A Christmas Truce

In December of 1914, what came to be known as World War 1 was well underway. Few anticipated the extent of the global tragedy that would ensue, that it would go on for another four years, or that it would result in at least 20 million military and civilian deaths. It’s hard to imagine that anyone who survived and celebrated the end of that war could have anticipated that it would give rise to an even greater disaster in the form of the great influenza pandemic of 1918-19, which accounted for a further (likely underestimated) 25 million deaths.

As that first Christmas of the war approached, hundreds of thousands of young men from Germany, France, and all parts of the former British Empire, including Canada, were entrenched in long lines dug into the ground facing each other across fields known as “no man’s land”.  Most were away from home for the first time in their lives, cold, hungry, desperately homesick and, one can only imagine, fearful of what lay ahead.

The events of that first Christmas have been recorded largely through the accounts provided by the soldiers themselves through letters preserved in a remarkable collection by the National World War 1 Museum (http://exhibitions.theworldwar.org/christmas-truce/incidents).

The words of those young men transcend the years to tell the story:

Sargent A. Lovell,  – 2nd Northamptonshire Regiment, writing to relatives at Walthamstow, on Christmas Day, says:

“Christmas Day! The most wonderful day on record. In the early hours of the morning the events of last night appeared as some weird dream – but to-day, well, it beggars description. You will hardly credit what I am going to tell you. Listen. Last night as I sat in my little dug-out, writing, my chum came bursting in upon me with: “Bob! hark at ‘em!” And I listened. From the German trenches came the sound of music and singing. My chum continued. “They’ve got Christmas trees all along the top of their trenches I Never saw such a sight!”. Climbing the parapet, I saw a sight which I shall remember to my dying day. Right along the whole of their line were hung paper lanterns and illuminations of every description, many of them in such positions as to suggest that they were hung upon Christmas trees.

And as I stood in wonder a rousing song came over to us – “The Watch on the Rhine.” Our boys answered with a cheer, while a neighbouring regiment sang lustily the National Anthem. Some were for shooting the lights away, but almost at the first shot there came a shout in really good English: “Stop shooting!”. Then began a series of answering shouts from trench to trench. It was incredible. “Halloo! Halloo! you English; we wish to speak.” And everyone began to speak at once. Some were rational, others the reverse to complimentary. Eventually some sort of order obtained, and lo! A party of our men got out from the trenches and invited the Germans to meet them half-way and talk. And there in the searchlight they stood, Englishman and German, chatting and smoking cigarettes together midway between the lines. A rousing cheer went up from a friend and foe alike. The group was too far away for me to hear what was said, but presently we heard a cheery “Good-night.” A Merry Christmas and a Happy New Year to you all,” with which the parties returned to their respective trenches. After this we remained the whole night through singing with the enemy song for song. “Give us ‘Tipperary'”, they cried. Whereupon an adjacent Irish regiment let loose a tremendous “whoop,” and complied with the request in a way as only Irishmen can.”

Published January 1, 1915 in The Bedfordshire Times and Independent 

Miss N. Thody, 1, Peel-street, Bedford, has received a letter from Lance Corporal Cooper of the 2nd Northampton’s which gives an astonishing account of Christmas Day in the trenches. It is dated December 27th:

“At last I have found the time to answer all your letters. Well dear, you asked me to let you know what kind of Christmas I had. Well I never had a merry one because we were in the trenches, but we were quite happy. Now what I am going to tell you will be hard to believe, but it is quite true. There was no firing on Christmas Day and the Germans were quite friendly with us. They even came over to our trenches and gave us cigars and cigarettes and chocolate and of course we gave them things in return. Just after one o’clock on Christmas morning I was on look-out duty and one of the Germans wished me Good morning and a Merry Christmas. I was never more surprised in my life when daylight came to see them all sitting on top of the trenches waving their hands and singing to us. Just before we came out of the trenches (we came out of them on Christmas night) one of them shouted across, “Keep your heads down, we are just going to fire” and they sent about a dozen bullets flying over the top of our heads. Now who would believe it if they did not see it with their own eyes? It is hard enough for us to believe. What kind of Christmas did you have? I do hope you enjoyed yourself. I thought of you a good many times. I don’t expect it was much of a Christmas in England. I haven’t received mother’s parcel yet. I wonder what has become of it. I have had some eatables but they were nowhere near as good as mother’s.”

