Tag Archives: Cutting for Stone

Like a surgeon

In Abraham Verghese’s debut novel, fate is stitched together with sutures ♦

Cutting-for-StoneAbraham Verghese is a man of science and fact. His experiences as a doctor in small-town Tennessee in the mid-1980s during the early years of the AIDS epidemic led to his first book, the well-received My Own Country: A Doctor’s Story.  After a flurry of articles and short stories on the medical profession for magazines like The New Yorker and Texas Monthly, Verghese followed up in 1998 with The Tennis Partner. It was another non-fiction book and sketched the agonies of a colleague’s battle with drug addiction.

Despite his extensive track record of chronicling real events, Verghese’s regular readers won’t be surprised to find that his third book, Cutting for Stone, is a novel. After all, he’s often written of his interest in narrative medicine, a new discipline that gets patients to tell stories about themselves and uses literature as a form of therapy. Verghese has long savoured the paradox implicit in make-believe tales. “Fiction is the great lie that tells the whole truth about how the world really lives,” Verghese said in an email interview with Time Out, quoting author Dorothy Allison.

Cutting for Stone, on which Verghese has been working for nearly a decade, draws much from his personal and professional experiences on three continents. The main characters are doctors and the book, set largely in Ethiopia,  follows its author’s geographical and professional trajectory. Verghese, 53, is a Syrian Christian who was born in  Africa, but returned to India to study medicine – a profession that eventually took him to the US.

His journey, like the journey of hundreds of other Malayali Christians, is the result of a quirk of fate that, had it not been true, would have seemed quite implausible. It was the product of a state visit to India by the Ethiopian Emperor Haile Selassie in 1956. “As the head of an old Christian nation, he was interested in seeing the churches of Saint Thomas in Kerala,” said Verghese. “Apparently he was so impressed by the sight of all these school kids in uniform clogging the roads that he hired all his teachers for the schools he was building from this one state.”

SonalShah_BooksFeature_Cutting-for-Stone

(Joanne Chan)

Soon after, there was such a sizeable community of Malayalis in Ethiopia, they even had their own church service. Verghese’s parents met in Addis Ababa and Verghese lived in Ethiopia, and started medical school there. But a military coup in 1974 that deposed the emperor disrupted his plans – and threw the Ethiopian Malayalis into disarray. “I was told that as an ‘expatriate’, I should leave,” Verghese said. “I had never heard that term before. What it meant was that I didn’t really belong, even though I thought I did.” Verghese casts his expulsion from his childhood Eden in a positive light, despite the fact that “obviously there is more than a little nostalgia”. Though he still thinks of Ethiopia as his homeland, Verghese – who now lives in California – said that for him, “home is really a state of mind… It’s the place where you are wanted and needed.”

The sense that people – not a place – are ultimately responsible for creating home bubbles through Cutting for Stone.  Though the novel draws from his own migratory experience, Cutting for Stone is no memoir. “When I actually sat  down to write this book, what kept recurring was an image of a beautiful South Indian nun who suddenly and  precipitously goes into labour in a mission hospital in Africa,” Verghese said. “That act of her going into labour throws  everyone for a loop.” The narrator, Marion Praise Stone, is one of a set of originally conjoined twins born to this nun, a  nurse at “Missing” (Mission) Hospital, near Addis Ababa.  Verghese skilfully weaves a world around the hospital and its staff: the twin’s biological parents, Sister Mary Joseph Praise and brilliant British surgeon Thomas Stone; and their adoptive parents, ob/gyn Hemlatha and general practitioner Dr Ghosh. Inevitably, the brothers’ destiny is bound up with medicine. Both become surgeons.

The most moving passages in Cutting for Stone are Marion’s visceral descriptions of surgical operations. This took some research because Verghese himself specialises in internal medicine and pulmonary and infectious diseases. “I  hope the reader will enjoy the technical passages, much as I enjoy learning about other occupations in the course of a novel,” he said.

Besides the surgical motifs, though, Cutting for Stone encompasses a larger theme that is much closer to the heart of Verghese’s own medical interests. He is currently the Professor for the Theory and Practice of Medicine at Stanford’s School of Medicine and – ever since the experiences that inspired My Own Country – has been an advocate of what is called “bedside medicine”. Verghese is known for making clinical rounds with students to see how much can be determined from a simple physical exam, a routine he feels has been sidelined in modern medicine. “One of my pet peeves is over-reliance on science and technology at the expense of a caring doctor-patient relationship,” he said. “There’s a subtext in our interaction with physicians where we also want them to say, ‘Don’t worry, it’ll be alright.’ One of the things I hope this book does is to portray that very well. This profession is a ministry of healing, it is a calling, and that sense has become greatly threatened.” The contrast is evident in the physician-patient relationships at Missing Hospital, where “the news to convey… was that you’d kept death at bay.” But in hospitals in the US “there is an expectation that medicine will provide a cure, mandate a cure”, Verghese said.

