Ideas - Hawkeye's Army: The War Metaphor in Medicine

Episode Date: December 13, 2024

We think nothing today of calling healthcare workers “front line workers,” engaged in a “battle” against disease. But the roots of the war metaphor in medicine go way back ⁠— entrenched by pop culture icons like the TV show M*A*S*H and Hawkeye’s army. Dr. Jillian Horton explores a less heroic but healthier way forward for doctors and health professionals. *This episode originally aired on Feb. 21, 2023.

Hey there, I'm David Common. If you're like me, there are things you love about living in the GTA and things that drive you absolutely crazy. Every day on This Is Toronto, we connect you to what matters most about life in the GTA, the news you gotta know, and the conversations your friends will be talking about. Whether you listen on a run through your neighbourhood, or while sitting in the parking lot that is the 401, check out This Is Toronto, wherever you get your podcasts. This is a CBC Podcast. Welcome to Ideas. I'm Nala Ayyad.

The unmistakable opening to MASH. The hit TV show ran from 1972 to 1983, about four times longer than the Korean War in which it was set. I said fire that weapon. Look of course, Haw the inside. The fictional wartime doctor has long inspired generations of real-life doctors and has found new currency in the COVID era. This doctor says she learned all about bedside manner from watching, get ready for this, the classic TV show MASH. Medicine has, of course, always been practiced in war. But it's also true that war has always been deeply embedded in the practice of medicine. As those two fields become more and more integrated, medicine's language starts to adopt the language of the military. And you start to see these sorts of metaphors,

like medicine's own front line about disease being a battle. Metaphors that can sometimes lead to contradictions. No matter how you look at it, if you're engaging in a war, you're looking to cause some people to die. So I can see not liking the implication that it's drawing on the language of hurt rather than health. And that language of hurt has consequences. I often have felt through medical school that I'm losing my soul. I'm dealing with all these horribly suffering people, and I was oftentimes suffering myself. It's a boot camp.

Dr. Gillian Horton knows medicine's front lines firsthand, as well as the much bigger war. She brings us this documentary we're calling Hawkeye's Army. I'm a writer and doctor of internal medicine at a hospital in Winnipeg, Manitoba, where I've spent most of my adult life looking after very sick patients and teaching young doctors to do the same thing. People often ask me when I first knew I wanted to be a doctor. Well, I first knew when I sat in front of a black and white TV screen watching MASH. Those characters shaped me.

They scripted my entire understanding of what it meant to be a doctor. Frank, you know what a hero is? 99 times out of 100, he's somebody who's tired enough and cold enough and hungry enough not to give a damn. I don't give a damn. Come on. But my attention was almost always focused on one doctor in particular, Captain Benjamin Franklin Pierce, Hawkeye, played by Alan Alda. Could I get you to begin by introducing yourself in a sentence? A whole sentence about who I am? A whole sentence about who you are. I'm Alan Alda, and I'm an actor and a writer.

Is there more to tell? Alan Alda is 87. From 1972 to 1983, he played the role of Hawkeye Pierce on MASH. He was also a lead writer on the series and directed a total of 32 of its episodes. You apparently nearly rejected the role. Why was that? Well, I knew it had to be shot in California. And our family lived in New Jersey. And as I said to my wife, too bad I can't do it.

It's a really good script. So she called back the next day and said, maybe we can solve the problems with travel. And that's what we did. I just traveled a lot. Alan, what do you think drove Hawkeye as a doctor? What was most important to him? I think what was most important to him was excellence, to be as good as he could as a surgeon. And he was working under the worst conditions because, as the character pointed out a number of times in the series,

he was patching up bodies so they'd be healthy enough to go back out and get shot at again. they'd be healthy enough to go back out and get shot at again. What are some of the most memorable things that people have said to you over the years in health care about how the character and your portrayal of him shaped their decision to become health care providers? Many, many people have come up to me on street corners and airports and said, I became a doctor because of your playing Hawkeye and the whole show, MASH. But nobody's ever said I became an actor because of you. You know?

