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The First Cut
The Course of Their Lives
Published October 12, 2013
The noisy, first-day-of-school chatter subsides. A hush falls over 200 students in a lecture hall at the Medical College of Wisconsin.
Already, their thoughts are drifting up a flight of stairs to the sprawling dissection lab, where in two days they will meet and become intimate with something many have scarcely encountered: Death.
Khalid Sharif-Sidi, a 24-year-old from Galesburg, Ill., who has never seen a lifeless human body beyond a few seconds at a funeral, is nervous. He wonders if it will look real or fake, if the person will have tattoos or nail polish or piercings. He wants the body he dissects to look anything but real.
Andrew Kleist, a cardiologist's son from Pittsburgh, who shadowed his father often, and last May watched him unblock a heart attack patient's artery at 2 in the morning, feels excited but uncomfortable. The 23-year-old has been thinking about the body upstairs and what he must do to it — not just a body, a person.
Hillary McLaren, a 23-year-old from Neenah who hopes to become the fourth generation in her family to practice medicine, has been steeling herself for the sight of the cadaver. Her mantra: "Don't be that girl who passes out on the first day of anatomy."
Today they begin the defining course of their medical education.
A required rite of passage on the way to a doctor's white coat, gross anatomy offers first-year students a hands-on tour of an actual human body, the chance to cut into leathery skin and sinewy muscle, to see pale, stringy nerves that run through the legs like wires, to manipulate tendons in the arms and watch the corresponding fingers move.
To hold a human heart.
To feel the moist ridges of a brain.
Before the young students meet their cadavers, they focus up front, where a projector beams the videotaped image of a woman named Geraldine Fotsch.
Rick Wood / Journal Sentinel
Geraldine 'Nana' Fotsch is the subject of a video shown to the students on their first day of gross anatomy class. Her late husband, Bill, agreed to allow medical students to dissect and learn from his body when he died. Nana has agreed to do the same.
Watch the video
Fotsch is just days from her 80th birthday. She prefers to be called "Nana," in homage to her 30 grandchildren. And she has made a decision these doctors-to-be will have to consider each time they wield a scalpel over the next five months.
Upon her death, she will not be cremated or buried — not right away. She has decided instead to allow medical students, young men and women like those watching her videotaped image, to dissect and learn from her body.
It won't be these students, of course. Nana was — and is still — very much alive. But her words will be the closest this class comes to understanding the anonymous human beings they are going to take apart.
In the video, she sits beside her interviewer, Todd Hoagland, associate professor for gross anatomy and a young man himself.
What would you like the students to know? he asks.
"I would want them to know it's OK to grow old. It's great to be old."
She shakes her head vigorously, aware she is contradicting a common image of aging.
"Grandchildren are the light of your life," she says. "I would not give up this time in my life for anything."
Do you have any fear of dying?
"I'm a little apprehensive," she says. "I figure I'm not sure if I've collected enough brownie points to go directly up."
She smiles and points toward the ceiling. The students laugh.
Has it been explained what will happen to your body?
"It has," she says, "and that's fine, because I'm not around. I'm someplace else.
"This is my gift to you. Do with it what you want."
While much in medicine has changed over the last century, no teaching tool has replaced the gift of a human body.
X-rays, MRIs and CT scans allow medical students to see inside flesh and bone to the sources of injury and disease. Special mannequins help future surgeons hone their incision techniques. Computer programs simulate what it is like to strip off skin.
Yet gross anatomy
remains a throwback to 500 years ago, when Leonardo da Vinci dissected cadavers to learn the subject of his art.
Modern anatomical studies began in the universities and academies of 16th-century Italy.
1500s: An early textbook was Andreas Vesalius' De Humani Corporis Fabrica, printed in 1543. Vesalius is considered the founder of modern human anatomy.
1770s: Scottish anatomist and physician William Hunter offered public demonstrations at the Royal Academy in London for sculptors, painters and paying members of the public.
1790: For years dissection laws were geared not toward the educational needs of doctors in training but toward punishing criminals. A 1790 U.S. law gave federal judges the right to add dissection to the death sentence for murder.
Early 1990s: By the beginning of the 20th century most cadavers used by medical schools were unclaimed bodies.
Today's embalming techniques preserve the body better. Dissection is no longer a two-day sprint to outrun decay. In most other respects, however, technology has not changed or improved the basic process.
