” – appeared at the office wearing a white lace dress and presented Coulehan with a potted plant, which she called “an act of Christian love.” Coulehan was stunned – and moved. Later, he wrote a poem called “The Act of Love,” using the language of poetry “as a lens through which to glimpse the deeper meaning of my work as a doctor and my relationship with Celia.” Somehow he felt himself become more connected to her.
As he put it, “So when I speak of the poetry of medicine, I’m not suggesting that all doctors should sit down and write poetry, or even read it; rather, I’m talking about paying close attention to those ‘aha!’ moments that are available to us and can sustain us, as well as making us better able to heal our patients, if we respond appropriately to them.”
It was this spring, when I got in touch with Coulehan, that I discovered he had trained in internal medicine at HUP. In addition, he has written several poems based on his time at Penn. Six appeared in his most recent collection, Bursting with Danger and Music (Plain View Press, 2012). “Journey” and another poem inspired by his Penn internship, “The Secret of the Care,” will be included in his new book, The Wound Dresser (J. B. Stillwater), appearing this year. The “internship” poems are situated in a world of conflicting value systems, conflicting duties, and long, exhausting hours. In “The Secret of the Care,” he describes himself as wearing “vestments to clinic – / pressed white pants, crisp shirt, and jacket, symbols of purity.” At the same time, however, he is “disguising the depth of my doubt” as he hoped to “grow in wisdom.”
Reviewing Bursting with Danger and Music, Martin Kohn, Ph.D., director of Medical Humanities at Cleveland Clinic, calls Coulehan “a giant in our field” as a clinician, teacher, and scholar. “Jack’s poetry brings us home – to deeper meaning, to compassion, to the struggle to remain human as one cares for suffering humanity” (Journal of Medical Humanities, 20 December 2012).
To read Dr. Coulehan’s “Journey” in full, please access it at the JAMA site. Copyright ©2015 American Medical Association. All rights reserved.
Given Coulehan’s artistically expressed concern and compassion for the patient, it is not surprising that he has also tackled another topic that sometimes appears lacking in relationships between physician and patient: humility. In addressing the Perelman School’s Class of 2011 during its graduation ceremony, Arthur Rubenstein, M.B., B.Ch., quoted from an article Coulehan had published on the subject earlier that year in Perspectives in Biology and Medicine. It was the last Perelman class that Rubenstein would address before stepping down as dean. As the students prepared to advance to the next stage of their professional lives, he wanted to emphasize this often overlooked characteristic. Humility is essential, he said, especially when doctors today “often seem superconfident, assertive, and impatient” with those they are treating.
In his article, Coulehan does not mince words: “Nowadays, humility is hardly a valued ideal. The words ‘good physician’ call up an image of confidence, technical skill, and assertiveness, a cluster of characteristics that seems inconsistent with humility. . . . In today’s medical culture, humility appears weak, wishy-washy, counterproductive, or even deceptive (as in the case of ‘false modesty’).” In contrast, Coulehan associates humility with other traits he believes are necessary for the profession, such as an awareness of one’s limitations; avoidance of arrogance; honesty, especially about mistakes; and the ability to maintain inner balance and to modulate self-interest. It also seems to follow that being so open to patients, circumstances, and experiences would help a writer of poems or narratives.
Today, Coulehan is emeritus professor of preventive medicine and senior fellow of the Center for Medical Humanities, Compassionate Care, and Bioethics at Stony Brook University. In 2012 he received the Nicholas E. Davies Memorial Scholar Award from the American College of Physicians for “outstanding contributions to humanism in medicine.”
Looking Back at “Journey” — Jack Coulehan, M.D., Puts His Poem in Context
In late June 1969, I arrived to begin my internship at the Hospital of the University of Pennsylvania (HUP). Although intimidated by HUP’s high-powered reputation, I was also gratified that Penn’s internal medicine residency program had selected me. At Orientation the Chief assured us that we were the chosen few. Someday we would become leaders of American medicine. Meanwhile, we had to work our asses off. I soon discovered my duties were all-consuming to an extent that I hadn’t anticipated. The endless cycle of admissions, rounds, procedures, emergencies, and conferences allowed me to spend little time actually talking with patients. I seemed to be out of sync with the prevailing ethos, which was academic and research oriented. My body managed to keep up, but my enthusiasm lagged far behind. Is an intern supposed to be so ambivalent about his work? I asked myself. I must not be cut out for medicine.
Though in reality only sixteen city blocks, the distance from my wife and baby daughter at home on Pine Street to the wards at HUP seemed almost like crossing a continent. Each morning I’d make that journey by foot, keeping an eye on the pre-dawn city, but allowing my mind to roam through an exotic world of high adventure. My job was intense and highly focused. Evenings at home were consumed by the demands of a colicky baby and a wife grieving her father’s recent death. But on that trek, my troubles disappeared, anxieties dissolved.
For some inexplicable reason, the hospital library included a collection of brightly illustrated travel books. I’d often borrow one and fantasize about visiting Paraguay, Cambodia, or Mozambique, especially on my daily walk to HUP. In this particular “Journey,” imagination carries me to a high pass in the Himalayas and to a jungle in Sarawak. Mostly, it carries me to freedom. Ah, freedom!
As I approach HUP, the narrative (“voiceover”) changes from escapist fantasies to a fantastic version of the hospital itself, “where wolves of compassion roam.” Why wolves? Because they’re determined, aggressive, clannish animals, just as I perceived my colleagues and attending physicians, who were nonetheless dedicated to healing, the work of compassion. In the poem I feel out of place. I’m not born to this pack. My sensibilities are slower, softer, more personal. Yet I need to
put away “geographies” and prepare to take out my “stacks of patterns” and “procedures” – in other words, to get to work. Though not indigenous, I’ve been adopted into this wolf pack. Perhaps “precious thimblefuls of love” will help me accomplish my hundreds of daily tasks.
In retrospect, internship was one of the great adventures of my life, certainly more meaningful than the exotic journeys that I daydreamed. The mystery of human illness, suffering, and healing confronted me every day. Ironically, the sidewalk in West Philly did, in fact, carry me to a new world, where, despite anger, ambivalence, and the numbing fatigue of working 80 or more hours per week, I learned to be a doctor.
But I wouldn’t want to do it again.