Another recurring theme is the description of medical textbooks – both real and imagined –as literary works. “In the  pre-internet era, [medical textbooks] were like mentors we carried around, they had a voice that we admired and  found to be unique,” Verghese said. For example, Dr Ghosh performs his first operation with the sing-song  instructions from a rhyming book of surgery echoing in his head. Verghese clearly sees medicine as a confluence of the  hard edge of science and the passion of art. “I wanted to write about the sense a young boy has of the wonder of  medicine and how it’s some secret ritual that if you could only learn it, would be like buying X-ray spectacles and suddenly you could see through people,” he said. “I did want the college age reader who is embarking on a career to  realise that the house of medicine is huge and has room for everyone, and that inherently medicine is a human pursuit,  a calling in which one must believe in the Samaritan function of being a physician.”

Cutting for Stone, Random House India, Rs 595.
Originally published in Time Out Delhi, March 2009.

Published: March 20, 2009

Eternal outsider

Abraham Verghese talks about Cutting for Stone and the idea of home ♦

This interview was conducted for a feature in Time Out Delhi.
SonalShah_BooksFeature_Cutting-for-Stone

(Joanne Chan)

Could you tell me a bit about how your family came to be in Ethiopia and the background of Malayalis in that country?
I am told that Emperor Haile Selassie of Ethiopia came to India on a state visit shortly after his country was liberated from Italy. As the head of an old Christian nation, he was interested in seeing the churches of Saint Thomas in Kerala. Apparently during that visit he was so impressed by the sight of all these school kids in uniform going to school and clogging the roads, that he hired all his teachers for the schools he was building all across his nation from this one state, Kerala. My parents came separately within a week of each other, and in a group of several hundred. There were enough of them in Addis to have their own Syrian Christian church service. My father and mother met in Addis Ababa and married, and I and my brothers were born there.What’s your personal, emotional relationship to Ethiopia like? Do you still consider it to be your homeland? Or is it less simple than that? Where/what is “your own country”?
I was born there and I had most of my schooling there including beginning medical school in a school started by the British Council in East Africa. About the third year of my medical school, the emperor was deposed and civil war broke out. The university was closed and the students sent to the countryside in a Cambodian style effort to get the intellectuals out of the cities. I was told that as an “expatriate,” I should leave. I had never heard that term ‘expatriate,’ before. What it meant was I didn’t really belong, even though I thought I did. But being an eternal outsider has enabled me to see things and given me great advantages as a writer. Ethiopia was my homeland. I loved the beauty of the land and the lovely people who are so different from the stereotype so many people have. But that displacement caused me to come to India to finish my studies and it deepened the existing bond I had with India from my many visits during the holidays. For me, home is really a state of mind, where you feel comfortable, needed and I refer to that in Cutting for Stone. It’s the place where you are wanted and needed. I became an American citizen years ago, an act that was very moving and emotional for me, not a cynical act of convenience by any means. It is not contradiction for me to be American and yet have roots in Africa and India.

I thought you avoided a trap that many novels that deal with immigration to America fall into and managed to keep Marion an intact, recognizable character even within the “superorganism” state. You even managed to write about hankering for injera and wot, without making Marion’s homesickness the predictable stuff of many Indian immigrant novels. Were you conscious of wanting to write about America in a particular way?
I am glad you think so. I do feel America has the capacity to swallow one whole, and he is certainly threatened with that, until fate conspires to change that.

In the end, Marion returns to Ethiopia. Do you ever think about doing the same, and why?
For more than 16 years I lived in Texas. I have lived in Tennessee and Boston and am now in California. My children are here and my family is here. My parents who had retired from their positions in America were going back and forth, living in India and American. But now they have decided to join us in California. I think it would be difficult for me to go back to Ethiopia in any permanent way—there are political reasons for that and also my sense is that when I left, the connection was broken – though obviously there is more than a little nostalgia. I have been back there twice and to India many, many times. I do hope and plan for the arc of my life to allow me to at one stage to work in a setting in India where my services would be most needed.

