The physician Anton Chekov (1860–1904) developed a passion for writing at an early age. Acutely aware of the social and health inequalities, his stories centre upon clinical encounters with poor and marginalised sectors of a society in turmoil. In Ward Number Six (1892), the setting is a destitute provincial hospital, the demise of which has gone unnoticed by the central authorities. The unwelcoming and rusting premises exude a ‘doomed air’. The story centres upon Andrej Ragin, the chief doctor, and his relationship with Ivan Gromov, a long-term psychiatric patient. Ragin is initially outraged by the filthy conditions and seeks to bring about change. However, the relentless flow of illness and death take their toll, and Ragin’s determination gives way to disillusionment and despair. A fatalistic attitude — ‘expel physical and moral filth from one place and it will only crop up elsewhere’ — eases his conscience and justifies his waning engagement with patients and dissipating sense of professional and moral duty.
Ragin spends more and more of his time debating the purpose of life and death with Gromov. Ragin has lived a protected and comfortable life and believes that suffering and hardship are bestowed upon individuals at random and that these individuals must learn to ignore their effects. His philosophical stance is countered by Gromov’s realism. Gromov is a product of the anguish and difficulties he has endured. A social reformer at heart, he harbours a desperate desire to affect change and a passionate love of life despite its injustices. Initially infuriated by each other, Ragin and Gromov soon develop a mutual respect. When Ragin’s sanity is called into question and he is admitted to his own ward, the physical and mental distress he suffers enable him to finally truly understand the lived ‘realities’ of Gromov and the other patients. Ragin renounces his previously held views and wholeheartedly takes on Gromov’s philosophy.
The themes of Ward Number Six provide relevant lessons for today’s medical practice on several levels. Firstly, there is the matter of ideology. Chekov struggled for much of his life to reconcile the opposing views of philosophy and realism. In Ward Number Six, the latter triumphs. But in reality, a healthy balance of each is necessary. A philosophical approach allows us to distance ourselves from the matter at hand — whether a clinical encounter or a population health challenge — and adopt a reflective, objective stance. Realism, however, is what keeps our actions and initiatives grounded, realistic, and relevant. On an individual level, a more conscious awareness of our own biases and an acknowledgement of how we have each been shaped by our past can encourage mutual understanding and enable collaborative working between clinicians and patients.
Secondly, Ward Number Six illustrates the complex determinants of health. The overwhelming inter-connectedness of the vast array of social, environmental and health factors causes Ragin to capitulate. Indeed, the links are so great and complex that tackling ill health in the real world is an impossible task for any single discipline. Success comes through partnership working, not only across all clinical disciplines but also including specialties such as public health, social care and other allied fields.
Finally, the dehumanisation of Chekov’s so-called ‘lunatics’ serves as a powerful reminder of the need to provide care with sensitivity, empathy, dignity and respect. While this principle applies equally to all, it is perhaps particularly pertinent to the most vulnerable and the most marginalised, who are often the ones most prone to maltreatment. In Ward Number Six, it takes Ragin a visit to the receiving end of care to grasp the importance of humane care. For the rest of us, it is worth stopping every once in a while to question whether we are really providing the best care that we can.
- © British Journal of General Practice 2014