At Wit’s End
By Noel P Pingoy, MD
Death be not proud, though some have called thee
Mighty and dreadfull, for thou art not soe,
For, those, who thou think’st, thou dost overthrow,
Die not, poore Death, nor yet canst thou kill mee;
From rest and sleepe, which by thy pictures bee,
Must pleasure, then from thee, much more must flow,
And soonest our best men with thee doe goe,
Rest of their bones, and soules deliverie.
Thou art slave to Fate, chances, kings, and desperate men,
And dost with poison, warre, and sicknesses dwell,
And poppie, or charmes can make us sleepe as well,
And better then thy stroake; why swellest thou then?
One short sleepe past, we wake eternally,
And death shall be no more, Death thou shalt die.
- “Death Be Not Proud”
(from John Donne: The Divine poems, edited by Helen Gardner, 1952)
The doctor is not the central character in
Wit, an HBO TV movie based on the
Pulitzer Prize-winning play by Margaret
Edson, and it is a verisimilitude that lends
credence to the entire movie and even to the
reflections it draws from the doctor-viewer
because the fact remains that in any clinical
situation, whether in the hospital
wards/suites or in the outpatient clinic, the
patients take center stage and are the focal
point
of
the
entire
proceedings.
Approaching the movie from this thesis
actually reveals a lot about the many BS
(basic strengths, broad spectra, belief
systems, even bullshits) of the medical
profession, it even posits the doctor’s role as
primarily, and that I believe will always
remain so, supportive. Considering how
doctors delight in hogging the spotlight (one
need not look beyond the bedside ward
rounds or the Grand Rounds to realize how
endemic it is in the community), some
colleagues might find the movie a little
unsympathetic to the profession.
In this intimate TV movie directed by
legendary director Mike Nichols, Emma
Thompson plays the lead role of Vivian
Bearing, a professor of English literature
with special interest on metaphysical poetry
whose life suddenly takes a rueful turn when
she was diagnosed with Stage IV ovarian
adenocarcinoma. She has spent most of her
life in the academe. Unmarried and without
kids, she also has no third-party person to
refer to.
Vivian is known for her expertise on
metaphysical poetry especially the Holy
Sonnets of John Donne, those scholarly but
intricate treatises on life, death and even the
afterlife. Holy Sonnet X (“Death be not
proud”) is an essential device in the movie,
both as a theme and as a counterpoint to
what transpires on the screen. It is often
recited in parts during the film and heard in
its entirety in the final voice over before the
credits roll in the end. Donne is considered
the dominant figure of a school of 17th
century English writers known as the
metaphysical poets. These writers were
linked by their style – their use of wit rather than by any thematic ideology.
Wit as defined by scholar Louis Marz is
“intellect, reason, powerful mental capacity,
cleverness, ingenuity, intellectual quickness,
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inventive and constructive ability, a talent
for uttering brilliant things, the power of
amusing surprise.”
smug demeanor and chuckles.) Insidious
means undetectable at an early stage.
Vivian: …insidious means treacherous.
The doctors are represented by pragmatic
senior oncologist Dr. Harvey Kelekian
(Christopher Lloyd) and his young research
associate Dr. Jason Posner (Jonathan M.
Woodward).
I am only aware of the 4th definition, and I
found out that I have exactly been living the
good doctor’s world: my vocabulary like
most of my colleagues has been limited to
textbooks and medical literature. It becomes
a metaphor of how, in my experiences from
med school up to the present, doctors can be
so self-absorbed in their own world,
complete with spots, shortages and surfeits,
and not realize that there are other life
forms in the universe other than
themselves.
I first caught snippets of the film on cable
several ago as I was then (I think)
preoccupied with tidying my study up. I
vowed to myself that I must get hold of a
copy on video as the perfunctory
introduction to this inchoate gem fomented
my curiosity enough to wish viewing its
entirety. Took a long while but got my wish
a few months back when I saw a VCD copy
in one of those bargains bins in the mall.
All those years of waiting were well worth
the belated revisiting of the movie as it
happened at a no better time than now: I am
nearing the 9th year of my practice as a
Hematologist/Medical Oncologist (and have
seen enough patients to know the subtleties
of clinical practice that are not written about
in textbooks and journals; the learning is
endless, mind you), I have somehow learned
even this late in life that prose and poetry
can be poignant and uplifting and
redeeming (now I know who John Donne is
and how relevant are his writings in my
journey both as a physician and as a
person), and I have never as passionately
and thankfully appreciated this life that is
both a grace and an accountability.
