Penn oncologist explores doctor’s role in life and death in new novel | 5 questions
“Night Theater” is the second novel by Vikram Paralkar, a University of Pennsylvania oncologist and researcher who specializes in leukemia.
In a rural, impoverished part of India, a disillusioned surgeon runs a small, under-supplied clinic.
One evening, three strangers arrive. The have horrendous wounds, but are not bleeding. They say that they have died. They were murdered. But a being in the afterlife has managed to give them a second chance. If the surgeon can fix their wounds by morning, they will once again live.
So begins Night Theater, the second novel by Vikram Paralkar, a University of Pennsylvania oncologist and researcher who specializes in leukemia. In January, Time Magazine named it one of “12 new books you should read,” noting that the “surreal premise gives way to a broader discussion of health care, mortality and the afterlife.”
We spoke with Paralkar recently about his book.
In the book, you explore life, death and the physician’s role in both.
When it comes to the living, I see the physician’s role as having two aspects. One is the medical and scientific aspect — diagnosis, testing, evidence-based medicine, treatment. But there is another aspect that’s perhaps more important — a humanistic one. The doctor has to relate to the patient on a human level. Try to understand their fears, their concerns, their anxieties. Try to understand why the patient has come to them and what they need. Help them understand how their disease fits into their life, how it might change their life, how their life can be brought back to normal.
As for the dying, as an oncologist, I unfortunately understand what it is like to give patients difficult prognoses and help them and their families through the process of dying. The obligation of the doctor is to recognize the point at which the focus needs to change from treating the disease aggressively to treating quality of life aggressively.
One of the advances of the last 20 years in oncology is that palliative care has become central to the care of patients with cancer. There comes a time when “What is the next treatment or chemotherapy to try?” is no longer the right question to ask. The question must then become, “What can we do to maximize the patients’ quality of life during the time they have left? How can we help the family cope with what is to come?” An essential skill for any doctor is helping patients navigate the inevitability of death, something of which we are all aware, but which we just keep out of our minds for a large part of our lives.
The line between life and death is blurred in your book. The physician is asked to “cure death.” What does that say about our society’s ambivalent relation to death?
Death is a feature of existence that is both trivial and tragic. Trivial in that every creature ever born on earth from the dawn of life has ceased, or will cease, to exist. But at the same time, it is tragic. Every human who dies leaves a vacuum in their circle of loved ones. Every death is a loss to some person who loves them. This is what makes our attitude toward death so complicated.
What I will say is this: Having trained in India, and now living in the United States, I’ve noticed that in the U.S. there is sometimes a yearning for immortality and a lack of recognition of its impossibility. Often, in the last two weeks of a patient’s life, a large amount of money is spent and many painful and medically futile procedures are performed. Our society should recognize that death is something that is going to come to us all, and what is important sometimes is not prolonging the days we have on earth, but maximizing the quality of the life that we do have.
This is a fine line that has to be walked, especially in the field of cancer treatment. There are always clinical trials with new advanced, experimental therapies, some fraction of which will turn out to be lifesaving. But sometimes the hope for the next treatment, and the next, and the next, leads patients to remain entangled with the medical system longer than is beneficial. Instead of hammering away at futile care and then having patients die in ICUs in discomfort, I hope we, as a society, can do a better job of recognizing when it is time to steer the goals of care toward palliation and hospice.
One of the questions you said you explored when writing this novel is whether the physician’s obligations to society change if the doctor is burned out or sleep-deprived or incapable of connecting with the value of his work.
On the one hand, there is the doctor’s obligation, but on the other, there is the brute reality of what the doctor is capable of delivering — as an individual, as a human being with limitations, and also as a component of a potentially flawed health system in which he or she is embedded. If doctors are sleep-deprived and exhausted, there comes a point where they may simply be incapable of delivering the empathy and care their patients deserve.
The U.S. is now hurtling into a pandemic that promises to be catastrophic. If you suddenly have a massive spike in the number of patients who need intensive care, you will see in real time a system where hospitals and doctors are overwhelmed. Despite a desire to give good medical care, they will be unable to. So while the obligation may not change, the ability certainly can.
The physician also cautioned his patients not to think of him as God or a saint. “If you mistake me for either, you’ll be very disappointed.” How does this magical thinking affect health care today?
There is sometimes a component of magical thinking in what patients and society expect doctors to deliver. In response to that, doctors should simply be honest. The most important thing is for patients to receive a realistic understanding of their disease. Magical thinking comes when doctors over-promise. There are diseases we can cure. There are disease we can control over long periods of time. And there are others about which we can do very little. I have found that when doctors are honest about what they can accomplish, the journey becomes one where the goals of the doctor and the patient are aligned from the very beginning.
What are some important health-care conversations our society needs to have?
There is one conversation that America absolutely needs to have, and that is whether health care is a human right or not. I absolutely think it is. The health of a society is determined by the health of its poorest and most deprived individuals.
Individualism is very embedded into the way Americans think about themselves and their status in the world. And there is a real resistance to putting into place policies that benefit everyone. But I think that the inability of each person in America to be assured at least a minimal level of health care is truly detrimental to all of society, and it affects everyone’s health. I fear that the coronavirus pandemic will bring this to the fore like nothing in recent memory.
Bonus question: Without spoiling the ending for readers, I’ll just say that an infant eventually enters the plot of your novel. Why?
What I wanted to show in Night Theater is that, even in death, there is always hope. There are new beginnings. There is new life that continues to blossom and flourish.