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Home Our Missions Mission of Education The Silent Speak Volumes

The Silent Speak Volumes

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In a ceremony of gratitude, the Tzu Chi University medical school dedicates another group of donated cadavers to its medical training program. Ceremony program in hand, a donor’s family member remembers a loved one.

For more than 15 years, Tzu Chi has advocated body donation for medical study and research. Its medical school has been a pioneer in Taiwan in using donated corpses for anatomy instruction and hands-on surgical simulation. Medical students and veteran surgeons alike have learned much from the program. Many of them have gained more than medical skills—they’ve also learned to cultivate a sense of warm gratitude to the cadavers, whom they reverently call their “silent mentors.”

A coffee maker sat in a corner of the clean anatomy lab, ready to serve people who wanted a cup of java to relax or to keep up their spirits. Someone had placed his cup on the edge of an operating table and was munching away on a donut, totally oblivious of cadavers lying nearby.

This is what Tseng Guo-Fang, Ph.D., (曾國藩), remembers about the casual atmosphere of an anatomy lab at his school when he studied in the United States in the 1980s. Tseng is now the vice president of research and development at Tzu Chi University. He also heads the university’s Medical Simulation Center.

In the book Intern: A Doctor’s Initiation by Dr. Sandeep Jauhar, there is also a passage about an anatomy lab: “In the formaldehyde-ridden anatomy lab, the humor was dark. When we were dissecting the heart, my partner took the organ, rested it precariously on our embalmed cadaver’s forearm, and said, ‘This guy really likes to wear his heart on his sleeve.’”

The casual atmosphere Tseng described and the dark humor Dr. Jauhar portrayed denoted a detached relationship between the cadavers and the living who studied them. The bodies were nameless, devoid of any human dimension beyond the physical, little more than objects or props the students used to further their knowledge. For privacy and other reasons, Americans withhold the identities of the deceased from medical students and others who learn from them in teaching labs. Cadavers are teaching aids, plain and simple.

As if this anonymity was not enough to ensure an air-tight emotional barrier between the students and the cadavers, institutions even divide whole corpses into body parts which they divvy out to appropriate users: a hand for a future orthopedic doctor or a stomach for a few students striving to learn general surgery.

Oftentimes, the predominant objective of working with a cadaver is to learn about the human body or the nuances of surgery. The participants probably must concentrate all their attention just to get a good handle on the task at hand, just to achieve their objective of learning. That leaves them little or no time to get to know their cadaver as a person. The hectic life of those in medical training also helps ensure that they don’t have much time to think about the people who have donated their bodies to help them learn.

In Stiff: The Curious Lives of Human Cadavers, Mary Roach writes: “Gross anatomy provides the medical student with what is very often his or her first exposure to a dead body; as such, it has long been considered a vital, necessary step in the doctor’s education. But what was learned, up until quite recently, was not respect and sensitivity, but the opposite.” Roach goes on to observe that the traditional anatomy lab represented a kind of sink-or-swim mentality about dealing with death. To handle what was being asked of them, “medical students had to find ways to desensitize themselves. They quickly learned to objectify cadavers, to think of the dead as structures and tissues, and not a former human being.”

Bodies with names and stories
The situation in Taiwan was much the same as in the United States, perhaps even a little worse in one respect: The Chinese traditionally believe that the body of a deceased person must be buried whole. Most people in Taiwan would never even bring up the topic of death, much less engage in any in-depth discussion of organ or corpse donation.

As a result, corpses for medical education used to be in short supply. The main source was unclaimed bodies from the judicial and police systems. These were, of course, provided without names.

Thus medical students in Taiwan, like those in the United States, were traditionally matter-of-fact and impersonal towards the corpses on which they worked. Dr. Lee Ming-che (李明哲), head of the Department of Surgery at the Hualien Tzu Chi Medical Center, recalled his days as a medical student in the anatomy lab: “We mostly chatted and laughed all through the sessions as we did our thing with the cadavers. Day in and day out, we never gave a thought to where the corpses had come from.”

Lee remembered that he once had to share a cadaver with 28 of his classmates. He ended up getting the cadaver’s left hand. He remembered that the hand was in pretty good shape, but he knew nothing else about its owner. He didn’t remember what the cadaver looked like, nor did he know the cause of his death. Perhaps it was closer to the truth to say that he and his classmates simply did not care about those details. Their experience typified the prevailing medical culture in Taiwan at the time.

That culture only began to change when the Tzu Chi medical school initiated its own body donation program.