Wit starts with Dr. Kelekian’s face in
extreme close-up and telling Vivian that she
has “advanced metastatic ovarian cancer.”
The initial conversation was interesting
enough to elicit a kind of kneejerk reflex to
reach for the remote and push the pause
mode:
Dr. Kelekian: Now it is an insidious
adenocarcinoma…
Vivian: Insidious means?
Dr. Kelekian: (Initially taken aback by the
question, pauses for a few seconds, keeps a
in-sid-i-ous adj. 1. Designed to entrap;
full of wiles. 2. Doing on contriving harm.
3. Awaiting a chance to harm. 4. Causing
harm by slow, stealthy, usually
imperceptible means. (Funk & Wagnalls
Standard Dictionary)
Vivian is hospitalized for chemotherapy as
she has decided to take part in a clinical trial
that required her to receive 8 cycles of the
antineoplastic regimen, full dose. The tables
are turned this time, the former stern
professor and examiner becomes the
specimen. She sees her exact mirror among
the hospital staff, emotionally removed,
even haughty and indifferent.
While there is a veneer of contrivance in the
movie as Vivian frequently talks to the
audience directly, the simplicity of the
scenes without the formulaic clichés draws
the viewer to Vivian’s world as she suffers
not only through the various side-effects of
the chemotherapy (alopecia, nausea and
vomiting, febrile neutropenia) but also the
seemingly institutionalized culture of
indifference and apathy from among the
hospital staff.
Doctors can be complacent about improving
their people’s skills, contentedly blithe with
merely memorizing the results of the latest
clinical trials down to the minutest
statistical detail like p value of 0.098765
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(when simply saying “not statistically
significant” would suffice). There seems to
be a constant pissing contest about having
the latest inside info on the most modern
tools in the armamentaria. Allow me to
disclose this upfront that there is nothing
wrong about statistics and gadgets and
algorithms, these are the basic tools in every
doctor’s search for detection of and cure for
what ails the patients. But to forget about
the human factor, especially about how the
patients feel and think and believe, negates
everything that is especially attractive and
valuable in the profession. Some physicians
can get too casual with their language that
they border on insensitivity and downright
heartlessness. I know of doctors who
habitually finish off every sentence when
talking to their patients with an exclamation
point. I say so! Take this! I know this for
sure! Believe me! And worse, some senior
(however that means in the context of the
succeeding
thought)
doctors
even
communicate with PGIs, residents, fellows
and nurses like some conquistadores
dismissing the coolies. Oftentimes, even
worse. And tyranny and subservience are
supposed to be anachronistic in this
century.
was precariously getting lower? Until that
time I didn’t realize that doctors can be
uncouth because I haven’t heard someone
from Davao, bless them, talk to younger
doctors that way. I had the urge to snap
back NOEL PO PANGALAN KO, HINDI
BULLSHIT. PERO SA TOTOO LANG MAS
BULLSHIT PO KAYO! but I was taught
better.)
ver-ism n. A style in art or literature that
follows the theory that reality should be
rigidly represented, even when it is ugly
or vulgar. [<L verus true] – ver’ist n & adj
Case 2: The Cardiologist
CENICU. The consultants scheduled a
meeting to discuss the decking policies,
“First Decked, First Admitted” among them.
The following day, this cardiologist asked
that I admit his patient to the empty bed
STAT.
Cardiologist: Pasok mo na pasyente ko!
(Note the exclamation point.)
Me: Po? Papasok na po yung unang
nakadeck, pangwalo po yung pasyente
ninyo.
Cases in point
Case 1: The Nephrologist
During my first 24-hour duty at the
CENICU during the first year of my
residency I was asked by the senior resident
to relay a lab result to this nephrologist
because she (the senior resident) was not on
speaking terms with one of my co-residents
(who’s supposed to relay the result).
01 February 1994, 9 PM (How can I ever
forget V Day – verism, that is):
Me: Good evening, Ma’am, I would like to
relay…
Nephrologist: BULLSHIT! Why are you
calling me at this time… blah, blah, blah!!!