Not only did I become a doctor because of Hawkeye, but in August 2020, in the first few months of the COVID lockdown, I wrote an op-ed for the Los Angeles Times about the ways in which Hawkeye Pierce had given me a blueprint for survival to get through the pandemic. I wrote that he taught me to be brave, be kind, be funny, because humor shines a powerful light on hypocrisy and absurdity while reminding us we are tough and still alive. The article went viral. I was even on Inside Edition with Alan Alda. I loved it that Jillian wrote so movingly

about the people who are our essential team to keep us alive. But what shocked me even more was the fact that something that had seemed so personal to me was actually universal. I was inundated with uncharacteristically emotional messages from other doctors and even chief surgeons whose professional identities had also been shaped by Hawkeye Pierce. I read your LA Times op-ed regarding MASH's influence on your life, and it really hit home for me.

A little over a month ago, I sent Alan Alda a thank-you note, thanking him for his influence on my own career as a surgeon. Your op-ed is certainly much more expressive than my note and gets to the very heart of the show, but I think we both sense the underlying goodness and depth of character that Hawkeye displayed. Dr. Kevin Bethke. So many others wrote and posted on social media with messages saying, you captured what I feel so deeply in my heart, or confessions like, I'm also a Hawkeye Pierce. My name is Dr. Heather Galbraith. I'm a retired Lieutenant Commander in the Canadian

Armed Forces. I am a military physician who has recently retired from that work, and I continue to provide care as a family medicine specialist in the community in Ottawa. Dr. Heather Galbraith is one of the physicians who reached out to me. You know, this was a, you know, an activity that we did as a family. We watched the sitcom, if you will. Hawkeye was the character who spoke to her the most. It resonates with me because as a military officer and medical provider, a surgeon, he showed this ethical side to him. He was without fault, right? He always did the right thing. Sometimes it would take a little bit of navigation to, you know, to get to that end stage.

But he always did the right thing. What the hell do you think you're doing? I'm taking out that guy's appendix in there. You're going to get into your whites or what? You're talking about removing a healthy organ. No, I figure his appendix is about as thick as his mind. Doctors aren't supposed to take bodies apart. They're supposed to put them together.

Why? So guys like that can take them apart again? You heard him. He's going to take those kids up that hill tomorrow and send them back to us in pieces. That man is crazy. That doesn't make this right. Some things are wrong, and they're always wrong. Fine, it's wrong. But there are going to be a hundred boys still alive tomorrow. Go tell them how wrong it is. He could be antic and silly. He could drink too much.

He could joke too much. He could be insensitive as a skirt chaser. And he could also have a great sense of empathy for somebody. And as much as a skirt chaser he was, he could tell a young nurse who was wounded and who had a crush on him, and who was much too young for him, in a gentle way, that it wasn't appropriate. You mean a great deal to me. You don't even know me.

I know enough. Marina, when you came here, you were sick. I literally swept you off your feet. All you've seen is the bedside of my matter. You haven't seen the bad side. So he had more sides to him than you could put in a thimble. If that character of Hawkeye and the other characters on the show had an impact on an audience. I think it was because we were acting out stories that had actually been lived by real people. And they were stuck in a situation where they didn't want to be trying to help people that they didn't want to see wounded, losing them. And before they even have a chance to react to the ones they've lost

a new batch is in. All of this punctuated by long days of boredom when nothing was happening, and then too much happening, more than they could handle. I saw the goodness and the humanity and the resistance in Hawkeye. I wanted to be that kind of doctor, but it would be years before I ever considered how much of Hawkeye was shaped by the war versus how much had been shaped by practicing medicine. I didn't understand that many of his most admirable qualities were the same ones that put him at risk for exhaustion, for chronic unhappiness, for the mental health crisis he experiences in the final episode. in the final episode.

Sidney, listen to me. I'm a doctor. There is nothing wrong with me. That's what you said the night they brought you here. You'd just driven your jeep through the wall of the officer's club and ordered a double bourbon. What's interesting to me now is that those qualities aren't really about Hawkeye as a soldier. He constantly lampoons his identity as an army captain. Now, later in my life, I understand these qualities have much more to do with who he was as

a doctor. I've also come to believe it's no accident that this still popular show about medicine is also a show about war. about medicine is also a show about war. I've watched guys die almost every day. Why didn't they ever cry for them? Look, all I know is what they taught me at command school. There are certain rules about a war. And rule number one is young men die.

