Diary: Atul Gawande, On Oliver Sacks
I first came across the work of Oliver Sacks when I was in medical school in the 1990s and picked up The Man Who Mistook His Wife for a Hat. The stories in the book were more than a decade old—ancient history in medical science—but Sacks’s voice was already timeless. He told, simply, of a few patients he had seen, and their unusual neurological conditions. But he did so with the sort of inquisitiveness and observational power that I, as a young doctor-to-be, could not help but want to emulate. He captured both the medical and the human drama of illness, and the task of the clinician encountering it.
There’s truth and there’s knowledge, and there are important things about the human experience that you just don’t get from medical textbooks. I did not learn from textbooks how to be a doctor. I learned content and I memorized all the drugs and all the different muscles of the body. But I didn’t learn about suffering and mortality, and doubt, and how you work your way through being puzzled by a situation, to getting to a diagnosis and an “Ah-hah!” To Sacks, these existential themes were crucial, and he did not hesitate at times to describe his patients’ predicaments by invoking poets, novelists, and philosophers when the medical language did not suffice.
Dr. P., the subject of the famous title story of this collection, was a distinguished musician and teacher at a school of music who had lost the ability to recognize the faces of his students. And, Sacks writes, there was another odd thing. “He saw faces when there were not faces to see: genially, Magoo-like, when in the street, he might pat the heads of water-hydrants and parking-meters, taking these to be the heads of children; he would amiably address carved knobs on the furniture, and be astounded when they did not reply.”
His observations could make me uncomfortable at times. Sacks viewed his subjects with a naturalist’s dispassion, and when his descriptions made me laugh or gasp or turn the page to find out more about the person’s predicament, I felt complicit. Following Sacks as he examined Dr. P. from head to toe, we learned that he could find no visual abnormalities or telltale signs. But when he asked Dr. P. to get dressed afterward, the patient had trouble figuring out if his foot had a shoe on it or not. Then, when that was sorted for him, “he reached out his hand, and took hold of his wife’s head, tried to lift it off, to put it on. He had apparently mistaken his wife for a hat!”
Sacks was unendingly curious, and I, like millions of readers, eagerly followed him on his explorations—into why music moves human beings, what it’s like to have amnesia or autism or drug-induced hallucinations, what was wrong with this man who could not recognize faces. Dr. P. was a puzzle, and Sacks regarded him with unapologetic fascination. So did we all.
As a student, I wanted my unabashed enthusiasm to be redeemed by an account of how Sacks’s often decidedly personal investigations resulted in a solution, a treatment. But mostly they didn’t. His careful observations of Dr. P. gradually led to the conclusion that he had a disease that caused severe damage to the areas of the brain that processes visual information. Nothing could be done about it. The disease advanced inexorably until Dr. P.’s death. But it was still essential, Sacks wanted us to know, simply to understand. This was his deeper lesson. His most important role, as a doctor and as a writer, was to bear witness. There was a tender passion beneath the dispassion.
“Studies, yes,” he writes in an original preface to the book, but “why stories, or cases?” Because, he explained, the understanding of a disease cannot be separated from the understanding of the person. They are interwoven, and this has been forgotten in our era of scans, tests, genetics, and procedures. He compared the modern clinical practitioner to the man who mistook his wife for a hat—able to register many details yet still miss the person entirely. “To restore the human subject at the center—the suffering, afflicted, fighting, human subject—we must deepen a case history to a narrative or tale,” he wrote.
Is Sacks’s work exploitive? At some level it is undeniable: every physician-writer is pinning people on the page and exposing them to others, and all of us end up having to navigate these moral questions. How do we have that permission? How do we seek it and obtain it? But in fact people would often come to Sacks with the desire to be regarded with that same prying curiosity and attentiveness. And though he wrote about only a tiny fraction of the patients he saw, he did so with empathy and respect.
Sacks was someone who stood out, for better and for worse. Though he was clearly brilliant, he was fired from a series of early jobs—he was clumsy in the lab and did not always get along with his bosses. He was someone who was very private and introverted, uncomfortable in a room with lots of people. He could be outrageous as well: in his youth, he experimented on himself with massive quantities of amphetamines and hallucinogens; he was a competitive weightlifter; he rode to work on a big BMW motorcycle. For most of his career he practiced not at one of the great academic medical centers but at nursing homes for the most sick and disabled, looking after people over stretches of time with seemingly nothing happening that could ever be of interest to anyone. And yet, he saw things others had missed.
He was at heart a nineteenth-century naturalist, undistracted, unendingly curious, deeply observant, like his heroes: Darwin, Homboldt, William James—all explorers and describers in their own particular realms. Sacks was not just interested in the average, which twentieth-century doctors were well-trained to recognize; he was interested in the widest possible span of human experience.
By 1985, when The Man Who Mistook His Wife for a Hat was first published, medical journals no longer had a place for extended case studies, and he had to find a different outlet for his work. Many of the stories in this book first appeared in The New York Review of Books or the London Review of Books. Most of his colleagues were dubious at the time—proper physicians, they had been taught, only published their work in academic journals. But Sacks found his own audience, and in his brief introductions to each of the four parts of this book he lays out a sort of manifesto that he would continue to refine throughout his life: that he would see patients not as collections of deficits but as unique individuals, often bravely living with and adapting to neurological conditions which were unimaginable for the rest of us. He captured their experiences, their hopes and fears, their humor and perseverance. It is heroic stuff, and he was well aware of its mythic resonances.
Atul Gawande is a surgeon, professor of medicine, and Assistant Administrator for Global Health at USAID. He is the author of four books, most recently Being Mortal: Medicine and What Matters in the End. This post is drawn from his introduction to a new Everyman Library edition of The Man Who Mistook His Wife for a Hat.
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