J o u r n a l of Religion a n d H e a l t h , Vol. 32, No. 2, S u m m e r 1993
Editorial
Examining Doctors In a remarkable, posthumously published book called Intoxicated by My Illness, Anatole Broyard, an editor and literary critic for The New York Times, who died in 1990, reflected on his own illness and approaching death. Few have done so more poignantly, more profoundly, and more cheerfully. Among the several pieces that make up the slender volume is a talk Broyard gave in a medical ethics seminar at the University of Chicago Medical School in April 1990, six months before his death. He called it "The Patient Examines the Doctor," and we are much indebted to Broyard not only for his own reflections, which you can read in his book, but also for causing us to reflect on our own experiences with doctors over many years back into youth and early childhood. In our childhood doctors were usually associated with unpleasant experiences and sensations like needles in the arm, sore throats, stomachaches, and the familiar childhood afflictions of measles, mumps, and whooping cough. When parents decided you needed to be seen by the doctor, you knew you were really sick, sick enough to be kept out of school, and out of play and friendly association with others for a time to be determined by those authority figures, the doctor and the parents. The doctor came in, looked you over, and told your parents what they should do about you or to you. He (we never saw a female doctor until much later) gave the orders, and if you followed them, you eventually got well again. Nobody dreamed of asking a doctor any more than that. The patient's job was to do what the doctor said. So it was with us until we came to know one doctor personally in a much deeper way. We had an older sister who became a physician. She could not attend the medical school of her choice. They did not accept women then; so she attended another medical school, of good reputation, and in due time was graduated with an outstanding record and an M.D. degree. In graduate school ourselves when she began to practice medicine in a small New England town, we saw her frequently and learned something new to us about doctors. Doctors have authority and knowledge and a will to use both in promoting health, but most of them have a lot of doubt and perplexity about how to apply their skills and information. They do not know as much as people think they know, and they proceed, therefore, by educated guesses, experimental study, and endless self-questioning about diagnostic decision and treatments. At the same time, they have to look assured and convey a certainty that they 85
9 1993 Institutes of Religion and Health
86
Journal of Religion and Health
often do not feel. They have to protect themselves against errors with the knowledge that at least occasionally mistakes are bound to be made. It is a tough assignment, but perhaps not so very different from what the minister, the judge, the lawyer, the teacher, the nurse, the social worker, and many others who deal with h u m a n suffering and need have to face. Doctors live by faith along with the rest of us. Our sister had one more quality, however, that made her a beloved doctor and in a way eventually cost her her life. She really cared about patients and tried to know them so that she could meet their needs as whole persons more adequately. She died at an early age because she let herself be worn out in the service of her patients. We remember her in many ways, of course, but as a doctor we associate her with the ironic comment of the scribes and Pharisees about Jesus on the cross: "He saved others; himself he cannot save." She spent herself for her profession and ran out of strength too early. It is perhaps the need of the doctors to husband strength and energy that accounts for protective rituals and devices that surround them and separate them from their patients. One enters the office and is confronted by the receptionist who takes your name and number (maybe she gives you a ranking, too, in some cases), and then you are advised to wait among the prints, potted plants, framed diplomas, and old magazines until the authority figure is ready to see you. When at length he or she appears, it is in uniform, a white coat with stethoscope draped around the neck. There is a routine--orderly, highly stylized, efficient no doubt, and when it is over and one has described one's symptoms and tests have been done or more likely ordered, one can wait for the results a few minutes, hours, days, or even weeks wondering where to, what next. There is nothing wrong with this routine. M o s t of it is essential to proper scientific exploration of a patient's condition. The differences among doctors are not in the basic routine of getting a sound diagnosis and treatment established. Yet the feeling created in many patients is that one has become a case, a file, a set of symptoms, even nothing much more than a piece of meat. What is wrong is not what is there, but what is often not there: namely, that one h u m a n being is aching to be treated like one, and another h u m a n being is afraid to get involved because it may destroy objectivity and become too upsetting. One point that Broyard makes very effectively is that perhaps there may be more stress in trying to protect oneself and one's feelings from another h u m a n being whose pain and need are real and reasonable than there would be in just opening up and being not only an objective scientist but a humane and compassionate healer. What the patient needs is not a profound and extended relationship with the doctor but an opening of the humane window, a sign that the doctor knows and understands the pain and perplexity the illness brings and, perhaps even more important, a sign that the doctor has felt the same kind of thing personally. Looking back over many years of association with doctors as patient, minister, co-worker, and personal friend, we are impressed with the number of doctors who have in specific situations said or done memorable things that
