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Commentary

Neilen, Deirdre PhD

doi: 10.1097/01.ACM.0000409939.17240.94
Medicine and the Arts
Free

Dr. Neilen is associate professor, Center for Bioethics and Humanities, SUNY Upstate Medical University, Syracuse, New York; e-mail: neilend@upstate.edu.

Third- and fourth-year medical students completing clinical rotations enter a new and challenging world. Finally, the students are face-to-face with patients on a daily basis; finally, they begin that delicate balancing act between symptoms and suffering. For two years they have focused on learning and memorizing the many ways the body can betray us. They enter the hospital determined to track every symptom into its original lair where they will attempt to help remove it, eradicate it, reduce it—whatever it takes to restore the patient and prove their own mettle as physicians in training. “Lighthouse Keeping” by Kay Ryan, though it never mentions medicine, can become a touchstone for medical students to measure their response to patients during clinical rotations.

This poem suggests to me the mystery that lies at the heart of medicine, the paradox with which students and clinicians wrestle. The student comes to medicine more often than not because of a desire to serve others, to rescue even. Yet the student is warned that too much personal involvement could damage objectivity and impede prognosis. Too much empathy might even detract from the physician's own personal life. How, then, to retain an ethic of true caring?

Kay Ryan, U.S. poet laureate from 2008 to 2010, is known for her short verses and her compressed lines. This alone makes her an ideal choice for harried, frenetic medical students, though they may be disappointed when they discover that short does not mean easy and compressed does not mean uncomplicated.

The title announces where the poet finds significance—not in the heroics of the person but, rather, in the sacredness of the role that person fulfills. The lighthouse keeper, like the physician, works in dangerous waters. For this lighthouse keeper, the sea is not calm; the waves are rolling and the wind is mournful. As the fog intensifies, vision is diminished. Ryan presents these physical facts as efficiently and succinctly as an attending at a bedside, and the facts prepare the lighthouse keeper for one simple yet tragic truth: “ships lean no/doubt.” Patients, too, under their own nature's onslaught or rebellion, may start to list, to bend, and to fall.

The initial four lines have set the physical scene; the next five describe the keeper's response to the conditions, beginning significantly with the word “doubt.” From this trepidation the line continues, and we discover the essence of the keeper's obligation. He or she maintains the light, continues to stand watch for “those left out.” The rhyme here echoes the earlier “doubt,” establishing a connection between those at sea—those whose welfare is yet unknown—and the keeper. The abruptness of “those left out” is disquieting. Where exactly are those souls now? As Ryan puts it, the “keeper keeps,” conjuring the image of a constant vigil for these individuals who rely on him or her, and I suggest that physicians in training may see themselves in this image: The healer heals. In other words, the role the physician in training is learning is not necessarily one of completion but one of constant presence when at work. The lighthouse keeper does not yet know the fate of those for whom he or she works; the keeper, like the physician, does his or her work and then bears witness.

The final four lines perfectly encapsulate what matters most, beginning with “It is intimate/and remote both.” Ryan's use of the conjunction to end the line suggests the complexities of these coexisting characteristics. The action of sending light forth is intimate because it connects individuals who were strangers, yet it is also remote since the connection is only particles of energy. But before we can truly think about this paradox, the poet uses the same conjunction to propel us to the concluding lines, where it serves them equally well: “both/for the keeper/and those afloat.” The keeper and the people at sea are connected now through the keeper's actions and yet remain physically separate. Once the light is sent and seen, the relationship between those at sea and the one sending lifesaving illumination truly begins.

For students, I emphasize the poem's paradox: There are professions whose work is nothing short of miraculous, and yet a distance between savior and saved exists. The poem assures us that if the keeper sees the work as part of an exchange between equals, the work itself creates an intimacy. Patients and physicians, in other words, can feel a similar intimacy when the physician is providing his or her best focused attention. Such attention, however, does not mean that the physician must enter the leaning boat or fall into the rolling waves. Healing, too, travels in many guises. Healing occurs even without a cure when the physician maintains this type of intimacy with the patient's situation.

“Lighthouse Keeping” is somber in its depiction of how fragile human relationships are: Someone, even if he or she is unknown to us, is always in danger. Yet, in its insistence that someone is always trying to bridge the distance, the poem also can be seen as a celebration of the physician's art, an art the medical student first learns on the wards.

Deirdre Neilen, PhD

© 2011 Association of American Medical Colleges