And rule number two is doctors can't change rule number one. I kept wondering why were war and medicine so deeply enmeshed? The answer goes much, much further back than the Korean War. I'm Dr. Agnes Arnold-Forster, and I'm a historian of healthcare, medicine, work, and the emotions. And I live in London, in the United Kingdom, and I work at the London School of Hygiene and Tropical Medicine. The relationship between medicine and war begins to crystallize just as medicine is taking shape as a profession? So it first emerges in around the 1600s. It takes several hundred years to get going, but it's partly a product of medicine's increasing role and increasing prominence in the military on the front lines of warfare.

The military is professionalizing, becoming more capacious, more well-funded, and various nations' armies are getting bigger and bigger, needing to extend their power over greater geographical areas. I'm thinking especially of the emerging European empires that are sort of extending the tendrils of imperialism and colonialism around the world. And so the military becomes more important. And as it becomes more important and more costly and more of an investment, there's a greater emphasis on medicine being a key part of that effort of keeping soldiers healthy, preventing them from dying from new weapons. And as those two fields become more and more integrated, medicine's language starts to adopt the language of the military.

Here is one example from 1907, a book called The Romance of Medicine by Ronald Campbell McPhee. Sometimes disease seems so strong and men's best efforts to combat it seem so weak that the heart despairs. But no one who studies the history of medicine can fail to be impressed by the slow but certain progress of medicine, by its increasing sanity and power. Century after century, by offensive and defensive warfare, disease is being conquered, and the story of the combat is a long romance which will have a happy ending.

And you start to see these sorts of metaphors with which we're now pretty familiar, like medicine's own front line about disease being a battle, about conflict between doctors and illness as a kind of general category, and also increasingly militaristic language, specifically in the discussion of surgery, of invading the body, of using weapons against surgical diseases, the body as a kind of territory that needs to be conquered by increasingly proficient and increasingly effective surgeons. So it has a very long history and it's really

tied up with all sorts of big issues in the history, not just of medicine, but the history of Western society. Was that infiltration of war language that you talk about, did it also manifest into a broader incorporation into everyday language in other arenas like politics or anywhere else? Or was it really quite specific to medicine? It absolutely infiltrates, that's a great word for it, and it absolutely gets its tendrils into all sorts of aspects of modern life. But I think medicine is a sort of special case, partly because for so much of medicine's history, and this is something that might feel surprising today, but for the majority of medicine's history, it has been trying to assert itself as a socially useful, socially relevant, something that can actually contribute something meaningful, practical, economically beneficial to states and societies. to states and societies. Now we might think of medicine's contributions to, you know,

the national effort to finances of a government as sort of self-evident. But for several hundred years before the end of the 19th century, medicine was really kind of performing a kind of PR campaign for itself. It was truly trying to establish itself as something worthwhile, something useful. And one of the ways it did that was to adopt the language of something that was also seen as useful and socially beneficial, which is the military. And so although it was part of all sorts of arenas of public life and public discourse from politics to science is another great example, natural history. It was particularly acute in medicine because it was particularly useful to medicine's own campaign to be taken seriously by both the public and the people with the cash, the governments, the states, the aristocrats. So we've talked about the origins of that language. How did we see it evolve in the

20th century? Well, I think to understand the role of military metaphors or military language in medicine in the 20th century, we really have to look to the 19th century. That sort of professionalization of medicine that's been going on since the 1600s really ramps up in the 19th century. At the beginning of the century, medicine is often diminished, cast over in favour of other forms of professional inquiry, and partly because medicine is still seen as a sort of preserve of quacks and charlatans, people standing in street corners purveying their wares, their medicines, their tonics, you know, whatever it is that's fashionable at the moment. But over the course of the 19th century, medicine's image changes dramatically. One of the

