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Dying Lessons

Kyle Nash prepares medical students for the worst.

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"Cadavers don't look like people who recently died," Kyle Nash tells first-year medical students at the University of Chicago. "Their skin is a strange color because of processing. Their hair is shaved off and their brain is removed. Their scalp is sewn together with rough stitches of butcher's string, which is a thick white string. There are slashes under their armpits and the tops of their legs where the blood was pumped out and the embalming fluid in. Their wrists and ankles will be bound together by rope. Their eyes might be open, and they might have nail polish on."

Any questions?

Medical students who cried or recoiled during dissection used to be told to rethink their career choice, so they learned to suppress their emotions. "There's the curriculum and then there's the hidden curriculum," says Nash, a Unitarian minister and an associate faculty member at the university hospital's MacLean Center for Clinical Medical Ethics. "It's not intentional, but in the past, anatomy served as an emotional hazing." She believes cadaver dissection can be used to teach medical students how to cope with the death and grief that is part of being a physician, and she tries to create an environment that allows them to experience and express their feelings without compromising their studies. "The cost of becoming a physician shouldn't be the self."

As a clinical thanatologist, Nash tries to demystify death. "I want people to use the words 'dying' and 'death.' They usually say 'expire,' but that's not right. Milk expires. People die....We live in a death-denying culture, where every death is conceived of as a physician's failure to cure. But death is a natural part of the life cycle. Someone has to be a leader, and I think it's health care."

Despite her profession, Nash is anything but grim. A slender 46-year-old with sparkling blue eyes and snow-white hair, she favors bright colors, skirts, and high heels. Her resonant voice hints at her years as a cabaret singer, and she's quick to laugh, hug, and compliment. She asks students to call her Kyle rather than Dr. Nash; her authority seems to come less from her PhD than from her experience as a hospice volunteer, where she had to be "present and unafraid" with hundreds of dying children and adults.

Ten years ago, Nash was a single mother going through a traumatic divorce, and only her young sons and her volunteer hospice work kept her going. She felt a special calling to work with dying people. "Working with the dying is a gift in a society on autopilot," she says. "It gave me the gift of knowing that life turns on a dime." She admits that her regular contact with death is sometimes depressing, "but more often it's profound."

Hoping to become a hospice chaplain by the time her sons were in high school, she enrolled in a divinity program offered jointly by Meadeville Lombard Theological School and the University of Chicago. Her original plan was modest--to take one class per quarter and eventually earn a master's degree--but over the course of nine years she completed a doctorate and wound up creating her own teaching position at the university.

Nash began to sense that something was missing from medical education when she met three first-year med students during a lecture series on religion and medicine. When they told her about their experiences in anatomy class, she decided that what she'd learned about accepting death could help them, and she volunteered to teach three sessions on death and dying to the fellows of the hospital's ethics center. Encouraged by the positive response, she asked the director of the school's anatomy course for permission to observe the lab for a year. Dissecting a cadaver, he told her, had been one of the most dehumanizing experiences of his life, and he had instituted changes in the course, like easing students into the experience rather than forcing them to cut on the first day. He was preparing to take another position the following year, but he agreed to let Nash counsel anatomy students.

She received only a $500 stipend for her first year's work, yet she audited the school's first-year curriculum so that she'd understand the students' experience. Finding her niche wasn't easy. "During that first year I'd cry in my car every day. I knew what I wanted to do but I couldn't explain it." Some faculty at Meadeville intimated to her that she was wasting her time--what could a seminary student have to offer medical students?--and some anatomy instructors considered her superfluous.

"One said she'd been teaching anatomy for 20 years and she'd never seen any emotional response," Nash recalls. But she knew what that was all about. "In my family we weren't allowed to acknowledge loss, so of course we weren't allowed to grieve. We were supposed to be stoic little people. And we were. But that doesn't mean it didn't still hurt." Once the med students were given an outlet, they began coming out of the woodwork.

At first, Nash "didn't know an intern from an attending," and her perspective wasn't far removed from that of a new student. She had questions the staff couldn't answer: Were the cadavers homeless people with no relatives? What happened to them before they arrived at the lab? Surely the students wondered too, so she asked to tour the Anatomical Gift Association of Illinois, where

cadavers are processed.

"I mean no disrespect, but it looks like a Jiffy Lube. It's located in a neighborhood where there's graffiti everywhere, but this building had absolutely none. Maybe people knew what was going on there and got spooked." The staff was eager to show her around--she suspects she's the only person who ever asked for a tour--but she wasn't prepared for what she saw. "There were about 100 bodies standing upright in water with their wrists and ankles bound. They wait in that liquid up to a year before they're winched up and drained. I know they thought I could take it because I work in this field, but oh my God, I just about lost it!"

In one respect, today's medical students have it easy: before the 1920s, obtaining and dissecting a cadaver was illegal, yet medical schools required students to complete a course of study on dissection and even to supply their own cadavers. This catch-22 forced students to rob graves with their professors or pay "resurrection men" to steal bodies for them.

In 1788 newspaper reports of body snatching incited an angry mob to ransack Columbia Medical School, and in 1807 similar reports prompted citizens to burn down the anatomy hall at the University of Maryland.

As late as 1913, 12 states still had no legal way for medical schools to obtain bodies for dissection.

These days, cadavers for Illinois medical schools are donated by the deceased or the survivors; none of them is without family, and very few are donated because the family couldn't afford burial. All social strata are represented among the donors, and according to Nash, most of the donors will their bodies to science "because they like doctors."

Nash thinks she's succeeded in making the anatomy lab a more humane place to learn. She invites each quartet of students who share a cadaver to choose a respectful name for it. "Naming is a nice way to bond. By the end of the year some students feel a sense of friendship with the cadaver." She makes her way around the dissection tables, offering a sympathetic ear. And at the end of the year she facilitates a collective funeral service for the anonymous people who have donated their bodies; the students thank their silent teachers by playing music and reading poetry they've written.

"I don't know if you can teach empathy, but I'm not sure you need to," she says. "What you need to do is retain it. Most students come in with tons of empathy and idealism. The system and process of medical education can beat it out of them, but if we affirm it and nurture it, at least they won't lose it."

Now in her eighth year at the university, Nash teaches courses on medical ethics, religion, spirituality, and palliative care to the school's students, interns, residents, and fellows. She's also extended her approach of "caring for the caregiver," counseling staff members who are struggling with specific patient deaths. She's tried to integrate mourning into the hospital's work environment, holding a monthly nondenominational service of "consolation and healing" in the hospital chapel. And twice a year she brings together hundreds of health-care pro-viders and patients' families to grieve for all the cancer and pediatric patients who die in the hospital each year. In 1999, Nash's work was recognized with the hospital's Martin Luther King Humanitarian award.

While Nash's primary goal is helping caregivers cope with death, she also believes that they'll do better work if they don't feel compelled to jettison their emotions in the name of science. "If you can't deal with your own mortality, you have to alienate the dying and their grieving families to preserve the fantasy of immortality. But our work is about people, and people die. We have to love our work and our patients enough to go the distance with them."

Art accompanying story in printed newspaper (not available in this archive): photo/Robert Drea.

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