(Huh? Was she in the middle of something
orgasmic to not mind that her patient’s pH
Cardiologist:
(Ever
the
pertinacious
monster) PUTANGINA MO!!!! Di ka ba
natatakot sa akin?!!! (Even questions end
on exclamation point.)
Of course, when you are a first year
resident, you were deathly scared. The
following day I was on the verge of breaking
the coffee mug or his face – even both – but
my co-resident pushed me away seconds
from achieving poetic justice. The
consultant did not notice, first year
residents were supposed to be non-existent.
I wondered how you can insult someone
else’s mother by referring to her as a whore
and casually stand beside him the following
day as if nothing occurred at all. In some
parts of the country, you run the risk of
getting punctured on the chest if you do
that. Was he plainly insensible or gravely
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insensate or downright insentient? That
would have been my last day at PGH.
in-sen-si-ble adj. Blunted in feeling or
perception
in-sen-sate adj. Manifesting or marked
by lack sense or reason; destitute of
sensibility
in-sen-ti-ent adj. Inanimate
Case 3: The Pulmonolgist
OPD this time. At PGH there was this rare
cultural phenomenon called “extensionitis,”
a practice that allowed families and friends
of PGH employees to take an imaginary
express line at the clinic, seemingly
oblivious to the long line of patients who
have started filing in at early as 5AM. (Don’t
know if it exists until now.) I was already at
the clinic, seeing patient #9 in the list of 26
when this pulmonary medicine consultant
called to ask me about his friend.
Me: Opo, Sir, nandito lang po ako sa OPD.
Pulmonologist: Hindi pupunta ang kakilala
ko riyan, puntahan mo na ngayon sa
office!
Me: Sir… (it was past 4PM, there were 21
patients yet to be seen, and leaving the OPD
complex to see his friend at the Central
Block seemed absurd)
Pulmonologist: PAPAHINTAYIN MO ANG
EXTENSION KO?!
(Of course, the gods couldn’t bear to leave
the sanctum sanctorum. You come to us, we
don’t come to you. When I get to think
about that episode, I can’t help but be awed
of how great a doctor and a man the late Dr.
Alendry Caviles had been. That very same
day, the kindly “Father of Hematology”
called me that same morning if I can see a
friend of his. Would you like me to see him
at the Hema office at the MRL, I asked. No,
he told me, he can fall in line at the OPD to
be fair with your other patients. Wow, that’s
THE man. I call that respect for other
people, integrity to oneself and to the
profession, and conscious effort to avoid
abusing
authority
(which
that
pulmonologist for all his credentials and
positions, have yet to fully comprehend).
Must be the result of all the years the blood
gases accumulating in his brain? No wonder
even the scalp is thinning out prematurely. I
have sat beside him three times in recent
years - once at the airport, twice at a
convention - and each time I searched my
heart for some respect befitting his
“academic” stature, sorry, wala talaga
akong mahugot. All I could muster was
“Good morning, Sir.” It would have been
easier to ignore him, but I was taught
better.)
sanc-tum sanc-to-rum 1. Holy of holies.
2. A place of great privacy; often used
humorously.
The worst of this subspecies of this ilk was
another cardiologist, but the least that he is
discussed, the better. Besides, the
Hippocratic Oath is emphatic about keeping
your mouth shut when you can’t speak
something decent about another human
being.
And I am talking about top tier (whatever
that means now in the context of dealing
with fellow doctors I am not sure)
consultants here, the purported crème de la
crème of their subspecialties, the so-called
movers in their respective societies, the ones
who get to sit on the presidential table in
conventions. I remember reading an article
by one of them on uplifting the status of
PCP in the new millennium and how each
internist should behave accordingly. Look
no farther Sir!
There is a scene in Wit that highlights the
importance of punctuation marks in the
sentences doctors use. Not so much as a
lesson in grammar, it underscores how
messages are received when the medium is
altered by subtle displacements of
something trivial as a comma or a semicolon. As written by Nichols and Thompson
themselves, it even had a metaphysical slant
that invites an earnest reflection.
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Flashback to Vivian’s graduate school days
with the imminent Professor E.M. Ashford,
professor emeritus of English literature.