In 1995, a woman telephoned Lee Ming-liang (李明亮), then president of Tzu Chi University, and expressed her interest in donating her body for medical use when she died. The university had no existing program or protocol to handle this request, so they created an application and program for it. This was the start of the body donation program at the school. Aided by Tzu Chi’s advocacy, more people have warmed up to the idea of giving their bodies to medical institutions for teaching or research.

In the Tzu Chi body donation program, cadavers used in anatomy labs and in simulated surgeries are no longer nameless objects. Instead, they are revered as “silent mentors.” In fact, medical students in the program are required to get to know their mentors before they work on their bodies.

To this end, students visit and talk with the family members of their silent mentors to gather information, which they organize and put on PowerPoint slides. They make their presentations in a gathering of donors’ families, faculty, and students of the Department of Medicine. If the cadavers are to be used for simulated surgery, then physicians from Tzu Chi hospitals are also present. Such a gathering usually occurs ahead of the official cadaver dedication ceremony.

It is easy through this process for program participants to see their silent mentors as real people with names, families, and life stories. In Tzu Chi, body donors are people who loved humanity enough to offer the totality of their physical beings to help advance the knowledge and skills of medical students and other professionals, skills which can then be used to benefit countless future living patients. The beneficial effects of the program are as far-reaching as they are long-lasting.

The familiarity and respect that participants maintain for their silent mentors have thus become a distinguishing characteristic that makes the Tzu Chi program stand out from those at other organizations.

The Tzu Chi simulated surgery program was started in 2002. It wasn’t long before the program attracted the attention of the Wall Street Journal. The paper’s Beijing correspondent, Ian Johnson, visited the Tzu Chi University Medical Simulation Center from February 18 to 23, 2009, during which he observed a four-day simulated surgery workshop, one of four such sessions that the school holds each year.

Johnson’s piece on the visit appeared in the Journal on April 22, 2009. He pointed out that the close interactions between student participants at Tzu Chi and the families of body donors could help ease or reverse the traditional Chinese aversion to body donation. Furthermore, at the end of the workshop students painstakingly suture all the body parts back and return each corpse to its original state. This gesture may have also helped to appease a public that holds deeply rooted beliefs that one’s body at burial should be whole.

Life’s last and lasting decision
Li He-zhen (李鶴振) is a well-known body donor in Tzu Chi. In August 1995, Li was diagnosed with pancreatic cancer. His doctors said that he had only six months to live and that neither surgery nor chemotherapy would be effective, not even just to ensure that his quality of life could be maintained.

He and his family were not certain about what course of action to take. One day while driving home from the hospital, Li listened to an audio tape about the body donation program at Tzu Chi. He learned that because the program did not use formalin to soak-preserve cadavers (using a dry method instead), it would not accept bodies that had undergone major operations. This knowledge cemented his decision for his next steps.

“That’s good. I will not receive any further treatment,” Li said right then and there. He decided to forgo treatment in order to preserve the integrity and eligibility of his body for donation to Tzu Chi.

He asked his wife, Chen Yi-mei (陳意美), to get an application form for body donation. Chen initially hesitated, and Li had to ask her repeatedly. Finally she realized that any further medical intervention would serve only to artificially and perhaps marginally prolong her husband’s life, but it would not improve his quality of living. With treatment, their family might get some extra time with him, but her husband would have to endure the torments of a rigorous treatment regimen. She asked herself if it would be fair to ask him to do that.

Finally she decided to support her husband’s desire to donate his body. They completed the necessary paperwork, and he checked into the palliative ward of the Hualien Tzu Chi Medical Center for the final stage of his life.

While there, Li met with some medical students from Tzu Chi University. “My illness is beyond treatment,” he said to them. “Surgery or chemo will not be necessary or helpful, and such treatments would disqualify my body for donation purposes. When I die, I want to give my body to you in its undamaged totality. In your hands, it might help with your studies and do some last good for mankind. My wish will be fulfilled when you operate on me.”

The day eventually came for Li’s wish to be fulfilled. When third-year med students Zeng Yu-fang (曾愉芳), Xiao Fu-zong (蕭輔宗), and others opened his abdominal cavity, they saw a pancreas disfigured almost beyond recognition by the tumor, which had also metastasized throughout the surrounding organs and blood vessels. The students could only imagine how much pain their silent mentor had chosen to endure in order to preserve the integrity of his body over treatment. His altruistic spirit helped them sense their future responsibilities as medical practitioners.