reasons for this is it really gets integrated into the imperial concerns of 19th century states and societies, particularly in Europe and in North America, where medicine is again brought to the front lines quite literally. And also you see the emergence of bacteriology, the discovery of specific disease agents. And so the way people think about disease also starts to shift. So rather than seeing it as it was in the 17th century and in the 18th century, as an imbalance of humours, the body out of whack with nature. In the 19th century, with the identification of things like bacteria, parasites, the body's processes begin to be seen in more confrontational terms, I suppose, as a body being invaded by hostile outside agents,

like bugs and germs and all that kind of stuff. And so the medicine's role is increasingly to protect the body against these invading agents. And in the 20th century, that only increases. And also you get a kind of better and more astute understanding of the body's sort of micro processes. And as medicine becomes more and more astute understanding of the body's sort of microprocesses. And as medicine becomes more and more complex, it also becomes more and more reliant on metaphors to explain itself to non-specialists because it's very, very difficult to sometimes articulate

exactly what's going on in the body without recourse to language that most people might understand. And so metaphors have a real use in that and everybody understands the language of war, unfortunately. have a real use in that. And everybody understands the language of war, unfortunately. Everybody understands the language of war. Despite my lifelong love affair with MASH, it was the COVID-19 pandemic that changed my understanding of medicine as war. Suddenly, medicine became synonymous with war. And for many of my health care colleagues,

being a doctor truly was like war. It became hell. This morning, some of the stories of frontline health care workers as they face equipment shortages and increased cases. Preparing for the impact of COVID-19 outbreaks at nearby long-term care homes, group homes, and shelters. Healthcare workers right across the country. They're on the front lines of this battle against COVID-19. In March 2020, the COVID front line moved from a battle being fought overseas to a fight in our own backyards. Lieutenant General Romeo Dallaire, who headed the United Nations mission to Rwanda during that country's genocide, addressed health care workers in terms he'd normally use for fellow soldiers. We will get through this. We will take casualties.

We will take casualties. Our frontline troops in the medical and in the first responders, yeah, we'll have casualties. But we weren't soldiers who'd been trained for a battle. We were health workers facing a terrifying disease with no known cure. And yet looking back, long before COVID, I see that kind of language seeping into all aspects of practicing medicine. Perhaps most relevant to my own research is the incorporation of military language into ideas about clinical training, clinical professionalization, and also ideas about well-being, burnout, and the kind of job of being a doctor. In the 20th century, it also became a way of articulating the relationship between doctor

and doctor, between doctor and the kind of industry of medicine, between the individual physician and the kind of structures in which they work. And you start to see the emergence of language like, when physicians are learning to be physicians, when they're training, or physician and the kind of structures in which they work. And you start to see the emergence of language like when physicians are learning to be physicians, when they're training, they're in the trenches. They're sitting there on the front line against a kind of more sort of structural problems. And that's new to the 20th century for various reasons, but mainly because the character of healthcare changes in the 20th century. It becomes more industrialized, it becomes more standardized, more mechanized, becomes much bigger.

You know, you have whole state-funded healthcare systems, which didn't exist in the 19th century and before. And so you need a new language to deal with this new state of affairs. But that new language would create a whole new set of problems. But that new language would create a whole new set of problems. Instead of describing the culture, it would quietly begin to define the culture. And that should concern us all. Because everyone knows what happens to soldiers when they come home from war. If they come home at all. You're listening to Ideas and to a documentary called Hawkeye's Army by Dr.

Gillian Horton. Ideas can be heard on CBC Radio 1 in Canada, across North America on Sirius XM, in Australia on ABC Radio National, and around the world at cbc.ca slash ideas. I'm Nala Ayed. I'm Nala Ayed. is an attempt to explain what vision loss feels like by exploring how it sounds. By sharing my story, we get into all the things you don't see about hidden disabilities. Short Sighted, from CBC's Personally, available now. MASH MASH was, of course, a TV show about doctors and nurses practicing medicine during war. Turns out that war has long been deeply embedded in the practice of medicine. Three hours ago, this man was in a battle.

