Tolstoy, Chekhov, and self-knowledge – portrayals of illness in novels – Editorial
Many physicians are familiar with The Death of Ivan Ilych, Leo Tolstoy’s short novel about a successful lawyer who contracts a mysterious disease. During the course of his illness, Ivan experiences great physical, psychological, and spiritual suffering. Doctors, friends, and family fail him. Only his valet, Gerasim, understands Ivan and provides the care he needs. Medical educators hope that reading this story will impel medical students and doctors to be more compassionate. However, the story may have greatest value for those physicians who recognize Ivan in themselves — physicians consumed with making a living, publishing research, or climbing the academic ladder without closely examining where they are going or what they are sacrificing to get there. Not until the end of his life does Ivan learn that excessive devotion to his career is empty and ultimately unfulfilling.
Anton Chekhov’s Nicholas Stepanovich (A Dreary Story) never learns the lesson. He is a renowned professor of medicine who has published widely and is respected by all his peers. When he becomes terminally ill, his life loses focus and meaning. Self-absorption prevents him from helping the person who needs him most — his adopted daughter, Katya.
Reading these stories may move physicians to reexamine the professional and personal lives they lead.
Ivan Ilych is a prosperous lawyer and government official who tries to live his life in a proper way. According to Ivan, to live properly is to live according to the standards and opinions of those in his social and professional circles. “He considered his duty to be what was so considered by those in authority. Neither as a boy nor as a man was he a toady, but from early youth was by nature attracted to people of high station as a fly is drawn to the light, assimilating their ways and views of life and establishing friendly relations with them.” Challenging professional conventions is anathema to Ivan.
Ivan enjoys the power that high governmental positions bring. He works hard to advance his career. When his wife makes increasing demands on him and a new baby disturbs his peace at home, Ivan devotes more time and energy to his work. Relations with his wife become strident.
Ivan’s comfortable life falls apart when he develops a mysterious illness. He first notices a “queer taste in his mouth.” He then experiences great pain in his left flank. Narcotics do not ease the pain. Work and cards no longer distract him from his problems and pain. Illness makes it impossible for him to go on with life as usual.
Like Tolstoy’s Ivan, Chekhov’s Nicholas achieves professional success. He climbs to the top of the academic ladder. He is widely respected by his peers. He takes great pride in his work and accomplishments. When he becomes ill, he realizes that he does not know how to live his life. Phrases like “know thyself” and “follow the golden rule” are meaningless to him. He alienates his family. When his adopted daughter seeks his counsel, he is at a loss to help her.
Ivan and Nicholas are similar in many respects. Both men are excessively concerned about advancing their own careers. Neither man has personal insight into how his career affects the lives of his family. In other words, both lack self-knowledge. They do not critically look at their lives or wonder whether there is another way to live — until they become ill. Illness and the possibility of death awaken them to the fact that they are ignorant about themselves and that they may not have lived the best kind of life. Nicholas never finds a way out of the hole of self-absorption. Ivan gets help from his son and valet.
Physicians can learn many things about themselves from reading these stories. First, they can learn from others’ mistakes. As noted above, Ivan and Nicholas sacrifice much to attain their success. Their attention to themselves and their careers isolates them from loved ones. Physicians are particularly prone to this isolation. Medicine makes great demands on one’s time and energy. It is easy to lose oneself in work in order to avoid other responsibilities (ie, at home). Physicians who read these stories may truly see the consequences of devoting excessive time and energy to further their careers. They see the consequences of blindly accepting the conventions of society or their professions. When physicians vicariously experience the consequences along with the characters in the story, they may be moved to reexamine their present commitments and interests. To put it another way, stories such as The Death of Ivan Ilych and A Dreary Story offer readers the possibility of experiencing characters who resemble themselves in their faults, foibles, and humanity. When this happens, the reader’s education begins. How is my life like Ivan or Nicholas? Am I making the same mistakes as these men? What can I do to avoid the mistakes they made?
Physicians also learn the importance of examining the kind of life they lead before illness and death occur. If Ivan and Nicholas had truly understood that death is always near for all human beings, they may have chosen to live their lives differently. Some may say that physicians do not need to read these stories. They are awakened to the possibility of death every day on rounds. Or are they? They are certainly exposed to much suffering, but they are not necessarily awakened to the fact of their own eventual death. On the contrary, physicians steel themselves against the idea of their own death in order to remain objective and dispassionate; in order to treat their patients with a clear mind and steady hand. Yet a certain degree of identification with the patient is necessary for the development of empathy and compassion. Without them, true healing is very difficult, if not impossible.
The self-knowledge gained from reading such stories also benefits the physician’s patients. Physicians who are comfortable with the knowledge of their own death are more likely to be comfortable talking to patients about death. They can use this knowledge to help patients ask and answer questions such as: what’s really important in my life? How should I spend my energy and time before I die? How do I wish to die? Honest and open discussion about death with a knowledgeable and trusting physician will go a long way toward easing the present difficulties many patients experience at the end of their lives.
Not every physician will benefit from reading about Ivan or Nicholas. Some will not see themselves in these men. They will read the words of Ivan, and believe them: “Caius is a man, men are mortal, therefore Caius is mortal’ had always seemed to him correct as applied to Caius but certainly not as applied to himself… Caius really was mortal, and it was right for him to die; but for me, Little Vanya, Ivan Ilych, with all my thoughts and emotions, it’s altogether a different matter. It cannot be that I ought to die. That would be too terrible.” In other words, some are unable to empathize with Ivan. They are unable to imagine that they could be in his predicament. Others may empathize, but shudder when they find themselves in the imaginary shoes. The pain and suffering are too great.
As colleagues or educators, we can do several things for these physicians. First, we can offer how these stories change the way we lead our own lives. Second, we can show them how these stories enhance our ability to move back and forth between empathic and detached perspectives — an essential skill for true healers. Convincing physicians of the value of empathy may encourage them to develop it.
Physicians are usually not encouraged to critically examine the kind of professional and personal lives they lead. However, without self-reflection, physicians may find themselves living lives that resemble Ivan Ilych and Nicholas Stepanovich. Reading The Death of Ivan Ilych and A Dreary Story may move physicians to reexamine their lives. Such examination may positively change the way they live their lives, and the way they care for patients.
References Tolstoy L. The death of Ivan Ilych and other stories. New York: The New American Library, Inc, Signet Classics, 1960; 95-156  Chekhov A. Chekhov seven stories. Oxford: Oxford University Press, 1974; 92-142  Gianakos D. Empathy revisited. Arch Intern Med 1996; 156:135-37
COPYRIGHT 1997 American College of Chest Physicians
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