Winter, 2005
"Ward No. 6" in Chekhov's Doctors: A Collection of Chekhov's
Medical Tales
Jack Coulehan, MD, Editor
(Kent State University Press, 2003)
Jack Coulehan, MD, MPH
Department of Preventive Medicine
State University of New York at Stony Brook
When Anton Chekhov graduated from the University of Moscow Medical School in 1884, he had a decision to make. During the previous four years, the young man had supported himself and his family by writing humorous sketches and stories for Moscow weekly magazines. By that time Chekhov was so well regarded as a writer - at least 150 published pieces - his editors clamored for more. Why waste his time practicing medicine? Nevertheless, the newly minted Dr. Chekhov hung up his shingle and for the next five years or so practiced primary care medicine.
But he managed to avoid that either-or decision. At night and on weekends, he wrote as much as ever, publishing an additional 190 stories before 1890 and, along the way, winning the Pushkin Prize, the Russian equivalent of America's Pulitzer, by the age of 28. As Chekhov's fame grew, he closed his urban practice and moved to the country, where he continued to work as a district doctor and public health officer until incapacitated by tuberculosis in 1897. For example, in less than five months in 1891, Chekhov reported seeing 453 patients at a district clinic and making 576 house calls. He also busied himself with grassroots activism, building schools for peasants, raising money for famine victims and, most famously, exposing inhuman living conditions in the czarist prison colonies on Sakhalin Island.
Chekhov always maintained that medicine was his lawful wife and literature, his mistress: "When one gets on my nerves, I spend the night with the other." But in reality, he never kept them separate; his professions interacted and enhanced each other, especially the influence of medicine on chekhov's plays and stories. Obviously, one such influence was the author's deep insight into the medical life, which he conveyed in his numerous stories about physicians. Chekhov's doctors range from callow medical students to obnoxious, insensitive practitioners and from courageous public health workers to beloved village physicians. However, some of his most fascinating creations are the physician characters who suffer from disappointment, ennui or burnout.
"Ward No. 6," a long story published in 1892, is a masterpiece of burnout. The protagonist is Dr. Ragin, the withdrawn and depressed director of a district hospital. He had arrived at the job 20 years earlier, as an energetic young doctor: "At first Dr. Ragin worked very hard. He received patients every day from morning to dinnertime, performed operations, and even did a certain amount of midwifery..." But over the years, his energy has dissipated. He now realizes how poorly equipped and out-of-date his hospital is. He professes the "palpable futility" of medical practice, because social and economic forces beyond medicine's control determine health and disease. thus, Ragin has retreated into a shell, detached not only from his patients, but also from all human contact. While a junior doctor actually takes care of the hospital patients and runs the clinic, Ragin spends his days sitting in his study and drinking beer.
While heavy demands and poor working conditions contribute to Ragin's predicament, he faces a deeper problem as well. Is his sense of futility solely a consequence of medical practice? Or is something deeper
missing? Ragin comes across to us as unreflective, apparently having suppressed his emotional life and replaced it with a set of abstract beliefs. Ragin's lack of self-knowledge has crystallized around a profound sense of emotional
numbness. When he was younger, he evidently meant well and worked toward his professional ideals, but the commitment was superficial. In the long run, he never learned to look beyond the accumulation of day-to-day disappointments to
find satisfaction in meaningful relationships with his patients and others.
Early in the story, Ragin visits the mental ward (Ward No. 6), where he meets Ivan Gromov, a brilliant paranoid who embraces life passionately. The passion attracts Ragin like a moth to a candle. Ragin yearns to feel something, anything, even to experience suffering, rather than to remain suspended in his emotionless cocoon. He develops an obsession that only by making himself suffer will he be able to experience an emotional life and, therefore, be truly human. Predictably, this new obsession makes him even more dysfunctional, a situation that allows the junior doctor to have him fired as hospital director and, ultimately, committed to Ward No. 6 as mentally ill. once Ragin becomes a "nobody," his isolating cocoon disappears. The ward orderly hits him when he tries to escape, thereby giving Ragin an opportunity to suffer. Shortly thereafter, he has a stroke and dies.
A dismal story, perhaps, but full of psychological insight. Many health care professionals become vulnerable to depression and burnout, because we lack the inner resources to cope, day in and day out, year after year, with our difficult work. We learn during professional school and postgraduate training to distance ourselves emotionally from the situation at hand, to be "objective" and exhibit "detached concern" (an oxymoron, if you think about it). Too often, we learn the "detached" part very well, by suppressing our feelings and avoiding self-reflection. But we often tend to intellectualize the "concern" part, so that caring becomes a series of concepts and procedures, rather than a compassionate presence for the patient.
In medical education you frequently hear repeated Dr. Francis Peabody's famous one-liner: "...for the secret of the care of the patient is in caring for the patient." While this is true as far as it goes, a further
step is necessary as well: the secret of caring for the patient is to develop selfawareness; that is, caring first for oneself. Dr. Ragin's plight is extreme, but the dynamics that led him eventually to withdraw from practice may threaten any health care professional who works so hard at detachment from patients that he or she also becomes detached from his or her own emotional life. "Ward No. 6" serves as fair warning of what can happen if we totally ignore the dictum, "Physician, heal thyself!"
in collaboration with
Dartmouth-Hitchcock Medical Center
The opinions expressed in the journal, Lahey Clinic Medical Ethics,
belong to the individual contributors and do not represent the institutional position
of Lahey Clinic on any subject matters discussed.