Two hours ago, we operated on him. He's got a 50-50 chance. We win some, we lose some. The character of Benjamin Franklin Pierce, or Hawkeye as he was better known, had a hand in reinforcing the relationship between medicine and war in contemporary culture. the relationship between medicine and war in contemporary culture. But the reasons we think of medicine as a kind of war are more complicated than we ever imagined. They go back far beyond the 4077

and hundreds of years into the medical profession's history. A history that Dr. Gillian Horton hadn't thought much about until COVID changed everything. Here again is Dr. Jillian Horton with Hawkeye's Army. Hawkeye flouted authority in ways that aren't always typical for doctors. But in many other ways, he was a typical doctor. And the characteristics that made him a great physician could also undermine his ability to continue being a physician. Does the physician personality

set us up for certain potential problems in medicine? Yes. You know, there are a lot of things about the characteristics of people who seek a career in medicine, our diagnostic rigor, our desire to be thorough, our commitment to the trust of our patients, which is so important, and our desire to stay up to date with everything that we do. Dr. Carol Bernstein is a professor of psychiatry in New York City and a former president of the American Psychiatric Association. The challenges on the other side are that it's very difficult for physicians often to differentiate healthy self-interest from selfishness, to take time away from work. And we have an excessive sense of responsibility and a need to control many things that often we

can't. These all can create challenges, if you will, to the well-being of a physician. of a physician. Dr. Bernstein believes, as many do, that COVID-19 has been a disaster for overextended healthcare workers. I thought before this, before COVID, that we were at a tipping point, that all along the challenges that exist in medicine have existed, but that a lot of changes to how healthcare was being delivered, particularly in this country, were contributing to an environment in which physicians in particular, but all the caring healthcare workers, the nurses, the PAs, everybody, we were getting progressively more removed from our patients, and it started to feel much more like a factory. It is a stressful profession. I used to say to my residents all the time, this is not like working at Google. You can't just pick up and leave. And the patients, because the patients keepism that really carried us through and a desire to

really help people. And when the system became unbalanced in that regard, where we were spending less and less time doing what we love, taking care of our patients and more and more time treating the chart and dealing with schedules and payment, the scales got tipped the wrong way. the chart and dealing with schedules and payment, the scales got tipped the wrong way. Then you had COVID. This was the perfect storm before, but even more so the perfect storm and the tipping point. The data isn't good. In the year before the COVID-19 pandemic, 30% of doctors were experiencing burnout. Data from 2022 shows that nearly two-thirds of American physicians are experiencing at least one symptom of burnout. The war that doctors are constantly fighting is claiming many of them as casualties. With soldiers, they will go out to fight. They will have an incredibly intense and,

sometimes, possibly very traumatic experience. But they will always have a moment to retreat, to step back, to recuperate, to reassert their psychological safety. And then they'll return to the front line. And I'm not at all suggesting that that makes it easy to deal with or that there aren't serious consequences for people's psychological or emotional health if they're in military contexts. But medicine isn't like that. And that's partly because of the same sort of language that we've been talking about, that medicine is relentless. Opportunities for taking holiday are very restricted. You know, there's very few opportunities for time off enshrined in job contracts, or it's people are dissuaded from taking time off. And doctors and nurses work very long hours, as we've discussed.

And so they don't have that opportunity for reprieve. When I started medical school, I never really thought I'd face burnout. But I did have a complex idea buried somewhere in the back of my mind. Medicine might break me. somewhere in the back of my mind, medicine might break me. And that breaking might even be a marker of my commitment, my devotion, my service. And I know now exactly where that idea came from. It came from Hawkeye in the final episode of MASH and the mystery of a chicken on a bus that wasn't a chicken at all.

Now, what happened on the bus? Nothing. You're wasting your time. Well, you never know. I suppose I thought that anyone who practices medicine like Hawkeye would eventually find themselves broken, if not publicly, then privately. I struggled for years with feelings of guilt for the people I couldn't save, with intrusive memories of mistakes I'd made,

and cases gone horribly wrong. I bungled an operation. Yes? I left a piece of shrapnel in a patient. Pierce had to go back in and bail me out. I wrestled privately with a serious eating disorder. I hit a point where I wondered if I'd be able to continue to practice medicine without it destroying me. Becoming broken felt inevitable, partly because of my commitment, but partly because

I had internalized what had happened to my hero, Hawkeye. It never occurred to me there was another way to make it through the war. I'd like to talk for a minute about what broke Hawkeye psychologically in that last episode. What do you think pushed Hawkeye over the edge? Was it practicing medicine or was it living through the war? I wanted to, in one way or another, show that everybody in that mass unit had received some kind of a wound that they would take home. Sometimes it was literal wounds. One of them got deaf. Hawkeye had that breakdown.