Harry C. Meserve
87
showed a deep understanding of the situation they were dealing with. Somewhere in the process of their education and experience m a n y doctors do learn to come out from behind the professional armor in brief, but appropriate and helpful, ways. They have a capacity for speaking the necessary word t h a t sums things up and stays in the memory of the one who receives it. We offer some examples from our own experience with doctors of what we mean. When my doctor-sister died, a young doctor, a contemporary of mine, was nearby and took over the situation. He tried in vain to save her life. He stayed on to pick up her practice and to care for our mother as if she were his own. Always he kept in touch, and when our mother in her mid-80's, afflicted with m a n y ills of old age, broke her leg in falling from her bed, he said in direct, simple language, "I will give her comfort care." What he was really saying, of course, was t h a t it was time for her to go and t h a t he would make t h a t transition as painless and easy as possible. This took place long before the widespread use of living wills and conveyed to us what we needed to know: t h a t our mother's end would be dignified and not delayed by futile heroic measures. We realize t h a t thoughtful and caring doctors have been doing this kind of thing for generations. We hope doctors increasingly realize how much it means not only to their patients but to the families and friends of patients to know t h a t the one in charge sees terminal situations in the light of the quality rather t h a n the mere quantity of life. Such sensitiveness indicates a larger sympathy and humanity, and it does not in our view violate the Hippocratic oath. Another incident in a similar situation remains in our memory. As minister of their church, we visited in the hospital a physician and his wife, who was dying of cancer. The doctor had often spoken of his agnostic point of view about religion, but also of his realization t h a t his wife needed it and t h a t she should have such comfort and strength in her illness as faith might bring. We called at the hospital when she was very near death. Both husband and wife were there. The doctor told us t h a t death was now very near. We wondered what religious comfort we might bring. As we wondered, he said to us rather impatiently, "Aren't you going to do anything?" Not being a Roman Catholic with the oils of extreme unction, or a prayerbook Christian with a holy office, we were at a loss as to what to do. Finally, we went to the bedside, dipped our hand in the glass of water there, traced the sign of the cross on the woman's forehead with our fingers, and said the Lord's Prayer. As we spoke, we heard the agnostic doctor speaking softly along with us. When we finished, he took our hand warmly in his and and said, "Thank you. That was a good thing to do."
Some years later, in a time of great perplexity about a personal matter, we turned to a psychiatrist whom we had previously known only as a community figure and social acquaintance. "Where do we healers go when we are in need of healing?" we asked. "To each other. Where else?" was the prompt answer. There come moments and situations in every life where the sense of selfsufficiency breaks down, and we know t h a t we cannot make it through the
88
Journal of Religion and Health
wilderness alone. It is then that the healer, the doctor, needs to say in effect, "Come in. I know about trouble too." Later on in this period of perplexity, we confronted another doctor and, as a personal friend, shared the situation with him. "What do you think?" we asked. He hesitated a moment and then said, "I think you are being self-indulgent." As things turned out, he was absolutely right, although we rejected his analysis at the time. Wisdom is too slow in coming, and good advice is often rejected because people are not ready to receive it. But at least the advice then given and not followed has remained in memory and helped guide us through other perplexing places. One difference between physicians and psychiatrists is that the former of necessity must be more directive. They know more about our bodies and their functions than we do and can therefore in many cases offer courses of therapy or medicine that will start a real healing process. Psychiatrists and psychologists, on the other hand, while they are fully aware of many physical conditions, also know that their cures are what Freud called "word cures." Words are the instruments the doctor uses to help change thoughts and attitudes from destructive to healthy directions. Many in our generation of word healers--ministers, psychologists, social workers, and other non-physical t h e r a p i s t s - - w e r e saturated with the teachings of Carl Rogers and his nondirective psychotherapy. It was and is a valuable technique, since it draws out the patient and helps him or her to express what is hurting. It also prevents an inexperienced and perhaps an ignorant therapist from making direct suggestions that m a y be premature and even destructive. But non-directive therapy has its limitations, and these are best illustrated in a story that stresses them by hyperbole. The story is as follows: The The The The The The
patient: "Doctor, I feel like committing suicide." doctor: "You feel like committing suicide." patient: "Yes, I could jump right out of that window next to me." doctor: "You feel you could jump right out of that window." patient: "Yes." And he jumps and falls to the pavement below. Plop. doctor: "Plop."
