Preface

“I, on my side, require of every writer, first or last, a simple and sincere account of his own life, and not merely what he has heard of other men's lives; some such account as he would send to his kindred from a distant land; for if he has lived sincerely, it must have been in a distant land to me.” HD Thoreau, Walden 18541

The American writer Henry David Thoreau was right. As my reader, you deserve a simple and sincere account of my life — from which these stories took shape. So here you have it. This book exists because I chose early on to follow my heart in two directions: medicine and philosophy, and now I hope to cut a path between them. This path is the art of medicine guided by wisdom – which is the fruit of philosophy, starting with empathy. I hope teaching the art of medicine  through short fiction will make the journey more enjoyable, for both a general audience and students alike; this book was written with every reader in mind.     

The Joy of Philosophy

While the art of medicine is improved through a study of philosophy, I must be honest: my desire to study philosophy did not stem from my calling to medicine. I simply hoped to blend a love for wisdom into my medical practice. And so with the ink not yet dry on my medical school acceptance letter, I requested a deferment to study ethics, the branch of philosophy most useful in medicine. This was an unusual request, and I am grateful to the University of Kentucky College of Medicine for honoring it. Twenty years on, it still seems inexplicable: the admissions committee voted with their hearts, blindly trusting a young man's enthusiasm. 

With this deferment secure in hand, I returned to Yale University, where I had spent the previous summer term taking a course called Ethics of the Human Genome. My enthusiasm for bioethics impressed the Associate Director of the Yale Bioethics Center, Carol Pollard, to whom this book is dedicated. Recognizing my eagerness to soak up the interdisciplinary environment at Yale, she offered me a dream job: coordinating workshops for a diverse faculty ranging from medicine, law, divinity, and the arts & sciences.  At that time, Yale was to bioethics what Paris was to writers and artists in the nineteen twenties: a place of infectious inspiration. 

Yale Bioethics instilled within me a profound respect for interdisciplinary study, and in her hallways I met life-long friends and mentors. Among them, I particularly admired physician and writer Dr. Howard Spiro, for whom I developed a deep respect — not just for his work but for his character; our friendship lasted until his death in 2012. He once told me, "Progress happens on the suture lines between disciplines." He was right, and I have sought to live on the suture line between medicine and philosophy ever since. In my mind, these two disciplines form an art, and this art is the subject of this book. Coming to Medicine is my contribution to the art of caring for patients.   

My friends and mentors at Yale further encouraged me, and the following year I completed a Master’s Degree at the London School of Economics in Philosophy of Public Policy∗. There, I learned to apply theoretical philosophy to real world problems, wrote a thesis arguing for children's right to healthcare, and fell in love with more old books, curled up in the wingback chairs of the Shaw Library on Houghton Street. Without question, these were decisive years of my life, because they frame the rest. 

Becoming a Doctor

Once back in medical school, I choose neurology as my specialty as naturally as I chose medicine and philosophy before it.   I then set out to complete my medical internship and neurology residencies at Vanderbilt University, where I trained rigorously and met the expectations of myself and the department. This effort prepared me to succeed as a neurologist specializing in stroke even without a formal fellowship, since I insisted on setting out early on my own, due to an uneasiness about my compounding loan burden from both medicine and philosophy. While I sometimes missed the camaraderie of academia, I also cherished the thrill of thinking on my own feet — as a stroke neurologist at Saint Thomas West Hospital in Nashville, where I spent the next two years working full time and also taking call for half the nights of the year. It was difficult work, but I met some fine people there. When an opportunity opened up to join a Comprehensive Stroke Center in beautiful East Tennessee — on the outdoor playground of Chattanooga, my heart moved ahead of me, and I merely joined it a few months later.  

It is there I have spent the last nine years, continuing my work as a neurologist with a specialization in stroke. I care for hospitalized and emergency room patients at Erlanger Baroness — a public teaching hospital with a storied history, founded by a French railroad baron in the 1880’s and named after his fiancée. It is Erlanger's mission to provide the highest level of stroke and trauma care regardless of ability to pay; her helicopters are a welcomed sight in Southern skies. I also teach Erlanger's medical students and residents, as assistant neurology professor at University of Tennessee College of Medicine. 