Another lost his ability to enjoy music because the musicians he was working with got killed by a bomb. enjoy music because the musicians he was working with got killed by a bomb. And what triggered Hawkeye's breakdown was a story that I had heard that came out of two specific wars. One was, I think, during World War II, and another was, I think, during the Korean War, where civilians were hiding from the enemy. We got to get this bus into the bushes. There's an enemy patrol coming down the road. Let's kill those lights. And among them was a little baby that was crying.

And the mother was urged to keep the baby quiet or they'd all be killed. They'd be found by the enemy and be killed. Hawkeye was the one insisting that the baby be quieted. Keep that damn chicken quiet! And in his guilt, he remembered it as a woman having a chicken rather than a baby in her arms. There's something wrong with it.

It stopped making noise. It just stopped. It just stopped. She killed it. She killed it. She killed the chicken? And in a moment of being led back to actually remember it, he realizes it wasn't a chicken, it was a baby.

It was a baby! She smothered her own baby! Baby! So it was not only that event, it was everything building up to that event, where he was trying to do something about the death and the maiming of so many people, often civilians who were just innocent bystanders. And then he becomes the instrument of death. And he just couldn't take it. You know, if we turn back to the idea of medical training,

for so many of us, we describe that it feels like a a war and you know that the hours are unrelenting and people experience profound exhaustion and bursts of intense life and death experiences and sometimes when I think about my relationship to my training and my childhood obsession with MASH I wonder if I created the expectation that my residency would be that way because of MASH, and then I just fulfilled it. What do you think of that idea? Which one of those things is more likely to be true? I don't know. The idea that some of us regard reacting to an illness as a battle against it. You know, one of the common phrases, he's fighting cancer. That implies that there are weapons to fight with, there's ammunition,

and the idea perhaps, well, you must have a shot for that. Give me a shot and I'll get better. Whereas my impression is that medicine does contain some of those elements of here's the problem here's the fix to the problem i'll see you in six months but a lot of science and medicine is evolutionary a lot of it is trial and error and that's not comfortable for a lot of us who want the doctor or the scientist to be more like a god. Give me an answer quick. Give me a solution. And if you give me a solution, don't tell me next week that it didn't work

and we're going to try another solution. That scares me. Yeah. We have to get used to that. Otherwise, we're going to continually be disappointed in the very people who can help us. But this is where I found myself wondering, what about our disappointment in ourselves? The ghosts of the patients we think or know we failed, even if our system set us up for those failures, the mistakes that haunt us, our feelings of inadequacy as we confront the suffering

we are often woefully unequipped to deal with. You know, you deal with death, you deal with mistakes, you deal with horrendous suffering. Dr. Bessel van der Kolk is a world expert on trauma. He's also the author of the international bestseller, The Body Keeps the Score. Medical training is very hard and very vigorous, very demanding, and certainly interferes with some aspects of your development in order to become very specialized in something else. I think many things that are highly skilled like that

require a very deep sense of dedication. And then the question becomes, in what context do you do it? But as long as you have a team of people who you can trust and who are protecting to each other, by and large, you will come out okay. So maybe it does all go back to training, to medical school, which I've often described as an initiation, a minimum six-year boot camp that changes you profoundly. I often have felt through medical school that I'm losing my soul.

I'm dealing with all these horribly suffering people and they needed to shut off their suffering. And I was oftentimes suffering myself. I needed to shut off my own suffering. So it's a boot camp. It is a tough experience. It's a growth experience. Can we make it better? Yes, I think we can make it better by really paying close attention to each other.