Published January 8, 1915 in Bucks Examiner 

Rifleman J. Reading, writing to his wife, Mrs. Reading, of Germain Street,

“I hope you all had a merry Christmas; let me tell you how I spent mine. My company happened to be in the firing line on Christmas eve, and it was my turn – with a non-commissioned officer and four others – to go into a ruined house and remain there until 6.30 on Christmas morning. During the early part of the morning the Germans started singing and shouting, all in good English. They shouted out: “Are you the Rifle Brigade; have you a spare bottle; if so we will come half way and you come the other half.” At 4 a.m part of their Band played some Christmas carols and “God save the King”, and “Home Sweet Home.” You could guess our feelings. Later on in the day they came towards us, and our chaps went out to meet them. Of course neither of us had any rifles. I shook hands with some of them, and they gave us cigarettes and cigars. We did not fire that day, and everything was so quiet that it seemed like a dream. We took advantage of the quiet day and brought our dead in.”

Published January 15, 1915 in Essex County Chronicle 

Private Farnden, of the Rifle Brigade, writing to his parents at Leyton, says:

“We had a very decent Christmas Day in the trenches. We had Christmas puddings sent up to us and a few of the boys and myself managed to hot them up, and with some sausage and potatoes and brussels sprouts, which we succeeded in foraging from a farm, we had a very good dinner. On Christmas Eve we were surprised to see Christmas trees alight on the tops of the enemy’s trenches. Some of the Germans (139th Saxon Regiment) shouted to our fellows to come over and have a drink and a smoke. They turned the searchlight on, and some of our boys went out and met them half-way. The first German who came along threw his arms around one of our chap’s neck and kissed him. Next they offered us cigars. On Christmas Day we were out of the trenches along with the Germans, some of whom had a song and dance, while two of our platoons had a game of football. It was surprising to see the German soldiers – some appeared old, others were boys, and others wore glasses. But they ‘played the game’ for that they, and some of them even went as far as to state they would not shoot so long as our regiment was on that particular set of trenches. A number of our fellows have got addresses from the Germans and are going to try and meet one another after the war.”

There are many such accounts. Apparently, a friendly soccer game broke out, won by the British 3-2!

What emerges in reading these accounts is the fundamental decency of these young people who found themselves caught up in world events far beyond their understanding or control. Despite all that, their instinct was to regard the men facing them across that space not as natural enemies, but as fellow human beings caught up in similar circumstances.  None of those men of Christmas 1914 are any longer among us, indeed many will not have survived that war, but their words reach us today.

One of those young men was my wife’s grandfather. Orphaned in Scotland and transported to Canada at the age of 8 as one of “Dr. Bernardo’s Boys”, he was fortunate to be adopted by a kindly farming family near Creemore Ontario. Not so fortunately, he was drafted at a very young age and found himself in one of those trenches that Christmas Eve. He would be involved in some of the most horrific battles of that conflict and, at one point, was exposed to “mustard gas” requiring a long hospitalization. In a postcard to his sweetheart back home (who would marry on his return and become my wife’s grandmother) he wrote the following on December 2, 1917:

Dear Elma.

Just a few lines to let you know I am about the same, hoping you are in the best of health. Cecil is here. I saw him yesterday. Dear Howard my pal was killed just two days after I got gassed. Poor chap. I sure feel sorry.

Your sincere sweetheart, Jack.

Like most of his contemporaries, he never wrote or even spoke of experiences after the war, becoming a quiet, unassuming, and dutiful husband, father and grandfather known as hard worker and prodigious gardener in his later years. In fact, little would be known of his wartime service if not for those postcards and a few artefacts found among his possessions long after his death.

Certainly, we can appreciate parallels in the crises we face today. The world remains an uncertain place. Both real and perceived enemies abound – human, biologic, environmental. The “better angels of our nature” that Lincoln evoked in his first inaugural address seem elusive, both in others and ourselves. Through all this, the words and actions of those young men from that Christmas so long ago seem more meaningful than the political conflicts that took them to those fields or results of the battles they fought. They remind us that most people, left to their own devices, will do the right and kindly thing, that wars and pandemics do eventually end and, ultimately, what persists and endures is how we engage difficult times and treat each other.

Here’s to our better angels.

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The Existential Conflict of the Clinical Clerkship

As one might imagine, I get a lot of questions from medical students. Many are on clinical topics. Most relate to my role with the MD program. Usually, they’re questions I’ve heard in various forms in the past and so can draw from previous experience in considering what to say.

Occasionally, I am posed a question that is completely fresh and rather profound. Such questions cause me to pause, reconsider previous assumptions and go back to first principles. I am grateful for such questions and regard them as one of the real benefits of working with bright and inquisitive young people.

One such question came recently from a third-year student about to start the clinical clerkship. The question came after we’d chatted about the clerkship experience in general terms and went something like this:

“I’m worried about a lot of things. I know that’s my nature and I know most of it will eventually turn out OK. But what do you think I really need to be worried about and focus on?”

Wow! Insight like that, I felt, deserves a thoughtful response. And so, I’ve been reflecting afresh on what the world must look like from the perspective of a student at the mid-point of their medical education, about to enter the world of clinical medicine for the first time. Of all the things they could worry about, what should they worry about?

