by JAMES C. SALWITZ, MD on November 4th, 2012, PHYSICIAN
In his brilliant 1993 satire Et Tu, Babe, Mark Leyner proposed a new concept in body art, which is the specialty of visceral tattoos. The narrator travels to Mexico where his chest is opened and the insignia of a guy surfing a wave of lava, wearing polka-dotted trunks, is tattooed directly on his heart. The dye used shows up on CT scans and apparently women, especially x-ray technicians, love it. Superficially, a jest at those who indelibly paint their skin, Leynors parody is an allegory to the brutal invasiveness of healthcare. Going even further, we must understand that medicine often causes deep injury beyond that of the flesh. That injury is a tattoo of the mind.
When someone is treated for disease, their body is invaded. We open someones chest and replumb the vessels of the heart, remove and rebuild a breast, reconstruct a larynx, open the skull to remove a cancer, resect and reconnect inflamed bowel or simply use a scope to repair a knee. With these procedures, a person is healed, fixed and often cured. They are whole and pure again. Perhaps
but what about the mind?
Any invasion of the body that scars bone, muscle, and vessel, also scars the mind. An imprint on the spirit if you will, changing us at the deepest level. The psychological damage may be slight, just a little irritation, to be tucked away and never again considered. Sometimes the cut is so deep, so profound, that the person becomes forever a patient transformed, always wounded. The emotional ghost of the invasive act is a complex visceral picture stamped on conscious and unconscious mind, like the residual image of a brilliant flash bulb to the eye.
How can we predict how deep a wound may become, and how much it may transform? Is it the person or the act? It was just a minor procedure, a one day stay in the hospital, not really much pain, rapid recovery, she was back to work in two weeks, but somehow the wound buries deep into the core of a mind changed forever, a deep pain that never heals. Stage 1 melanoma
take out the ovaries
a near lethal aneurism
no big deal
Such transformative wounds humiliate and confuse. How do you tell those that you love that though you are cured you are still in pain? How does one say, I am different. Should you not just be happy to be alive, and healthy? It is time to enjoy life and get back to the day-to-day! The world knows that you are well. Why does it not feel that way?
I have a patient who is born again healthy. His diverticulitis was treated with two surgeries, heart disease bypassed, prostate cancer in remission, hip replaced, cataracts removed, laryngeal polyps gone, hypertension controlled, hearing aids fitted and ulcers healed. He is perfect and has a fine prognosis. Nonetheless, he is a shell of the man who raised children, built a career, reveled in sunsets and deeply loved his wife. A posttraumatic skeleton. Empty, depressed, nervous
the surgeons brand burned into his mind.
The critical lesson for doctors is the deep psychic effects of even successful therapy. Physicians must be aware that we invade not just the body, but also the psyche, leaving behind transformative images of pain, humiliation, and fear. This means choosing therapies carefully, educating well and giving care gently. It requires engaging with each patient after it is over to help him or her reconnect and heal. It means being aware that very long after the procedure, the invasion, wisps of suffering remain deep inside.
As family and friends of patients, we must also remember that healed and Healed are not the same thing. Just because the body is better, does not mean that the mind has followed. We need empathetic support and understanding long after the crisis has past. New trauma or stress can release demons, and we must all be aware and sensitive, for yesterdays surgery is tomorrows pain.
Finally, as patients we must understand we have been changed. There is something brutal about invasive medical care, which may affect us deeply. We must be gentle with ourselves and realize healing is more than tissue deep. Healing is of the mind, and may in part take a lifetime. A wound hard to expect, a sore slow to mend. If we are not cautious, it can change our soul. A tattoo on the brain.
James C. Salwitz is an oncologist who blogs at Sunrise Rounds.