It seems to us that the good healer, whether physician or word healer, is one who knows the place to intervene positively with insight and guidance. We recall an event that marked the turning point in our own period of perplexity and depression mentioned above. We were in the office of a doctor who had been counseling with us for some months. He had listened a long time. Apparently perceiving that the depression had reached a point where it was causing all but total indecisiveness, he took a risk and said, "I guess I'll have to pull your chestnuts out of the fire for you." He picked up the telephone, made an appointment at a private hospital, wrote an address on a card, handed it to us, and said, "Go there by nine this evening. They will be expecting you. I'll see you tomorrow." We went. It was the turning point in a long,
Harry C. Meserve
89
difficult road, but it was a step up and not down. The doctor had spoken the necessary word. A subsequent encounter with a doctor strengthens our conviction that when the doctor comes out of the professional background and takes a risk, the patient responds with appreciation and even affection and trust. We lost the sight of one eye a few years ago. It was not a bad accident, nothing traumatic about it. We just realized all of a sudden one night that we were not seeing out of one eye. We went to our doctor, who examined the situation and diagnosed it as a retinal arterial occlusionp "I couldn't have treated it had I been there," he said. "But I will tell you this: the eye has a wonderful backup system. You can learn to see with one eye 80% of what you could see with two." It was a sentence that transformed near-despair into possibility. It turned out to be quite true. The medical center with which we are now associated as a patient has two doctors, with several nurses and assistants. It is a community agency which has as its object not merely the providing of medical service, but the wider purpose of building a community health consciousness and of teaching people how they, with the center's help, can build and maintain health for themselves and their families. The doctors are in charge, but they listen to their colleagues and their patients and the lay people who work with them to fulfill the purposes of the center. They have sacrificed some authority of the old type and some money for a larger measure of humanity. What they may have lost in specific power they have gained in understanding and influence. Looking back over these and other encounters with doctors in the perspecrive of many years, we feel a profound sympathy and respect for members of the medical and psychiatric professions. To help in the healing process is a difficult task calling for much patience, insight, and not a little delicacy and gentleness of touch, together with clarity of mind and firmness. In the end, of course, all healers are losers, since death gets us all. But death, as Dr. Johnson observed, "wonderfully concentrates the mind." Since our time is short, we want to do the best we can with what there is. We conclude, therefore, with some suggestions based both upon Anatole Broyard's essay, "The Patient Examines the Doctor," and our own observations. First: The patient does not require all your time, but when you are with the patient, give him or her total attention. Second: Studied non-involvement may produce more stress than openhearted concern for the patient as a h u m a n being like yourself. Third: Explain to the patient what is wrong as you see it with complete honesty and in the simplest possible language. Avoid jargon. Explain what is right about the situation, too. Offer some positive suggestions.
