My First Medical Patient Was A Dead Man

The cadavers my medical classmates and I have learned to dissect remind us of the debt we owe to everyone who places their body in our hands.

I saw my first dead body when I was 9 years old. Set to the tune of a melancholic violin, I stood at the foot of the casket and kept my gaze focused on the polished dress shoes and sleek trousers that I had never seen our family friend wear while he was alive. He was a thoughtful man, generous with his time, remarkable in his steadiness and dependability. At my side, my parents kept their heads bent. In my periphery, I could see the tips of his pallid fingers, resting against his sides. Our silence stretched. Then my father sighed. My mother pressed a hand to my shoulder. They turned and walked toward the back of the room and I followed, passing by the casket without looking at his face.

I didn’t think of the funeral often, afterward. Death didn’t permeate my life; it existed in the recesses of my mind, in a box that I opened from time to time. I didn’t know what to do with it, or how to process it, or even what it was, really. And so it felt appropriate to keep my distance.

Dissection isn’t just about our own learning; it’s not about taking the body apart and studying it as you would an engine.

Thirteen years later, standing in a medical school lab this fall as my classmate sawed through the rib cage of the cadaver we were dissecting, I no longer had that option. The bone saw churned up white dust and an odor of burning hair. I slipped my fingers in between the separated bone and cartilage and pulled. Bones cracked, one after the other, until the rib cage came loose.

I imagined an unconscious patient in an emergency room, their pulse nonexistent, me compressing their chest with enough force to artificially pump blood through the body. It wouldn’t be a perfectly resilient plastic mannequin that looked pristine after I finished with it. I would be hammering my weight into the center of a person’s chest against resistance, hearing the pop of cartilage displacing, maybe ribs fracturing, willing life into a dying body.

With my hands deep in the cadaver’s chest, I realized that I didn’t have the luxury of staying aloof the way I had during that funeral years ago, or even during the anatomy classes I took in college. The people who make the decision to bequeath their bodies to medical institutions do so without ever meeting or knowing those of us who will be handling them, learning their nooks and crannies in a way that even their loved ones did not. Some may be contemplating that choice because of our failures as health care providers in the first place.

There’s a weight to that decision that demands that we, as doctors-to-be, acknowledge the trust that has been placed in us. Certainly, we have to be respectful, attentive, and committed to learning the material. But the dissection isn’t just about our own learning; it’s not about taking the body apart and studying it as you would an engine. Above everything, it’s an act of shared humanity. Viewing it as anything else would be a disservice to our donor, and to the debt that we owe to everyone who places their body — living or not — in our hands.

I was no stranger to corpses when I started medical school. I’d spent the past three years in an undergraduate health sciences program, and as part of the curriculum, we had to take a yearlong anatomy and physiology course with a laboratory component. Our university was unique in that it had a robust cadaver donor program — a meticulous process of collecting and preserving human bodies for the education of students like me. The bodies had already been dissected. Some of them were concealed in metal trolleys, arranged in rows along the walls. Others had been plastinated or cut into different parts called prosections and ensconced in clear acrylic cubes, displayed on shelves labeled by organ system. The chemical scent of formalin lingered in the room.

As we gathered around a trolley during our very first lab session, the teaching assistants assured us that there were students who had to step outside every year. It was nothing to be ashamed of, they said. After all, death could be difficult, messy, and a little smelly. But I could sense that everyone in our group was resolved not to embarrass themselves; squeamishness was supposed to be a thing of our high school biology past.

They unwrapped the wet cloth that moistened the cadaver, careful to keep the face covered. Pale skin, wrinkled and tinged yellow. Bright pink nail polish. A puddle of liquid and bits of flesh surrounding the body. The skin of the forearm was stripped away, baring muscle and sheaths of silvery tendon. I put on latex gloves and reached around another student to gently pull at a forearm muscle. The wrist flexed. No queasiness. Satisfied, I stepped back to let others have their turn.