"I don't think there's any way you could reproduce the experience of actual dissection," says Christopher Ruff, professor and director of the Center for Functional Anatomy and Evolution at Johns Hopkins University School of Medicine.
No mannequin or computer can duplicate the force it takes to guide a scalpel through fat and fascia, the connective tissue.
A computer can't capture the diversity of human bodies, the way muscle appears pale yellow in some, the color of red clay in others.
Most of all, a computer cannot fully prepare students for the difference between the beautiful color illustrations in the textbooks and the actual bones, organs and arteries they will encounter in their patients. Textbooks show structures of the young and healthy. The patients in a doctor's office are usually older and sicker.
Hoagland remembers dissecting a cadaver in medical school, studying the networks that send blood and oxygen and brain impulses through the body.
"It was the first class I'd ever taken where the light bulbs kept going off," he says. "I had been a biology major, but I didn't have a sense of how it all fit together. This was like looking at a car as a whole system, instead of just getting all of the little pieces. It's seeing how the pieces all operate in a person. If you understand the big picture, all of the rest starts falling into place."
It is a fitting place to begin. Students start with the foundations they will use their entire careers — the map and the vocabulary necessary to communicate with anyone in medicine.
But gross anatomy also provides something less scientific. Students share an experience that will bond them long after they have graduated, entered practice and forgotten most of their time in medical school.
"This is an elucidation of death and dying," Hoagland says. "It's a way for students who have never experienced that to confront it."
That first class, on a Monday in August 2012, Hoagland tells the students what he expects.
Get to class early. Be scholarly and professional at all times.
No flip-flops in the lab. No shorts. No iPods.
Students will work in teams of six. There are 36 teams; 36 bodies.
Don't talk about the donors in the elevator.
Don't discuss them at Starbucks.
"Treat them well," Hoagland says. "Be good stewards of the gift. These are some of the most altruistic people around. They donate knowing what we are going to do to the body."
We view every gift as special and precious
— Todd Hoagland
It was six years ago that Nana Fotsch and her husband, Bill "Pa" Fotsch, first considered becoming body donors. They had two grandchildren at medical school taking gross anatomy. Also, two of their children had been through the course on the way to medical degrees.
"There was a reverence they had for their cadavers," Nana Fotsch recalls, singling out her daughter in particular. "Colleen had a cadaver. He was a priest. She thought how wonderful it was that he dedicated himself in life to his faith and society and people. And he did the same thing in death."
The Fotsches did not embark on a lengthy discussion.
"It was just a no-brainer," Nana says. "It was almost like, 'Yeah, this is what you should do.'"
Pa signed up first, Nana followed.
They'd had long, happy lives. They felt lucky. Pa and Nana were high school sweethearts at Niles Township High School in Illinois. They'd dated, decided they couldn't stand each other, then got to college and changed their minds.
In 1954, they married at Our Lady of Perpetual Help, or as kids back then nicknamed it, Old Lady's Pickle House.
The Fotsches struggled at first. When their twins were born six weeks early, before their insurance had kicked in, the couple had to borrow $500 from Pa's father. After hospital expenses "we had nothing left," Nana recalls. "We had to borrow the money just to exist."
Pa spent two years in the Army, serving as a specialist first class, shuttling back and forth between the Frankford Arsenal in Philadelphia and Washington. By then they had three little children. They lived in a tiny apartment in Philadelphia.
After his Army stint, Pa designed special machines for Kearney & Trecker in Milwaukee, then was asked by his father and two partners to run a small tool and die company near South Bend, Ind. The Fotsches skimped on food and clothing, took no vacations and eventually saved enough money to buy out the partners. Later they bought another company called Baush Machine Tool, which made automotive machinery.
The couple moved from Indiana to Wisconsin in 1965. They bought a house in Elm Grove and raised their children; there were eight of them now, a daughter and seven sons.
The Fotsches were do-it-yourselfers, remodeling, pulling the kids into various projects. They bought a vacation place in northern Wisconsin, and that meant a whole new round of repairs and upgrades.
The boys built models and learned carpentry and electrical work. Colleen learned to sew. She was cooking meals and helping her mother with housework in first grade.
"We were a nuts and bolts family," Nana says.
Pa's reverence for fixing things, however, did not extend to the human body, not for some years.
"My husband, to get him to go to a doctor, well, they were all quacks," Nana recalls. "Gradually he changed his mind."
Pa might have been forced to revise his view of doctors had he met the three young men and three young women who gather at Table 1 on the first day of dissection.