90
Journal of Religion and Health
Fourth: J u s t as the observer, even at the most scientific and objective moments, influences the picture of what is observed, so to a degree doctors insert their own mind and feelings into their judgment. Do not be ashamed of this human quality. Speak in your own voice, too. Fifth: The patient is interested not only in his or her own illness but in who you are, since in being brought into the sphere of the illness you become part of his or her own life experience at very intimate levels. Respect this intimacy. Do not abuse it, but use it for healing purposes. These guidelines, is seems to us, have been followed by many of the doctors we have known and have made them into healers in the deepest and best sense. They can be of use to all people who undertake at whatever level the difficult and essential task of trying to help their fellow h u m a n beings. Harry C. Meserve
Editorial
Examining Doctors In a remarkable, posthumously published book called Intoxicated by My Illness, Anatole Broyard, an editor and literary critic for The New York Times, who died in 1990, reflected on his own illness and approaching death. Few have done so more poignantly, more profoundly, and more cheerfully. Among the several pieces that make up the slender volume is a talk Broyard gave in a medical ethics seminar at the University of Chicago Medical School in April 1990, six months before his death. He called it "The Patient Examines the Doctor," and we are much indebted to Broyard not only for his own reflections, which you can read in his book, but also for causing us to reflect on our own experiences with doctors over many years back into youth and early childhood. In our childhood doctors were usually associated with unpleasant experiences and sensations like needles in the arm, sore throats, stomachaches, and the familiar childhood afflictions of measles, mumps, and whooping cough. When parents decided you needed to be seen by the doctor, you knew you were really sick, sick enough to be kept out of school, and out of play and friendly association with others for a time to be determined by those authority figures, the doctor and the parents. The doctor came in, looked you over, and told your parents what they should do about you or to you. He (we never saw a female doctor until much later) gave the orders, and if you followed them, you eventually got well again. Nobody dreamed of asking a doctor any more than that. The patient's job was to do what the doctor said. So it was with us until we came to know one doctor personally in a much deeper way. We had an older sister who became a physician. She could not attend the medical school of her choice. They did not accept women then; so she attended another medical school, of good reputation, and in due time was graduated with an outstanding record and an M.D. degree. In graduate school ourselves when she began to practice medicine in a small New England town, we saw her frequently and learned something new to us about doctors. Doctors have authority and knowledge and a will to use both in promoting health, but most of them have a lot of doubt and perplexity about how to apply their skills and information. They do not know as much as people think they know, and they proceed, therefore, by educated guesses, experimental study, and endless self-questioning about diagnostic decision and treatments. At the same time, they have to look assured and convey a certainty that they 85
9 1993 Institutes of Religion and Health
86
Journal of Religion and Health
often do not feel. They have to protect themselves against errors with the knowledge that at least occasionally mistakes are bound to be made. It is a tough assignment, but perhaps not so very different from what the minister, the judge, the lawyer, the teacher, the nurse, the social worker, and many others who deal with h u m a n suffering and need have to face. Doctors live by faith along with the rest of us. Our sister had one more quality, however, that made her a beloved doctor and in a way eventually cost her her life. She really cared about patients and tried to know them so that she could meet their needs as whole persons more adequately. She died at an early age because she let herself be worn out in the service of her patients. We remember her in many ways, of course, but as a doctor we associate her with the ironic comment of the scribes and Pharisees about Jesus on the cross: "He saved others; himself he cannot save." She spent herself for her profession and ran out of strength too early. It is perhaps the need of the doctors to husband strength and energy that accounts for protective rituals and devices that surround them and separate them from their patients. One enters the office and is confronted by the receptionist who takes your name and number (maybe she gives you a ranking, too, in some cases), and then you are advised to wait among the prints, potted plants, framed diplomas, and old magazines until the authority figure is ready to see you. When at length he or she appears, it is in uniform, a white coat with stethoscope draped around the neck. There is a routine--orderly, highly stylized, efficient no doubt, and when it is over and one has described one's symptoms and tests have been done or more likely ordered, one can wait for the results a few minutes, hours, days, or even weeks wondering where to, what next. There is nothing wrong with this routine. M o s t of it is essential to proper scientific exploration of a patient's condition. The differences among doctors are not in the basic routine of getting a sound diagnosis and treatment established. Yet the feeling created in many patients is that one has become a case, a file, a set of symptoms, even nothing much more than a piece of meat. What is wrong is not what is there, but what is often not there: namely, that one h u m a n being is aching to be treated like one, and another h u m a n being is afraid to get involved because it may destroy objectivity and become too upsetting. One point that Broyard makes very effectively is that perhaps there may be more stress in trying to protect oneself and one's feelings from another h u m a n being whose pain and need are real and reasonable than there would be in just opening up and being not only an objective scientist but a humane and compassionate healer. What the patient needs is not a profound and extended relationship with the doctor but an opening of the humane window, a sign that the doctor knows and understands the pain and perplexity the illness brings and, perhaps even more important, a sign that the doctor has felt the same kind of thing personally. Looking back over many years of association with doctors as patient, minister, co-worker, and personal friend, we are impressed with the number of doctors who have in specific situations said or done memorable things that