What is the “nobility” of suffering? How does it vary from culture to culture?
I’m not sure there is much nobility in suffering. Perhaps it is just something we say to make it bearable. Some cultures are more resigned to suffering, feel it is part of the human condition perhaps, and can be accepting – sometimes to the point of passivity. In other places—here for example in the States- there is an expectation that medicine will provide a cure, mandate a cure even. People don’t want pain, they don’t want suffering and they resist it and sometimes that will to live helps to bring about a cure. Often though it results in unreasonable expenditures and suffering at the end of life.

Your acknowledgements and bibliography in this book are painstakingly exact. Reading over them after finishing the book, your fictional work appears very much like a patchwork graft of real and imaginary fragments: memories, texts, people… How does this format reflect the nature of your story?
I think one can get away with less of an acknowledgment. But fiction, most fiction, is based on credible research, and on sources that have come in handy. I think it is helpful and necessary to acknowledge sources, influences, quotes, even thoughts and ideas that come to permeate a work of fiction.

You allude to a Greek text about lithotomy in your title, Cutting for Stone. Could you elaborate on the multiple meanings of this title – as they relate to medicine and to the narrative?
In Greek, ‘lithos’ is stone and’ tomos’ is cut, and lithotomy refers to the surgical method of removal of kidney or bladder stones. Hippocrates noted it as ‘lethal’ work that should be left to surgeons. In the Hippocratic Oath, there used to be a line there that said, ‘I will not cut for stone.’ It stems from the fact that in medieval times and perhaps more recently than that – Victorian times – bladder stones were epidemic. The population suffered . . . little kids and adults were in agony because they had stones that were blocking the bladder. So there were these people who traveled from city to city who would ‘cut for stone’ – obviously without anesthetic and using the same knife again and again. They were expert at doing it and they would relieve your suffering, but of course, that would cause infection, and you’d be dead the next day, and they would have left town. So I think that’s where the proscription came, ‘Thou shall not cut for stone.’ It’s always seemed a curious thing for us to be saying since it really doesn’t have applicability now, and yet I liked saying it – I thought it was a nice line. And the characters in my book are surnamed Stone, so I was hoping that the title would resonate on many different levels. And I include the actual quote in the third section as an epigram.

What were the challenges you faced in writing this novel, as opposed to your earlier nonfictional writing?
I have always longed to write a novel and although I was offered the opportunity to do a third non-fiction book, I turned it down in favor of going back to fiction. I say ‘going back’ because I had written fiction at the start. My first long piece in the New Yorker, “Lilacs”, was fiction. I love to quote Dorothy Allison who said that that ‘fiction is the great lie that tells the whole truth about how the world really lives.’ The great advantage of writing non-fiction is that when something really happens, we all as readers have an inherent interest in it. That is a great help to the writer. By contrast, when as a novelist, you are creating an imaginary world, you have to work so much harder to get the reader to suspend their disbelief at the outset and then you can never break the fictional dream after that, never let the reader be reminded that this is not real.

Where did the idea for the story of these twins germinate and how did it grow?
When I actually sat down to begin to write this book, what kept recurring to me was an image of a beautiful, south-Indian nun who suddenly and precipitously goes into labor in a mission hospital in Africa. That act of her going into labor throws everyone for a loop and causes utter confusion at the hospital. That’s all I had to begin with. I saw her succumbing in that labor, and I saw one of the twins becoming the narrator of the story and looking back in somewhat of an antique voice.

So I kept writing, developing the ideas, themes, and characters. When I reached about two hundred pages, I convinced my agent, against her better judgment, I might add, to tentatively shop a portion of the book around – an unusual and risky approach for fiction. But I wanted some affirmation that this was interesting to anybody. I didn’t want to spend another three or four years only to find that nobody wanted this. My writing time is too precious to spend on something that isn’t of interest.

The overall message of your novel seems to be a humanistic one. As a leading advocate of bedside medicine, did you consciously set out to illustrate through literature your arguments against dehumanizing patients? What were some of the themes you definitely knew you wanted to convey?
I did not set out necessarily to write a polemic or advance a certain agenda. I think it is not surprising and usually the case that the novelist’s biases come out in the work. One of my pet peeves is over-reliance on science and technology at the expense of a caring doctor-patient relationship. There’s a subtext in our interaction with physicians where we also want them to say, ‘Don’t worry, it’ll be alright.’ Or ‘Don’t worry – this is not your fault.’ Or “don’t worry; I’ll be with you this through the end – no matter what it takes.’ One of the things I hope this book does is to portray that very well. Because I think people are starting to assume, ‘I guess that’s how medicine is: you show up and somebody sees you here and orders 17 tests and sends you somewhere else, sends you to someone else, and pretty soon you’ve seen all these people and you have no idea who you really belong to as a patient. This profession is a ministry of healing, it is a calling, and that sense has become greatly threatened.

