Sherwin Nuland has lived in the presence of death all his life. It is only in his recent years that he has begun to write about what it means to be alive.
“I spent the first 18 years of my life in a four-room apartment with five other people, watching somebody die,” recalls the surgeon turned writer.
In a tiny apartment in the Bronx, Nuland lived with his immigrant parents, grandmother, aunt and older brother. A young Nuland witnessed the death of his grandfather and two uncles from tuberculosis shortly after their arrival from Russia.
Nuland’s mother was taken from him when he was 11, and Nuland entered adulthood facing the decline of his aging grandmother.
“We not only shared a bedroom, there were years when we shared a bed,” Nuland said about his grandmother. “She had no secrets from me.”
The experience influenced his decades-long career as a surgeon, and his more recent achievements as a best-selling author.
“Sickness,” recalls Nuland, now a 72-year-old professor of clinical surgery at Yale School of Medicine, “was not a pathological condition, it was a sick person.”
Quill and Scalpel
Surgery and writing are “polar opposites,” Nuland says. One is an exercise in precision, the essence of bringing order back to its place. The other, a sense of freedom that carries both author and reader to unexpected places.
Their only connection, the way a No. 2 Everhard pencil feels in his hand, the instrument that brings his thoughts to the page.
“When I write, I try to let my memories wash over me,” he said. “Emotions give rise to unformed thoughts, formed thoughts, four abstractions away, give rise to words, and words to sentences.”
Nuland has become one of the nation’s most prominent writers on medical issues for a mass audience. His books include a recent biography of Leonardo da Vinci, “How We Die,” and its companion volume, “How We Live.”
“He’s just one of those humanistic doctors who combines his medical expertise in thinking about issues of life and death,” said Nuland’s longtime friend, Branford Master Steven Smith. “He strikes me as someone who combines both science and humanism in a very attractive and forceful way.”
But writing only recently came into Nuland’s mind as a professional pursuit. Graduating from New York University in 1951 and earning his medical degree. at Yale in 1955, Nuland practiced surgery in New Haven from 1963 until 1992. It has only been in the last 15 years that he has become a prominent author.
In the early 1950s, Nuland was a first year medical student. On his first day on the wards, the chief-resident at the time, who was a surgeon, called to Nuland and encouraged him to become a surgeon.
“I had a great suspicion of surgeons in those days,” Nuland said. “To me, surgeons were all 6-feet, 3-inches tall, 280 pounds, wore pinky rings, drove those fin-tailed Cadillacs, smoked cigars — It just wasn’t my kind of situation.”
But the dutiful Nuland listened to the chief-resident’s entreaties.
“To my amazement, I was fascinated,” he said. “[I thought surgery would be] the last thing I wanted to do. All the intellectuals were in internal medicine, and of course I wanted to be thought of as an intellectual.”
It was not just the intricacies of surgery that drew Nuland to his field, but another resident whom he met while on rotation.
“Jose Patino, a South American-trained doctor, was a painter, a poet,” Nuland said. “He had an aesthetic sense about surgery: the colors, the textures, the way the instruments feel in one’s hands. At the end of those two weeks, I was hooked.”
The American Way of Death
Nuland says he became a writer in very much the same way.
He was in the middle of examining a patient on a Thursday afternoon in September 1981 when he received a phonecall from a literary agent.
This agent proposed a book idea to Nuland. They needed a doctor to write a book about death and dying in America, Nuland said, a critical subject about which most Americans know little.
“I didn’t realize I was being handed the perfect opportunity to summarize my career and my life.”
In 1992, Nuland stopped practicing surgery and began to focus entirely on his writing.
“At that point, I had been a surgeon for over 25 years, and I was getting a little battle fatigued,” he said. “It seemed like a very appropriate segue.”
In the 1994 National Book Award winner, “How We Die: Reflections on Life’s Final Chapter,” Nuland draws upon his own experience in describing the course of the six most common causes of natural death.
In one chapter, Nuland describes his grandmother’s final years to capture the experience of death from old age.
He initially wondered, “Who cares about my 4-foot-10-inch immigrant grandmother who spoke only Yiddish, who didn’t understand the world we lived in?” Nuland said. “How can anybody identify with such a person?”
To his surprise, the most common theme in the mail he received from readers was about his 4-foot-10-inch, childhood roommate.
“Everybody had a grandmother just like mine, in one way or another” he said. “The lesson I learned in not censoring myself is that the more intimate you become, the more universal you become. Everybody’s got the same secrets.”
“I realized, the real reason you talk to people is not to hear their stories, but to evoke your own,” he said.
Two weeks before “How We Die” was set to be published, Nuland received a call from his editor, asking the doctor to reread his final manuscript, something Nuland had already done a half dozen times.
But the busy surgeon took one last look at the manuscript and was surprised at what he saw.
“I couldn’t believe what I had done,” he said. “I had no idea that I had such strong philosophies about death, philosophies about patient care. Where the hell did it come from?”
It is imperative, says Nuland, that “we die in a timely time and not drag ourselves on until we’re 120, keeping the young from inheriting the earth.”
“I think that’s the major thing that I never realized I knew and had been living consistently with but had never put into words,” he said
In one of the book’s chapters, Nuland recalls Hazel Welch, a 92-year-old woman with advanced arthritis and arteriosclerotic obstruction in the arteries of her legs, rendering her unable to walk without assistance.
Nuland convinced Welch to get a potentially life-saving surgery, but was not completely forthcoming in its costs. Nuland writes in his book that Miss Welch told him she just wanted to die gracefully, but trusted him, and so went ahead with the surgery.
The surgery was a success, but was not without complications. Welch was confined to the intensive care unit of the hospital for a week after the surgery, reproachful toward Nuland for her decrepit state. To her, the costs of living were not worth it.
Two weeks later Welch died.
“In the end, she was right and I was wrong,” said Nuland. “I should have let her die as she had wanted to.”
Nuland suspects that peer pressure would prevent him from acting differently, even if he had to make the choice again today.
“The code of the profession of surgery demands that no patient as salvageable as Miss Welch be allowed to die if a straightforward operation can save her,” he wrote in “How We Die.”
“Although my intentions were only to serve what I conceived to be her welfare, I was guilty of the worst sort of paternalism. I had withheld information because I was afraid the patient might use it to make what I thought of as a wrong decision.”
Through a Patient’s Eyes
Nuland is also an ardent critic of medicine today. In essays and editorials he has complained that the current medical community is overreliant on technology, and that its bottom-line practices are too removed from the ancient art of patient care.
Nuland’s ideas about the nature of the doctor-patient relationship extend to the very structure of medical education itself.
“There is very little cross-pollination between the department of philosophy or the department of religion and the medical school,” Nuland said, visibly disappointed.
Medical school, he says, has become a trade school.
“I would make medical school a true graduate school,” he said, “an extension of the undergraduate curriculum, with an emphasis on more humanities-based courses.”
Nuland feels that in an age of managed care and government regulations, emphasis has been taken away from the heart of patient care: taking care of the patient.
“It is important for doctors to be able to see themselves through the eyes of their patients,and know what their expectations are.”
“Some of the most rewarding relationships we have are when we identify with patients,” he said. “It just gives us energy to go on.”
Nuland is currently working on a memoir about his father, who died of a neurological spinal disorder when Nuland was 28.
“After realizing my father was not mentioned in ‘How We Die,’ I knew just why,” Nuland said. “And if you ever read this book, you’ll know just why too.”