Harry C. Meserve
87
showed a deep understanding of the situation they were dealing with. Somewhere in the process of their education and experience m a n y doctors do learn to come out from behind the professional armor in brief, but appropriate and helpful, ways. They have a capacity for speaking the necessary word t h a t sums things up and stays in the memory of the one who receives it. We offer some examples from our own experience with doctors of what we mean. When my doctor-sister died, a young doctor, a contemporary of mine, was nearby and took over the situation. He tried in vain to save her life. He stayed on to pick up her practice and to care for our mother as if she were his own. Always he kept in touch, and when our mother in her mid-80's, afflicted with m a n y ills of old age, broke her leg in falling from her bed, he said in direct, simple language, "I will give her comfort care." What he was really saying, of course, was t h a t it was time for her to go and t h a t he would make t h a t transition as painless and easy as possible. This took place long before the widespread use of living wills and conveyed to us what we needed to know: t h a t our mother's end would be dignified and not delayed by futile heroic measures. We realize t h a t thoughtful and caring doctors have been doing this kind of thing for generations. We hope doctors increasingly realize how much it means not only to their patients but to the families and friends of patients to know t h a t the one in charge sees terminal situations in the light of the quality rather t h a n the mere quantity of life. Such sensitiveness indicates a larger sympathy and humanity, and it does not in our view violate the Hippocratic oath. Another incident in a similar situation remains in our memory. As minister of their church, we visited in the hospital a physician and his wife, who was dying of cancer. The doctor had often spoken of his agnostic point of view about religion, but also of his realization t h a t his wife needed it and t h a t she should have such comfort and strength in her illness as faith might bring. We called at the hospital when she was very near death. Both husband and wife were there. The doctor told us t h a t death was now very near. We wondered what religious comfort we might bring. As we wondered, he said to us rather impatiently, "Aren't you going to do anything?" Not being a Roman Catholic with the oils of extreme unction, or a prayerbook Christian with a holy office, we were at a loss as to what to do. Finally, we went to the bedside, dipped our hand in the glass of water there, traced the sign of the cross on the woman's forehead with our fingers, and said the Lord's Prayer. As we spoke, we heard the agnostic doctor speaking softly along with us. When we finished, he took our hand warmly in his and and said, "Thank you. That was a good thing to do."
Some years later, in a time of great perplexity about a personal matter, we turned to a psychiatrist whom we had previously known only as a community figure and social acquaintance. "Where do we healers go when we are in need of healing?" we asked. "To each other. Where else?" was the prompt answer. There come moments and situations in every life where the sense of selfsufficiency breaks down, and we know t h a t we cannot make it through the
88
Journal of Religion and Health
wilderness alone. It is then that the healer, the doctor, needs to say in effect, "Come in. I know about trouble too." Later on in this period of perplexity, we confronted another doctor and, as a personal friend, shared the situation with him. "What do you think?" we asked. He hesitated a moment and then said, "I think you are being self-indulgent." As things turned out, he was absolutely right, although we rejected his analysis at the time. Wisdom is too slow in coming, and good advice is often rejected because people are not ready to receive it. But at least the advice then given and not followed has remained in memory and helped guide us through other perplexing places. One difference between physicians and psychiatrists is that the former of necessity must be more directive. They know more about our bodies and their functions than we do and can therefore in many cases offer courses of therapy or medicine that will start a real healing process. Psychiatrists and psychologists, on the other hand, while they are fully aware of many physical conditions, also know that their cures are what Freud called "word cures." Words are the instruments the doctor uses to help change thoughts and attitudes from destructive to healthy directions. Many in our generation of word healers--ministers, psychologists, social workers, and other non-physical t h e r a p i s t s - - w e r e saturated with the teachings of Carl Rogers and his nondirective psychotherapy. It was and is a valuable technique, since it draws out the patient and helps him or her to express what is hurting. It also prevents an inexperienced and perhaps an ignorant therapist from making direct suggestions that m a y be premature and even destructive. But non-directive therapy has its limitations, and these are best illustrated in a story that stresses them by hyperbole. The story is as follows: The The The The The The
patient: "Doctor, I feel like committing suicide." doctor: "You feel like committing suicide." patient: "Yes, I could jump right out of that window next to me." doctor: "You feel you could jump right out of that window." patient: "Yes." And he jumps and falls to the pavement below. Plop. doctor: "Plop."