You’ve spoken elsewhere about wanting to bring back a sense of excitement and usefulness about practicing medicine, and have argued that the way to do this is to increase compassion for those who are suffering rather than preach detachment. Could you elaborate briefly on why you feel this is necessary today and how you hope your book might work towards recognition of that need?
I love medicine and the study of medicine. I do see it as a passionate and romantic pursuit. To me, medicine is life. Sometimes the most elemental struggles – to have food to eat, to have money to clothe oneself, to be able to feed one’s children, to have their suffering relieved – these societal problems are often first encountered by physicians. They are medical problems at one level, but they are really political and social problems at another level. It would be tough to write a novel about medicine that does not engage with these issues, unless the novelist turns an eye to the nature of suffering. But you are right, I did want the college age reader who is embarking on a career to realize that the house of medicine is huge and has room for everyone, and that inherently medicine is a human pursuit, a calling in which one must believe in the Samaritan function of being a physician.

What was the most enjoyable part of writing this novel?
I think the writing of this novel was enjoyable in that it was a great learning experience. All writing is a process of discovery—that is what makes writing so worthwhile. You are not sitting down to write what is in your head, but to discover what is in your head. Then with a novel you have to wrestle with things like pace, and profluence and plot. I certainly struggled with all that, but was conscious all along that I would look back and relish the memory of the process.

And what was the most difficult?
Most difficult was time it took and the sense of frustration sometimes that I would never complete it. Again, I have to thank my editor, Robin, for her commitment to both the book and to me. Time was also a great difficulty as for most of the years I was writing this book.

How long have you been working on this novel? What was your writing process like? And are there any parallels between the way you approach your medical practice and your writing?
I’ve been writing this novel on and off for close to a decade, and I was always trying to carve out time to write. I had a very demanding day job that allowed little time for the continued concentration you need for writing. I burned the midnight oil a lot and weekends were often writing time, which took away, of course, from my family time. The parallel between my medical practice and writing, if there is one is that I’ve always thought that the study of medicine – the appeal that an adolescent sees as the great mystery of what people learn in medicine had never been quite celebrated in a book as well as I would have enjoyed seeing it. I wanted to write about the sense a young boy has of the wonder of medicine and how it’s some secret ritual that if you could only learn it, would be like buying X-ray spectacles and suddenly you could see through people.

In your earlier books, you touch on the breakup of your personal life due to the strain of practicing medicine. Do these experiences echo through Dr Stone’s choosing work over life – and to what degree?
Yes, I felt a great empathy for Stone and his feeling that medical work is the most wonderful work you can ever do and yet how he hurt the people around him by losing himself in a love for his work that was so extreme. An aim of the novel was to show just how medicine and the magic word, ‘work’ can both heal and cripple, how it is a trap and yet it is a balm and as Yeats would say, the challenge is to find that balance between the ‘perfection of the life or of the work’ and in the book there are characters who exemplify both ends of that spectrum. Dr. Stone was very skilled, he focused on the moment and had great knowledge and wisdom, but it was not enough to save him. Perhaps there is some of my own life in that thought, who knows?

Though you are not a surgeon by profession, perhaps the most gut-wrenching passages in Cutting for Stone are the visceral descriptions of wounds and sutures. The action almost seems to rise to these episodic surgeries, then fall again for a time. How did you decide to approach writing these seminal narrative moments? What do you think readers’ responses might be to them?
I hope the reader will enjoy the technical passages, much as I enjoy learning about other occupations in the course of a novel. I do think the human body is inherently interesting and we are all drawn to it. I am someone who toyed with the idea of being a surgeon, and writing this book is as close as I will get!

There’s a theme of very literary medicinal texts running through the book – most brilliantly written into the description of Ghosh’s first surgery. Where do you see yourself in the history of these real and imagined texts? What does it say about your views on medicine as both a science and an art?
In the pre-Internet era, we all used to form relationships with textbooks. They were like mentors we carried around, they had a voice that we admired and found to be unique. I think students at least in America get their information from Google and other sources in little bytes and they miss the notion of a ‘voice’ in a textbook. That is what I wanted to capture.

After completing this book, what’s on your agenda for the coming months? Are you working on other writing projects as well?
I do think that if my publishers will let me, it is fiction that I want to keep writing. I can however see myself writing non-fiction pieces, say for magazines or even at book length if I find the right topic.

Read the feature on Cutting for Stone
Originally published in Time Out Delhi, March 2009.

Published: March 8, 2009