Dr. van der Kolk's words hit home. Curiously, it sounded more like he was describing a military unit than a medical team. than a medical team. Maybe that had something to do with experiencing prolonged stress together. And what could be more stressful than working together every day in life and death situations? Somebody double-cross you? Yeah, that kid over there. Yesterday I repaired a hole in his iliac artery. I removed a large fragment near his spinal cord. Penetrate the dura? No. I have very warm memories of the intensive care unit,

which was about as stressful as you can be. But what I also remember of the intensive care unit is that we worked together very closely, and people really had each other's back. Things were tough, but they were not like, oh, if you do it all right, everything's going to work out okay. So there was a deep sense of we are in this challenge together and we pitch in as well as we can. And that, of course, is very different from the one-to-one experience that many physicians have with their patients,

who may be very challenging and that you cannot talk about it or you're by yourself. and that you cannot talk about it or you're by yourself. And so the team part of medical school was always sort of a pleasure in that you can learn from people and you have people you look up to and people you admire. And as long as people don't humiliate you for not being perfect, the challenge can be quite interesting. Dr. van der Kolk's experience in medical school is remarkably similar to Alan Alda's on the set of MASH. That was our job as actors on the show.

We had to become a team. We had to become forgiving of one another's strange character quirks. forgiving of one another's strange character quirks. And it was really hard work. It was like being in therapy every day. But it turned into our being glad to sit around together between shots, between setups of the camera. They'd have to relight it for the next setup. So that sometimes takes an hour or more.

So instead of going back to our dressing rooms and listening to the radio or reading a book alone, most of the time we sat in a circle of chairs. Sometimes we went over our lines so we'd know the scene, but most of the time we made each other laugh, made fun of each other, told stupid stories. Yeah. So that we took the closeness that we had established without talking about it, without thinking about it. We took that closeness we established in the chairs and brought it into the scene so that the characters had that same closeness. And that has the effect when it works well, has the effect on making the audience feel that they're in the company of people

who are used to being together and not just getting paid to be together. They're reading one another's body language and emotions and tone of voice, and you have to do that as an actor, but it became much easier to do because we had established the closeness off-camera. And we do similar things when we train scientists and doctors

to relate to an audience or to patients or to one another as part of a team. What's really interesting, it almost gave me a chill, what you said a few minutes ago, just the power of what looked like complaining or what looked like tomfoolery. It was actually deep, deep emotional bonding. And it reminded me so much of medical training, you know, where so much from the outside of what we're doing looks weird to other people, is impossible to describe to other people. And yet you leave residency and you never have relationships that are as intense with

friends again in your life. Nothing can ever quite compare to it. I'm just taking a guess at this, but I would imagine that trauma itself, being put through trauma as a training experience, for instance, is not in itself a constructive situation. What would be more constructive is learning as you're absorbing that trauma, learning how to not let it affect you, not let it interrupt your life now or later.

To learn an immune response to it rather than just be wounded. Burnout costs systems millions of dollars a year. And it's not just a problem for doctors and health care workers. It harms patients, people in real need. And the seeds are sown in medical training and the language of preparing for work on the front lines. on the front lines. I think one of the biggest influences that military language had on clinical training, on medical training, is that it really reconceptualizes the training process as conflict itself, as a kind of almost hazing ritual.

So there's this really pervasive idea in mid to late 20th century medicine in much of Europe and North America, and this continues, I would argue, to the present day, that you have to tough it out in order to be a good doctor. That becoming the Becoming the ideal doctor means going through something almost traumatic. In the UK, it was 120-hour weeks where doctors would basically never sleep and be working incredibly long hours with no break. And this is seen as akin to the sort of military world, right? There's no space for weakness in medicine. It's very macho, very masculine. And it is a way of shaping medicine's culture as well as a way of shaping medicine's knowledge

and interventory capacity. And there's a lot of camaraderie in there as well. You know, there are positives to this culture, you know, that you don't leave anyone behind, that you work kind of collaboratively, that you find a lot of meaning in your job, but also that you have to be incredibly resilient to be able to cope with the onslaught that is medical education and training. I think not making room for people's needs is very devastating. And I think that's why I see so many people looking for alternative ways of practicing their profession. Because it's just too hard to work in a setting where people don't see you, know you, and take your particular needs into account.