They are part of a medical college class that scored in the 85th percentile on the MCAT exams and graduated with a 3.76 (A) grade point average from such schools as Yale, Stanford and the University of Wisconsin-Madison. They include 19-year-old prodigies, valedictorians and published poets. They speak Farsi, Russian, Chinese and Portuguese.
These facts are a source of pride — and anxiety. At their previous schools, the students of Table 1 were all at or near the top; now, wherever they look there's someone just as smart and just as driven.
On this Wednesday afternoon in mid-August, with directions given and dissection minutes away, they have little time for introductions.
Select a student to hear why they want to become a doctor
Lori Wong is a 24-year-old from Los Angeles whose mother died from kidney and liver failure when Lori was a freshman at the University of Southern California. The experience left Lori a legacy of frustrations (the redundant tests, the doctors who lacked empathy) — and a firm belief that medicine can do better.
Joseph Zilisch is a 22-year-old from Kenosha, who carries this message tattooed on his back, "God will give me justice," and this one programmed on his cell phone screen: "I'm going to be a doctor." As a certified nursing assistant for several years while in college, he diapered and turned over the elderly and dealt with the naked human body until nothing about it bothered him.
Hillary McLaren, the young woman from a medical family, majored in biology and women's studies at the University of Michigan, and she talks of promoting equity in health care. Years ago an aunt learned Hillary was considering becoming a writer and offered this advice: You can always write when you're a doctor. But you can't always be a doctor when you're a writer.
Andrew Kleist, the cardiologist's son from Pittsburgh, is eager to begin dissection, to find out for himself why our bodies endure, or as he puts it, "why they don't just crap out like a Toyota after 15 or 20 years." He expects the experience to raise other questions, admitting, "I can't go to anatomy without thinking where the hell we came from."
Ashley Hinkamper is an outgoing 22-year-old from Quincy, Ill., who began volunteering at her local hospital in eighth grade. To cure herself of an aversion to needles and blood, she watched YouTube videos of blood draws. She cured herself so well that she was able to dissect a human cadaver while an undergraduate at Marquette University.
Khalid Sharif-Sidi, the son of Somali immigrants, saw his father's respect for doctors in that proud smile when Khalid gained admission into medical school. But the academic challenge Sharif-Sidi faces is never far from his thoughts: "I feel like failure is always around the corner," he says.
There is one more member of the group they have yet to meet, someone about whom each of the students has privately wondered and worried: the body.
Kleist believes he is about to disfigure a human being. He tells himself, "You signed up to be a physician, and this is part of it."
McLaren feels more at ease, especially after hearing from Nana Fotsch.
Zilisch keeps turning over in his mind what it would mean to give this gift.
"You're pretty useless lying in a casket," he says. "But I don't know if I'd want to see other people cutting up my grandfather."
The steel table before them is actually a long, raised metallic box, almost a casket. Students open two doors on top, revealing a sunken interior. They step on bars at each end of the table, lifting the interior.
Rising into view is a figure shrouded in white towels. A few pale toes jut out.
The air thickens. An odorous wave of embalming fluid washes over the room.
Rick Wood / Journal Sentinel
Andrew Kleist (left) gets his first look at the body he and other team members will dissect.
They unpack scalpels. They leave most of the towels draped over the cadaver, which lies face down. Only the back, where dissection begins, is uncovered. The skin is beige and wrinkly, more like a leather couch than someone's back.
The students look at each other, then at the steel table.
Who will make the first cut?
The tension reminds Sharif-Sidi of one of the last days before the start of medical school. Just a few weeks earlier, he and five friends drove to a remote cabin in the mountains of northern Tennessee.
I looked at it more as a body, as a learning tool.
— Ashley Hinkamper
One day they took a boat out on Norris Lake and decided to scale a steep rock and leap off it into the water. During the climb they all realized it was much higher than they'd thought. At the top, they could see the full expanse of the lake and the mountains beyond, and they waited, all of them.
Five minutes ticked by, maybe 10. Each wondered who would jump first.
That is how Sharif-Sidi feels looking down at the body. He is remembering that when the time came to jump, he waited and went second, and for one very deep breath, his feet were touching nothing at all until they slammed into the water.
So it is that Hinkamper, the only one who has previous experience dissecting a body, gently traces the first incision with her scalpel and begins.
I looked at it more as a body, as a learning tool.
— Ashley Hinkamper
Their professor is 43, but younger looking, tall with a beard and mustache, and a vivid memory of his own professor for gross anatomy.