So, here goes…

My young friend’s question and struggle is rooted in what has become in recent years a highly troubling conflict with respect to the objectives of the clinical clerkship. Pedagogically, the clerkship is intended to provide clinical experiences that will allow students to consolidate and refine the fundamental knowledge and skills they’ve acquired in the pre-clerkship years. It’s a protected, highly supervised proving ground where they will encounter real patients in authentic clinical situations. It’s intended to allow students to transition from the abstract and theoretical to the “real world” of clinical medicine, encountering patients who are, in whatever means available to them, seeking help as they suffer from medical issues.

As they engage the clerkship, students will gain much knowledge about clinical medicine and how it’s provided in all its forms and settings. They will gain practical skills in the procedures that are commonly carried out by doctors. They will become familiar with the various settings in which medical care is provided in our institutions and communities, and about their comfort within each. They will learn how to work with doctors who are engaging various medical roles, and collaboratively with nurses and a myriad of highly skilled allied health providers.

But the most profound learning they will experience is about themselves. Specifically, about how they will accept and respond to the experience of engaging patients in need. For the first time, in real life settings, they will encounter real patients (not actors, not “virtual” patients) who are truly suffering in some way and our students will be, in some small way, in a position to contribute to their care.

They will need to find a way to relate to those patients. Those relationships, to be optimally effective, must be rooted in a genuine sense of caring about the welfare of that person they are encountering for the first time. They can’t fully care for a person unless they care about that person. Will they be able to find that delicate balance that allows them to fully commit to the patient while still retaining objective judgement about the circumstances and options available?

Achieving all this requires immersion in a clinical setting, close supervision with ability to review problems that arise, and sufficient time to develop a relationship with patients through their illness experience. None of this is specialty specific. These encounters, and the essential skill development that they allow, can occur for a student in a great variety of clinical settings. The ability to engage and connect with a patient is not dependent on the condition or problem for which they are seeking help, or the setting in which it is being provided.

And therein lies the existential conflict and the core of my student’s question.

The modern clerkship has become, at least in equal parts for most students, an exercise in career exploration and preparation for the residency match. Consequently, the focus has shifted over the years from long, immersive placements in medical care settings, to a series of much briefer discipline-based exposures with a generous admixture of electives, all intended to provide the maximal number of experiences and exposures. It has become the medical education equivalent of choosing to visit 12 European countries in 14 days rather than spend the entire two weeks in one place. The consequence is that student interactions with individual patients, although numerous, are increasingly brief and superficial. Their exposure to faculty members is similarly brief, often far too fleeting to allow for the development of relationships that provide deep teaching or the development of true mentorship. All this is degrading the educational experience in favour of specialty tourism.

Importantly, this is not their fault. Students are essentially forced to adopt such strategies to navigate what has remained a highly balkanized educational process with rigid separation of the university-based undergraduate experience from the discipline-based residency process. The result is a jarring transition from the one-size-fits-all MD program to approximately 30 entry level residencies, eventually leading to over 100 specialty programs.

It’s also not the fault of undergraduate programs which have adapted to meet the needs of their students, which is their primary obligation. It’s not the fault of the myriad college-based specialty programs which are rightfully focused on providing valid training programs leading to qualification in their various specialties.

The solution to all this lies collectively within the broader profession and the plethora of deeply entrenched institutions involved in various ways with important but unaligned components of the education and qualification of doctors. We have collectively been either unwilling or unable to look beyond our individual institutional responsibilities and engage the larger problem, which is eroding and, importantly, progressively lengthening the process by which we train doctors, all at a time when our country desperately requires qualified physicians, particularly in generalist roles. The issue facing our universities, colleges, specialty committees and regulators is not whether the collective system of education needs to change or whether they need to be involved in that collective “re-think”. The question is who will blink first and be willing to rise above their parochial interest to begin the process.  

And so, given that this will not be solved within the next year, what advice for my young friend and all the students of today?

I’m tempted to draw their attention to an oft-quoted fake-Latin phrase that appears in Margaret Atwood’s Handmaid’s Tale. It goes “nolite te bastardes carborundorum”.  Basically, don’t let the system get you down. Stay true to your roots and educational purpose. Yes, you need to think about specialty choice and navigate an admittedly perverse process, but you will be best served both in the short and long term by developing your fundamental skills in the many opportunities that are available to you. Engage the patient first, the problem second. Seek out role models, watch what they do, and seek out their guidance regardless of their specialty. You will be surprised at how welcoming they will be and how willing they will be to engage an eager learner.

Because that is what we do. That is how you will develop as a doctor. That is how you will find the fulfillment and satisfaction that this wonderful career you have chosen truly provides.

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