I spent hundreds of hours in that lab over the course of the year, visiting in between and after classes and on weekends with friends. We’d learn by quizzing each other: Someone would point at a heart valve or a liver segment, and one of us would name it; another would ask a follow-up question about its function. Some of the bodies bore marks of age, having been in the lab for four or five years, and student curiosity — frayed nerves, thinning tendons, torn veins. We examined every specimen available to us, multiple times, from multiple angles, covering up body landmarks to make identification more difficult.

Some of the bodies bore marks of age, having been in the lab for four or five years, and student curiosity — frayed nerves, thinning tendons, torn veins.

This ritual was meant as preparation for the end-of-term practical exam: twenty stations — one a small chunk of the colon, another the knee joint, yet another a transverse section of meat that turned out to be an oxtail and was meant to test our ability to identify the ligaments surrounding the spinal cord. One minute per station to jot down the name of the part and answer questions about it. If an answer didn’t snap to mind within a few seconds, it was hard to hold back the panic.

I was tired of the cadavers by the end of those two semesters of anatomy — tired of the complexity of the human body, the overwhelming volume of material, and the demands on time that I didn’t have to absorb it. I just wanted the scent of flesh and formalin out of my nose and hair and clothes for good.

So when I was interviewing for medical school, the structure of the anatomy program was far down on my list of priorities. Despite the fact that dissecting a cadaver has long been considered a rite of passage for first-year medical students, there is an academic shift toward using prepared prosections and virtual learning tools instead as a more effective, efficient way of teaching anatomy. When I interviewed at schools that still used cadavers, student tour guides and professors discussed the opportunity to dissect as if it were a sacred prize. Given my time in the college anatomy lab, I was ambivalent. Why would it matter if I used a scalpel this time around? I just needed to learn the material.

Ultimately, I did end up at a school with a dissection program. And less than a week into the first quarter, there I was again — dressed in scrubs, standing in a group quietly gathered around the trolley containing our assigned cadaver, paying our respects. Then we started delegating tasks: unzip the body bag, lay out the equipment, mount the scalpel blades on their handles, mark the site of incision. We would be starting at a site just below the notch between the cadaver’s collarbones.

I felt a hesitation that had never struck me during my undergraduate anatomy course; I passed up the chance to make that first cut. Instead, I watched as my classmate drove the blade into the chest. Skin parted; liquid oozed as the blade dove deeper, slicing through connective tissue and fat. Using forceps, I grabbed at the free edge of skin; I cringed at the ripping sound as tissue tore loose. These were not the cleanly dissected, carefully prepared bodies I was used to.

Over the course of three-hour sessions, twice a week, much of our time was spent peeling off skin, hacking away at tough tissue, or suctioning the fluids that gathered in puddles around the body. At the foot of the cadaver was a pink hazard bag meant for disposal. It grew heavy with chunks of skin and bone, globs of fat, parts of organs — the lobe of the left lung that we had accidentally cut through, for instance. Everyone paused and went silent once we realized what had happened.

A classmate placed the two parts of the organ together, where the attachment used to be. Afterward, we went through the steps of the dissection more slowly, double-checking and triple-checking with one another and faculty before doing anything, distinctly aware of the permanence of our every action. There was a shared sense that every misstep was a violation.

In many ways, the role of the physician is fundamentally intrusive. As a medical trainee, I am being taught to ask patients questions and lots of them, ranging from prior illness to mental health concerns to sexual history. There are inclusive and compassionate ways of doing this, but at its core, we are asking patients to share intimate details of their lives that they may not have disclosed to anyone else. I am also learning how to conduct a physical examination, from peering into eyes and ears to feeling pulses on the ankles and feet, and everything in between.

Health professionals make every effort to ensure that patients are providing informed consent to what occurs in the medical setting. But no matter what, there will always be a degree of uncertainty for patients; they can only expect, or hope, that a doctor will minimize their pain or discomfort, will use the knowledge gained from exams in a productive way, and will communicate with compassion and empathy. The practice of medicine is predicated on this exchange of trust between patients and providers. I understood this, but when our professors referred to our cadavers as our very first patients, I was taken aback.

