Metaphors for the pressure of our work in medicine

Sometimes I need to clear away the chaos and confusion of medicine, so I walk down the worn path in our backyard (also trod frequently by children, dogs, cats, and deer). Sitting at the end of the path is the shop, which the kids and I helped a friend build. We helped set the foundations and nail the floor; we raised walls and put in roof trusses.

The shop sits in what was once a garden, but it was so soil-poor that it yielded more blackberries, brambles, and hornets’ nests than corn or beans. The best crop of the garden was a treasure trove of arrowheads and Native American pottery; what still lies there I can’t imagine, but it is evident that someone, some people, camped or lived in what is now my yard a very, very long time ago.

Our smithy sits under the extended roof at the back of the shop. Years ago, my son Seth asked if he could learn to blacksmith. He may have been born in the wrong century. He also plays the bagpipes and banjo. So we learned to blacksmith. Or I should say we’ve learned a bit, thanks to our gracious teacher George, the man who cannot seem to feel the heat of the hottest fire. We don’t really even rise to the level of his apprentices, but we can build and tend a coal fire, we can handle a hammer and anvil, we can forge-weld iron, twist iron, and curve iron, we can quench the iron, and we can do most of it without being burned (very often) by the lemon-yellow and orange-colored metal.

I walk down that path when I want to let my mind rest from medicine just to look at the old tools and the old anvil and the vise. I look first for wasps and rattlesnakes, of course. But then I just take it in. The old colors, the bits of rust, the ordered disorder of a workplace, gravel on the ground, coal in the corner. It isn’t professional, and it isn’t perfect, but it’s beautiful.

Rarely has a hobby captured my mind like this one. And seldom has any activity enabled me to slip the bonds of medicine so readily. I drift into a different place and time from the moment I start the walk. When I start the fire, when the coal burns, when the green sulfur clouds the air and blows around me, when I turn the crank of the blower that feeds air to the fire, I am meditating.

It can be a hot day or a cold day, but cold days are best, when standing by the fire is a comfort, when it’s so hot there that a T-shirt is enough. It can be a sunny day or a rainy day. Rainy days fill our bucket with water in which we quench hot metal from the earth. It is mystical.

Taking that metal, cutting it, heating it until it is more than 2000 degrees, then shaping it from a mundane round or square stick into a wall hook, a decorative leaf, or even a new tool, that’s pure joy.

It’s unlike the emergency room. It is single-minded. The interruptions are virtually nonexistent, but if they come, they are laughter and jokes between my sons and me or gentle arguments about how best to accomplish the task at hand. Or the warning shout, “Hot iron!” which reminds us to watch out lest we be burned.

There are mistakes, but they are of small consequence. Burned metal can be cut off and thrown on the ground. Crooked metal can be hammered straight. An item made poorly can remind us what not to do next time.

It’s so unlike the emergency room where mistakes can be life-ending, where danger lies at every turn, where if we shouted out every danger, we would shout for eight hours straight. Heat and smoke bring the risk of injury, but there’s the shaping of something, the transformation of something. Hammer and hot iron, anvil and water, tongs and vise. The change from what was to what is. The rescue of an old piece of scrap, a lawn mower blade, a piece of rebar, and the gift of watching those things have new life. And the ring of that anvil, made around 1850, that says “I’m alive! I’m alive! I’m still here and needed!”

They seem connected to me, those two divergent places. Writers see everything in metaphor and simile. Maybe the heat is a metaphor for the pressure and stress of our work in emergency medicine. Maybe hammer striking metal on anvil is a metaphor for the way we want to shape a new reality, from sickness to health, from injury to healing. We are blacksmiths of the human body, or redsmiths maybe, for the blood we see spilled.

I see another metaphor here as I grow older. I see my patients like those unshaped bits of iron, of uncertain value and utility, dirty and sometimes abandoned. But I know that in them lies potential, beauty, and goodness beneath years of rust, disuse, and neglect. Like the way I put the grinder against my 150-year-old anvil and how its rough surface ends up as shiny as a new platinum ring.

Most of our hobbies, our avocations, give us insight into our medical work. Perhaps we choose them for that reason. Or maybe just for the escape, for the Zen moments of “no mind” that allow healing and rejuvenation as we work at a thing without feeling as if it is work.

All I know is that medicine seems to be getting more difficult all the time, and the house of medicine is leaning on our specialty more heavily than ever before. But whatever your hobbies, we all have walked through the smoke and fire. We have all been shaped by the fire, the hammer and anvil of suffering and struggle. We have also shaped new realities for the people we have treated and saved. And most of us keep coming back because we feel a comfort in the artistry that medicine has become, a deep, abiding pride in our craft.

So I say this, friends: be strong. Do not be afraid of the struggles to come. Embrace them with joy. Find the peace that comes from artistry well practiced. Remember, medicine is art, and however hot it gets, however choked you are by smoke and ash, however tired your limbs, be proud of the skill and strength that brings you back to the fire each day.

Only a few can do it, and you are numbered among them.

If you’re looking for me, I’ll be down the path, hammer in hand.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test. This article originally appeared in Emergency Medicine News.

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  • Rob Burnside

    This is beyond beautiful, well-past profound, and as fine a piece of work as any ever forged–”Hot iron” indeed!

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