Moments of realizations and reflections like this one not only help make program participants more appreciative, they also help them to become skilled, caring, loving, and humane medical care providers—the ultimate goal of Tzu Chi’s medical education.

“Recycling” human bodies
In the sense that otherwise useless cadavers are put to productive educational use, the body donation program at Tzu Chi is in essence a body recycling program. As such, its value is commonly recognized among all those who value the benefits and need for recycling.
However, the body donation program at Tzu Chi is much more involved than a typical recycling program. Many factors can prevent the successful donation of a body. Although the donor’s sign-up card starts the donation process, it is the surviving family members who must carry his or her wishes out. Furthermore, the donor’s family must make the actual donation without delay upon the donor’s death.

At such moments, the donor’s family is understandably upset at the loss of their loved one. It is therefore not uncommon for some of them to have second thoughts about the wisdom of donating the body for strangers to cut open and examine. Hard discussions and even arguments among family members sometimes ensue, eating away precious seconds and minutes in which to call for an emergency vehicle to take the body to Tzu Chi University for immediate preservation, a time-sensitive and essential step in body donation.

Arriving at the school too long after death makes a body unfit for the purpose of the body donation program. If the cadaver is to be used for an anatomy program, it must arrive within 24 hours of death. But more stringent guidelines are applied if the corpse is to be used for surgery simulation. In those instances, the quick-freezing preservation of corpses must start within eight hours of death.

To help minimize any posthumous delays, donation program workers start working with a prospective donor and their family members while the donor is still living. “It is not just a matter of survivors calling the donation center when the donor passes away,” said Xie Wei-can (謝為燦), a program volunteer worker. “The donation process goes a lot more smoothly when we start caring for and communicating with family members before he passes away.”

There are other factors to consider before a donor’s body is accepted. Being too thin or overweight can disqualify one from donating, as can major wounds, severe edema, or communicable diseases such as syphilis, AIDS, or malaria. Volunteers have to evaluate each case to make certain nothing is amiss. When the time comes, they also assist family members in obtaining death certificates from the hospital. When a donated cadaver has been loaded into an ambulance to be delivered to the anatomy department of Tzu Chi University, volunteers immediately phone the department so that the personnel there can prepare to receive the body.

Tidbits about the program
The facilities for body preservation and storage are on the second floor of the Department of Anatomy building. It is a place that family members, Tzu Chi volunteers, and guest groups visit from time to time. Openness and warmth abound in the body donation program at Tzu Chi.
Early on, students at the medical school played a relatively passive role in the life of the Tzu Chi anatomy program. For example, it was Tzu Chi documenting volunteers, not medical students, who interviewed family members of the donors to collect the donors’ personal data. The students were mainly involved only in learning from the cadavers.

But that changed in 2000, when Professor Wang Yueh-Jan (王曰然) started requiring students in anatomy classes to collect information about body donors themselves. After that, the students began the tradition of visiting family members and writing brief biographies of body donors.

That tradition carried over to the simulated surgery program, which started in 2002. Now, attending and resident surgeons from the six Tzu Chi hospitals join students on their visits to donors’ families. This tradition is quite a reversal from the conventional physician/patient relationship, in which the traffic flow is almost exclusively in the opposite direction. The visits of the physicians make family members feel that they and the bodies of their loved ones are respected and valued.

Third-year students in the anatomy program use a cadaver for a full semester, during which it is thoroughly utilized to offer educational training. At the end of that period, students suture all parts of the cadaver back together. This assignment, in addition to being a gesture of respect for the donated body, can also help students learn and practice the art of suturing. Following this, the students’ work is carefully examined by Professor Wang. She accepts only the most respectable and presentable efforts from the students.

In the simulated surgery program for surgeons and sixth-year students, a cadaver is used for four consecutive days. As in the anatomy program, the cadaver is sutured together at the conclusion of the last day’s work.

After that, a farewell ceremony follows. Many people are involved: representatives of the anatomy department, the university, the Tzu Chi Foundation, the Tzu Chi hospitals, volunteers, and nuns from the Jing Si Abode (the Tzu Chi headquarters). Last but certainly not least are the family members of the donors.

After the farewell, the cadavers are taken to a crematory.

Understandably, the farewell and the cremation ceremonies entail a lot of work. In the earlier days of the program, students took little part in this work. However, Professor Wang, always mindful of cultivating loving students, also wanted to use the ceremonies as educational opportunities. “The students have been the primary beneficiaries of this program, but they gave precious little in the way of helping. They didn’t even accompany the cadavers to the crematory,” she said.