Ashford: Your essay on Holy Sonnet VI,
Miss Bearing, is a melodrama, with a
veneer of scholarship unworthy of you – to
say nothing of Donne. Do it again.
Vivian: Oh I, ah…
Ashford: Begin with a text, Miss Bearing,
not with a feeling.
Death be not proud, though some have
called thee Mighty and dreadful, for, thou
art not so.
You have entirely missed the point of the
poem, because, I must say, you’ve used an
edition of the text that is inauthentically
punctuated. In the Gardner edition of the
text…
Vivian: That edition was checked out in the
library…
If you go for this sort of thing, I suggest you
take up Shakespeare.
Gardner’s edition of the Holy Sonnets
returns to the Westmoreland manuscript
source of 1610, not for sentimental reasons,
I assure you, but because Helen Garner is a
scholar. I reads:
And death shall be no more, comma, Death
thou shalt die.
Nothing but a breath – a comma –
separates life from life everlasting. Very
simple
really.
With
the
original
punctuation restored, death is no longer
something to act out on stage, with
exclamation marks. It’s a comma, a pause.
This way, the uncompromising way, one
learns something from the poem, wouldn’t
you say? Life, death, Soul, God. Past,
present. Not insuperable barriers, not
semicolons, just a comma.
Vivian: Life, death… I see. It’s a
metaphysical conceit. It’s wit! I’ll go back to
the library and rewrite the paper –
Ashford: Ms. Bearing!
Ashford: It is not wit, Ms. Bearing. It is
truth. The paper’s not the point.
Vivian: Sorry.
Vivian: Isn’t it?
Ashford: You take this too lightly, Ms.
Bearing. This is Metaphysical Poetry, not
the Modern Novel. The standards of
scholarship and critical reading which one
would apply to any other text are simply
insufficient. The effort must be total for the
results to be meaningful. Do you think that
the punctuation of the last lime of this
sonnet is merely an insignificant detail?
The sonnet begins with a valiant struggle
with death, calling on all forces of intellect
and drama to vanquish the enemy. But it is
ultimately
about
overcoming
these
seemingly insuperable barriers of life,
death and eternal life.
In the edition you chose, this profoundly
simple meaning is sacrificed to hysterical
punctuation”
And Death – capital D – comma – thou
shalt die – exclamation mark!
Ashford: Vivian, you’re a bright young
woman. Use your intelligence. Don’t go
back to the library. Go out. Enjoy yourself
with your friends. Hmm?
Vivian: I, ah, went outside. It was a warm
day… There were students on the lawn,
talking about nothing, laughing. Simple
human truth, uncompromising scholarly
standards? They’re connected? I just
couldn’t…
I went back to the library.
Vivian, like some doctors, seems to have
created a world that revolves around the
library,
the
academe,
oftentimes
overlooking the simple joys of the company
of friends. She hasn’t learned to grasp fully
the weight of Ashford’s lessons on life
beyond the library until the end.
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Dr. Kelekian like most senior doctors is
authoritative, confident and unperturbed.
He is well versed with the subtleties of
medical jargon and was most impressive
when dealing with the disclosure process:
precise, sympathetic yet uninvolved. Yet for
all his scholarship he had his share of flaws.
In one scene where Vivian was doubling up
because of extreme pain and the nurse was
suggesting immediate patient-controlled
analgesia, he remains unmoved and even
asks the patient if she is in pain. To which
Vivian remarked as she faces the audience: I
don’t believe this.
the guinea pig in this clinical experiment.
Talk about dehumanization in order to
contribute to the improvement of humanity,
that’s a common paradox that we often see
in large teaching hospitals. Doctors and
students huddled around the patient’s bed,
discussing her innards and her prognosis,
even her personal and social history,
nonchalantly oblivious to the fact that the
person they are dissecting that very moment
is also around. Vivian learns about how it is
to be at the receiving end of the steely
coldness that she once forced her students
to endure.
On the other hand, the idealistic but callow
Dr. Posner symbolizes the young doctors’
insolence and indifference to the entire
establishment. Young Posner once got an Ain Vivian’s class in literature. He prefers to
pursue a career in research rather than
remain a clinician. “Clinicians are such
troglodytes,” he would conclude; thus, his
choice of cancer as the field of study. He is
enthralled by cancer and the many complex
mechanisms on the cellular level, but finds
talking to patients an annoyance.