It seems to us that the good healer, whether physician or word healer, is one who knows the place to intervene positively with insight and guidance. We recall an event that marked the turning point in our own period of perplexity and depression mentioned above. We were in the office of a doctor who had been counseling with us for some months. He had listened a long time. Apparently perceiving that the depression had reached a point where it was causing all but total indecisiveness, he took a risk and said, "I guess I'll have to pull your chestnuts out of the fire for you." He picked up the telephone, made an appointment at a private hospital, wrote an address on a card, handed it to us, and said, "Go there by nine this evening. They will be expecting you. I'll see you tomorrow." We went. It was the turning point in a long,
Harry C. Meserve
89
difficult road, but it was a step up and not down. The doctor had spoken the necessary word. A subsequent encounter with a doctor strengthens our conviction that when the doctor comes out of the professional background and takes a risk, the patient responds with appreciation and even affection and trust. We lost the sight of one eye a few years ago. It was not a bad accident, nothing traumatic about it. We just realized all of a sudden one night that we were not seeing out of one eye. We went to our doctor, who examined the situation and diagnosed it as a retinal arterial occlusionp "I couldn't have treated it had I been there," he said. "But I will tell you this: the eye has a wonderful backup system. You can learn to see with one eye 80% of what you could see with two." It was a sentence that transformed near-despair into possibility. It turned out to be quite true. The medical center with which we are now associated as a patient has two doctors, with several nurses and assistants. It is a community agency which has as its object not merely the providing of medical service, but the wider purpose of building a community health consciousness and of teaching people how they, with the center's help, can build and maintain health for themselves and their families. The doctors are in charge, but they listen to their colleagues and their patients and the lay people who work with them to fulfill the purposes of the center. They have sacrificed some authority of the old type and some money for a larger measure of humanity. What they may have lost in specific power they have gained in understanding and influence. Looking back over these and other encounters with doctors in the perspecrive of many years, we feel a profound sympathy and respect for members of the medical and psychiatric professions. To help in the healing process is a difficult task calling for much patience, insight, and not a little delicacy and gentleness of touch, together with clarity of mind and firmness. In the end, of course, all healers are losers, since death gets us all. But death, as Dr. Johnson observed, "wonderfully concentrates the mind." Since our time is short, we want to do the best we can with what there is. We conclude, therefore, with some suggestions based both upon Anatole Broyard's essay, "The Patient Examines the Doctor," and our own observations. First: The patient does not require all your time, but when you are with the patient, give him or her total attention. Second: Studied non-involvement may produce more stress than openhearted concern for the patient as a h u m a n being like yourself. Third: Explain to the patient what is wrong as you see it with complete honesty and in the simplest possible language. Avoid jargon. Explain what is right about the situation, too. Offer some positive suggestions.
90
Journal of Religion and Health
Fourth: J u s t as the observer, even at the most scientific and objective moments, influences the picture of what is observed, so to a degree doctors insert their own mind and feelings into their judgment. Do not be ashamed of this human quality. Speak in your own voice, too. Fifth: The patient is interested not only in his or her own illness but in who you are, since in being brought into the sphere of the illness you become part of his or her own life experience at very intimate levels. Respect this intimacy. Do not abuse it, but use it for healing purposes. These guidelines, is seems to us, have been followed by many of the doctors we have known and have made them into healers in the deepest and best sense. They can be of use to all people who undertake at whatever level the difficult and essential task of trying to help their fellow h u m a n beings. Harry C. Meserve