It used to be Tzu Chi volunteers, some quite elderly, who scrubbed the crematory clean the day before a scheduled cremation. But Wang envisioned something different. She thought that students learning from the cadavers should be the ones to prepare the crematorium.

That idea led to another new tradition in the school. Since the school’s anatomy program uses one batch of corpses a year and the simulated surgery program holds four or five sessions a year, the teachers and students of the anatomy department go to the crematorium five or six times a year to clean up. This change has further involved the students in the care of the bodies from which they learn.

At the end of the semester, the teachers and students also thoroughly spruce up the anatomy lab. For example, they scrub the operating tables right down to the roller wheels in order to rid them of all foreign substances and fluids that may have escaped the regular cleanings after each use.

Visiting family members, suturing bodies, and cleaning the crematorium and the anatomy lab—these are activities that in other medical schools might be considered peripheral or non-essential to the learning of core medical skills. But in Tzu Chi, they have everything to do with learning the core skills of being a caring physician. They are considered important tools that can add a dimension of compassion to the realm of skillful medical care.

A skilled doctor without a compassionate touch is incomplete. “You’ll not become a good [skillful and loving] doctor overnight simply because you graduate at 25. You need to make an effort to gain the required abilities and compassion,” Wang says. This philosophy is the impetus for the changes that she and others have instituted in the Tzu Chi body donation program.

A guest participant
Ren Linglan (任泠斕) was a fifth-year medical student at Lanzhou University, located in Gansu Province, China, when she participated in an exchange program with Tzu Chi University. While there, she took part in a simulated surgery workshop.

One day the workshop participants gathered to share their thoughts about the program that they had just completed. At the podium, Ren said, “Standing here, I feel deeply grateful. Over the last four days, our silent mentors lay there quietly, completely at our disposal. From them, we’ve learned not only medical techniques, but also how noble life can be.”

With obvious emotion, Ren recalled an incident in the program. “The moment I touched my mentor to practice intubation, I couldn’t keep my tears from falling and my body from trembling. I couldn’t do the procedure because I was thinking of my first emergency operation six months before at a hospital back home.”

The night that Ren was referring to occurred when she was on duty as an intern and saw a patient who had disseminated intravascular coagulation and dilated pupils, and who was unable to breathe. Her first thought was to intubate the patient to restore breathing.

“My teacher had gone to order the large amount of medication needed for the emergency procedure, leaving me alone with the patient,” Ren continued. She hurriedly reviewed in her mind the steps for inserting a breathing tube: Open the patient’s mouth, insert the tube down the throat. It seemed simple enough on paper, but she had never done it before. “My mind was a blank, but I knew there was no time to waste.” Despite her best attempts, the tube just would not go in. “Later, my teacher came back and got the intubation done. However, the patient died anyway of organ failures.”

Ren could not sleep that night. She blamed herself for being so panicky, inept, and utterly helpless. She told herself that she had to try harder to learn and be more professional.

“I had always wanted to be a good doctor with compassion. But after that failure, perhaps unconsciously I drifted away from that goal and inched towards becoming just a skillful medical technician who treats illnesses.”

It was with that frame of mind that Ren went to Hualien for the exchange study. She thought she might pick up a technique or two from the exchange, but she was not expecting much else. However, the simulated surgery program really made an impact on her.

The silent mentor gave Ren plenty of time and opportunity to learn techniques, including intubation, which had been haunting her. What’s more, the family members of the body donors also surrounded her with kindness and love. The program taught her appreciation, gratitude, and love—indispensable ingredients with which compassionate physicians are cultivated.

“I thank Tzu Chi University for this program, and the mentors for their selfless offering and Great Love. I believe that they will guide me when I work with future patients and their families and when I experience difficulties and emotional lows,” Ren concluded.

The four short days in the program had helped her find her love and confidence once again. Rounds of applause followed her talk, wishing her well on her way to becoming a good doctor.

By participating in the program, Ren witnessed the Tzu Chi core values of gratitude, respect, and love. Through the body donation program, Tzu Chi hopes to serve as a cradle for more good doctors for society.


By Ye Wen-ying
Translated by Tang Yau-yang
Photos by Chen Hong-dai
Used with permission of Rhythms Monthly Magazine
Source: Tzu Chi Quarterly Winter 2011

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The Beauty of the Jing Si Abode

Volunteers

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