Vivian (after an exhausting battery of tests):
It’s highly educational; I am learning how
to suffer.
On Posner, Vivian laments: The young
doctor like the senior scholar prefers
research to humanity, at the same time the
senior scholar in her pathetic state of
simpering victim wishes the young doctor
would take interest in personal contact.
Now I suppose we shall see how the senior
scholar ruthlessly denied her simpering
students the touch of human kindness she
now seeks.
Except for the kindness of her nurse Susie,
Vivian suffers from the terrible absence of
human warmth and empathy in her ordeal.
In her life prior to the diagnosis of cancer,
caring for others is something that is
extraneous to her academic mind. Her work
was all that mattered. She finally meets her
match in the young Posner who regards
people as mere lab mice, nothing more than
processes and signal transductions and
neoangiogenesis that need to be understood
in the search for the perfect cure.
While they were unswervingly involved in
the treatment protocol of the clinical trial,
counting even down to the last milliliter of
the urine output, both doctors failed in
many cases especially in asserting another
person’s humanity beyond the mere
physiology of her body and her capacity to
endure
the
assault
of
the
toxic
chemotherapeutic agents. In their relentless
pursuit to find an effective regimen for the
disease, they have forgotten that the patient
also has other concerns than merely being
Like in the scene where she was berating the
high school jock for not coming prepared to
class.
Vivian: (Dryly) Did I say: You’re 19 years
old, you are so young. You don’t know a
sonnet from a steak sandwich. By no
means…
In the end, the chemotherapy failed and
Vivian has finally seen the significance of
compassion.
Vivian: Now is not the time for verbal
swordplay, what could be worse than
detailed scholarly analyses of erudition,
interpretation, complication… Now is the
time for simplicity. Now is the time for,
dare I say it, kindness. I thought being
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extremely smart would take care of it. But I
see that I have been found out.
Before the final scene, she has one visitor. In
town for her grandson’s fifth birthday, Dr.
Ashford visits Vivian and learns about her
former student’s grim situation. Comforting
Vivian, she asks her if she wants to listen to
a Donne sonnet but Vivian refuses. So she
kicks off her shoes, climbs into the bed and
takes out a book called The Runaway Bunny
by Margaret Wise Brown that is supposed to
be her gift to her grandson and begins
reading. The Runaway Bunny begins with a
young bunny who decides to run away. The
mother replied “If you run away, I will run
after you.” The book traces the imaginary
chase that the mother undergoes for her
little one and no matter how cleverly the
young bunny conceals itself in the many
forms –a fish in the stream, a crocus in a
garden, a rock on a mountain, his steadfast
and unyielding mother has never failed to
reclaim him. (There is something Biblical, I
discovered, in this simple children’s book,
how God in His infinite love and boundless
mercies would go at great lengths in order
to find the lost sheep.)
Knowing that the end is near, Vivian opted
for a DNR. Posner’s initial attempts to
revive her despite the DNR status much to
the disappointment of the nurse smacked of
arrogance.
Vivian Bearing finally learned in her
deathbed the meaning of compassion. She
found it in the arms of two people who
represented the major phases in her life: her
old professor Ashford from the academe,
and her nurse Susie from the hospital.
Sadly, her doctors failed her in all accounts
much as words have failed her (as they
eventually must) and as Medicine has failed
her doctors. But she found her final
redemption, by signing the DNR option and
facing Death squarely and lovingly, thus,
depriving it of its mightiness and misery.
This is my playes last scene; here heavens appoint
My pilgrimages last mile; and my race
Idly, yet quickly runne, hath this last pace,
My spans last inch, my minutes last point
And gluttonous death, will instantly unjoynt
My body, and soule, and I shall sleepe a space,
But my’ever-waking part shall see that face,
Whose feare already shakes my every joynt:
Then, as my soule, to’heaven her first seate, takes flight,
And earth-borne body, in the earth shall dwell,
So, fall my sinnes, that all may have their right,
To where they’are bredand would presse me, to hell.
Impute me righteous, thus purg’d of evill,
For thus I leave the world, the flesh and devil.
- “This is my Playes Last Scene”
(from John Donne: The Divine poems, edited by Helen Gardner, 1952
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