I've got the aorta. Give me some retraction and suction. Father Mulcahy, I can't get a pressure. I've lost the pulse. I'm going to open the chest. Give me a knife. I said give me a knife. Pierce, go help McIntyre. Come on, move.

We're jammed up in here. To be honest, I don't know what to make of all this. I'm left with a broken hero, a profession in crisis, and a metaphor that seems to have done just as much harm as good. I wonder if we should just do away with the language of war. As a historian of medicine, I spend a lot of time criticizing metaphors, particularly military metaphors, which I think are very incompatible with the interests of medicine as a profession, as an industry, as a system. But I do also think that human beings always make recourse to metaphor, that things that are as complex as emotions, as psychological health, as well-being, as disease, as mortality, as survival, these things are very difficult to pass in the language that we have. And they're very difficult to pass even in medical scientific terms. And so metaphors, even if they're flawed, they do help us make sense of incredibly complex and emotionally weighty

problems. And it's quite hard to imagine a world where we dealt with healthcare and didn't use some sort of metaphorical language. And maybe we need a different set of metaphors, but I don't know how you would do it really without some form of analogy, because it's too much. We will get through this. We will take casualties. I told Alan Alda about Lieutenant General Dallaire's address to health care workers in the early days of the pandemic. Our frontline troops, the medical and then the first responders. the medical and then the first responders.

How he'd used the language of war to help prepare us, and how some doctors, like me, found it comforting, while others objected to the language, insisting it didn't have a place within a profession dedicated to healing. The implication that war is causing death, no matter how you look at it, if you're engaging in a war, you're looking to cause some people to die. Whereas if you're engaging in medicine, you're looking at as many people as possible to live. So I can see not liking the implication that it's drawing on the language of hurt rather than health. But there are things about it and preparing for it, marshalling your resources, getting your intelligence tied down, accurate, figuring out a plan.

All of that is a smart thing to do in the service of health. All of that is a smart thing to do in the service of health. But maybe there are ways to do it without suggesting that we're going to kill something. Well, it was fun talking with you, Jill. Thank you. Alan, it was a privilege to talk to you again. Thank you. Some days I still find myself thinking back to Lieutenant General Roméo Dallaire, his words and his invocation to us. and his invocation to us.

It is essential that the families maintain close communications with those on the front lines, that you keep supporting them to reinforce those on the front lines. To me, that language suggests there is something redeeming in the comparison, especially in the pandemic era. But what if we reject the rest? Medicine as hazing, medicine as initiation, medicine as something that will leave us burnt out, bitter, and broken. I don't want that militarized language anymore. I don't want that macho, masochistic culture. I want, and what I believe we all want, is something better, something less heroic, something where working in healthcare is actually healthy for everyone. Doctors, nurses, patients, everyone. There has to be a way we can do it without destroying ourselves,

without breaking over and over and over with the best parts of us on display, our strength, our courage, our humanity, and our fragility. All the qualities I first saw reflected back at me by a fictional doctor practicing medicine in a war zone. What I want to do is rewrite the ending of both our stories, Hawkeye's and mine. You know, just because you're a doctor doesn't mean you're supposed to be perfect. Your patients are. Yeah. They have pain. Your patients are. Yeah. They have pain,

they're afraid. Actually, they're probably better off if you know how they feel. Might make being a surgeon a little harder, but it might make you a better doctor. Hawkeye went home in the end. He left war behind. Maybe we can too. You've been listening to Ideas and to Hawkeye's Army, a documentary by contributor Dr. Jillian Horton, medical doctor and author of We Are All Perfectly Fine, a memoir of love, medicine, and healing. This episode was produced by Jillian Horton and me, Nala Ayed,

with production assistance from Annie Bender. Many thanks to Brian Harder of CBC Winnipeg for his technical assistance. If you'd like to comment on anything you've heard in this episode or in any other, please visit our website at cbc.ca slash ideas. We're also on Facebook and on Twitter. Our web producer is Lisa Ayuso. Technical production, Danielle Duval. Our senior producer is Nikola Lukšić.

The executive producer of Ideas is Greg Kelly. And I'm Nala Ayed. For more CBC Podcasts, go to cbc.ca slash podcasts.