It was the fall of 1997. Student Todd Hoagland sat in a lecture hall at Indiana University School of Medicine in South Bend listening to professor John O'Malley.
The man was an encyclopedia. He taught without a book, without even notes. Just a blackboard and chalk. A two-hour talk would flow seamlessly.
O'Malley took pains to reduce the distance between teacher and student, to make sure he was not placed on a pedestal. He addressed every student by name. He encouraged questions, praised accomplishments, challenged classes.
His face radiated an enjoyment of life.
"He had this gentle way and he knew everything," Hoagland says.
The human body was Hoagland's other teacher. He still remembers seeing the heart for the first time, how awed he was that this one muscle propels blood throughout the body.
He remembers admiring the elegance of the valves, massaging the coronary arteries with his fingers.
He remembers holding the brain, how densely packed it felt in his hands.
Until gross anatomy, so much of medicine had seemed theoretical. Picturing the work of cells and DNA requires imagination; muscles, nerves and arteries can be seen and felt.
Hoagland has taught gross anatomy for more than 10 years, the last two at the Medical College. Each time, the human body reveals something new. He has examined bodies with an extra cervical rib, an evolutionary holdover that can create a number of problems. He's come across bodies with six lumbar vertebrae instead of five.
The first day of med school you kind of want to prove yourself a little bit.
— Joseph Zilisch
He has noticed that different students approach anatomy in different ways. Some have been waiting years for this chance to get under the hood of the human body, to see how it's all wired. Others are nervous, uncertain of what it will feel like to see a preview of their own mortality.
And then there are the Type A students, who come to gross anatomy having led a largely goal-focused existence.
"They haven't had much time to think about their place in life. Where we go when we die," Hoagland says. "How can you not think what it is to be alive when you dissect a hand? How can you not think about who you are when you hold this brain in your hand?"
Hinkamper makes a gentle sawing motion with the scalpel. The skin separates. Fluid appears.
The students follow a manual of plain black-and-white drawings, which have all the aesthetic beauty of directions for putting together a crib. They also refer to Frank H. Netter's "Atlas of Human Anatomy," which has replaced "Gray's Anatomy" at many medical schools. If the manual makes the human body appear dull, Netter makes it appear impossibly beautiful, muscle the color of red wine, bones pure as ivory.
The students have one more source to guide them: Hinkamper, who has done dissection before. As she cuts, she points out fascia, pale connective tissue beneath the skin that wraps over muscles, vessels and nerves.
McLaren makes the next incision.
Sharif-Sidi pulls skin back to the right and left, laying open the inside of the back.
Using scissors, Kleist trims hair from the neck so that it won't impede the scalpel.
Zilisch squeezes skin around the waist, feeling how thick, how firm it is. Then he cuts horizontally across the lower back. Moisture — embalming fluid — seeps up and Hinkamper dabs at it with a paper towel.
Rick Wood / Journal Sentinel
For students (from left) Lori Wong, Khalid Sharif-Sidi, Joseph Zilisch and Andrew Kleist, the dissection process seen becomes part of a familiar routine.
More photos (Note: Some images show details of dissection.)
Mark L. Harlow, one of five professors who pass from table to table overseeing dissection, shows the students how to let the scalpel follow the path of least resistance. The din of 36 groups of students fills the expansive room, so the members of Table 1 must lean in close to hear him.
As the professors move about demonstrating proper technique, a difference becomes clear. The students cut delicately, almost tentatively.
The professors cut briskly. They tug at skin. They dig their fingers beneath muscle or other tissue in order to reach the structures beneath.
"The idea is to find the things," explains associate professor, David Bolender, addressing the students at Table 1. "You don't need to make the dissection look like a picture in an atlas."
Gradually, the students apply more pressure as they cut. They are careful, knowing they are being graded on the quality of their dissection, knowing, too, that no tissue is to hit the floor.
Every piece must be placed inside a gray plastic tub to be cremated later with the rest of the remains.
After almost three hours when they have finished for the day, they wash the scalpels. They clean the table and reposition the flaps of skin that have been pulled back. They place the arms at the body's sides and draw the white towels over the top. Then, using the foot control, they lower the body back into the sunken portion of the table. All around them, bodies sink back into the other steel tables.
The room empties.
The students at Table 1 were so busy that they missed something. They do not know whether they are dissecting a man or a woman.
Only the next day do they notice the tag attached to their table. On it someone has drawn a little figure in red magic marker.