Reflecting On the Art of Medicine

This has been my academic and professional life to date. In my life more generally, to borrow wisdom from my favorite sport of mountain biking, I've made some mistakes for not looking far enough ahead, or around the corners, or from going too fast. As they say, "that's life." Perhaps it is. But don't expect me not to reflect on it. This is the joy of philosophy and increasingly for me, the joy of medicine. 

I have aimed to reflect deeply on life in medicine, and in the words of the American writer Henry David Thoreau: 

cut a broad swath and shave close, to drive life into a corner, and reduce it to its lowest terms, and, if it proved to be mean, why then to get the whole and genuine meanness of it, and publish its meanness to the world; or if it were sublime, to know it by experience…2

Well over the years I have discovered a predictable truth: the practice  of medicine is not wholly mean or wholly sublime. But when it is mean it is often vicious. And when it is sublime it is often euphoric. Medicine is therefore a lively theater for taking observations.      

I have served over ten years as a hospital-based neurologist, treating stroke and other neurological emergencies in some of the sickest patients, from ER to intensive care. So why do I prefer to write fiction instead of sharing true stories?  Because patients deserve privacy. And because through fiction I can bring the inner life of the patient to the reader: whereas I can only guess what my real patients are thinking, I know my characters’ thoughts. In this way, fiction is more honest. 

While none of the patients in my stories are based on real people, you can expect autobiographical elements in some of my stories; these are unavoidable, and they add to the authenticity of my work. A single story, A Granddad’s Final Heroic Act, is a work of nonfiction. This story is about man who cared for his wife during the pandemic; it’s titled A Granddad and not A Husband, because it was me, his grandson, who watched his moral progress with such admiration.  The rest of the stories are fictional — blending my most salient clinical experiences into universal truth. On what I have not carefully observed or personally experienced, I promise to remain silent. 

I truly believe that fiction, done well, is the most powerful medium for sharing the art of medicine. And to ensure I did it well, I took a night class on writing short fiction through Harvard University. I like to think my commitment to honesty and brevity follows in the steps of  Thoreau  — an early 19th century Harvard graduate. As Thoreau penned beautifully in the opening chapter of his book Walden:

To be a philosopher is not merely to have subtle thoughts, nor even to found a school, but so to love wisdom as to live according to its dictates, a life of simplicity, independence, magnanimity, and trust. It is to solve some of the problems of life, not only theoretically, but practically.  

We can trust Thoreau because he crafted his philosophy from direct experience, living in solitude in a cabin in the woods. In Coming to Medicine, I sought to do the same. My medical practice is my woods — so rich with direct experience, and my philosophy is distilled into this collection of stories. 

In each story, I aim to teach a lesson in the art of medicine. My intent is to give you only the freshest wisdom — straight from the bedside of patients and free of jargon.     

May I now present to you Coming to Medicine, a collection of stories born of patient, provider, and caregiver experiences. I read each story draft aloud and made corrections until they sounded a little more poetic. The right words are useful. But they are also beautiful — which in art is the same thing. Medicine, despite the ambitions of an adolescent science, remains an art.  

So, whether you are facing illness, know someone who is, or simply curious about our shared humanity, I hope you will find something useful and beautiful here. Trust your heart the rest of the way: a little cliché perhaps, but one we shall let stand.

James Fleming, MD, MSc

Chattanooga, TN

∗ Master’s degree program was initially called Philosophy, Policy, & Social Value, but, in subsequent years, it was changed to Philosophy of Public Policy for clarity.

1. Thoreau, Henry David. Walden: or, Life in the Woods, 1854. Ticknor & Fields of Boston. 

2. Thoreau, Henry David. Walden: or, Life in the Woods, 1854. Ticknor & Fields of Boston.