It seemed like a strange way of framing the experience. After all, the person who donated their body would never know our names or faces. Nothing that we did would directly affect them — an imprecise incision wouldn’t cause any lasting damage that they would have to live with. And there was certainly no shared dialogue between us. At a minimum, doesn’t a patient relationship require the fundamental act of a patient coming in to tell the physician about whatever’s worrying them? And if the cadaver was a patient, then we couldn’t just carry out the steps of a laboratory procedure. We were expected to provide a standard of care.

As our class proceeded with the dissection, we began to piece together the stories of our donors. Some groups found masses in the liver, or the pancreas, or ovaries; others found scars in telltale places, like the abdomen or knees — remnants of appendectomies and joint replacements. We began to develop an idea of the experiences that they’d had, both within and outside of the health system, and what had eventually ended their lives.

Our cadaver was a middle-aged man, likely in his fifties. Black stitches ran along the base of his neck where the embalming fluid had been injected into his arteries. Coarse, dark hairs covered his chest, arms, and hands. The pads of his long fingers were heavily calloused; I imagined him strumming a guitar and humming quietly to himself after a long day at work. His lungs were dotted with black stains, leading us to assume that he was a smoker. We later learned that the stains were typical, likely the result of decades of breathing in environmental pollutants, and that our own lungs would look exactly like his some years down the road.

Through the bequeathal of his body, our cadaver had invited us into his life.

He wasn’t able to articulate his health concerns, but he allowed us to witness and even feel them firsthand. Patients usually have the opportunity to scope out their doctors, to interact and determine if they’re comfortable with them. Without the benefit of being able to meet with us and discuss exactly what we would be doing to his body, our cadaver had placed his faith in our integrity and commitment to learning. He had considered and accepted the risk, however slight, of his body ending up in the hands of a student who might be careless, make a sloppy cut or an insensitive remark — who, after his death, wouldn’t see him as a person, but only as a collection of tissue. Through the bequeathal of his body, our cadaver had invited us into his life.

If thinking of a dead body as a patient seemed strange at first, I’ve begun to see it as a microcosm of the health care system at large. As medical students, residents, and fellows, we train by caring for patients. We ask patients to take part in research studies, which might involve anything from filling out a survey to undergoing an entirely new surgical procedure. Trust is requested, patients provide it, and we do our best to be worthy of it.

We have failed this responsibility repeatedly. In the 1840s, the gynecologist J. Marion Sims (who created the speculum that is widely used in physical exams today) practiced surgical procedures on enslaved black women, without anesthesia. In a 1950s study under the direction of award-winning researcher Saul Krugman, children with intellectual disabilities at Willowbrook State School in Staten Island were deliberately infected with a hepatitis virus. The urologist Perry Hudson recruited people who were homeless in New York City in the 1950s to participate in prostate cancer experiments, promising them food and shelter.

Cumulatively, this history has led the profession to move toward a patient-centered model that is emphatic about informed consent and shared decision-making. While institutional review boards and strict ethical guidelines have reformed research and health care delivery, it would be inaccurate to say that paternalistic, unethical care is entirely in the past. For instance, there continue to be significant disparities in the quality and accessibility of care that disproportionately affect people of color, queer people, women, and other marginalized communities. As physicians, we have a responsibility to hold ourselves and our colleagues accountable in advocating for and providing culturally competent care that recognizes the needs of these communities. And our cadavers, unable to speak or even twitch in response to something painful, gave us an important introduction to caring for those who have been rendered silent or invisible.

As we yank and tug at arteries clotted with blood and stringy nerves, as we cringe at oozing clumps of fat that splash everywhere when we flip the body to dissect the back, as we reduce a human being to the minutiae of their parts, there is a sense of obligation — not just to be respectful of the body and to dedicate ourselves to learning the material, but to recognize that medicine is built on sacrifice.

Many advancements in medicine have resulted from a violation of the vow to do no harm, and yet we continue to ask for and receive the trust of patients. Providing compassionate, knowledgeable, and ethical care, and continually pushing the boundaries of the field forward, is both our responsibility and an acknowledgment of a debt that we cannot repay. ●

Anna Goshua is a medical student at Stanford University with interests in mental health, chronic pain, and narrative medicine.

This story is part of a series about debts of all kinds.

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