He who learns must suffer
In our sleep, pain which cannot forget
falls drop by drop upon the heart
until, in our own despair, against our will,
comes wisdom through the awful grace of God.
—Aeschylus (525–456 BCE)
from Agamemnon 1, 179–1832
This past week, I had the pleasure of attending a seminar on ancient medicine and the modern physician on the UGA and Medical Science campuses. With an opening presentation by Rich Panico, who spoke of the need for both “hard” or scientific competencies and “soft” or empathic, humanistic competencies, the mini-conference addressed the ancient physician’s use of performance, humor, case studies, and finally, errors, all of which were written about in what are now called Hippocratic writings, dating from the fifth century BC to the fifth century AD. It was interesting to glimpse across the centuries the roots of modern Western medicine. It was particularly interesting to learn of the importance of rhetoric in ancient medicine, as well as humor.
“And I will tell you a striking proof of this: many and many a time have I gone with my brother or other doctors to visit one of their patients and found him unwilling either to take medicine or submit to the surgeon’s knife or cautery; and when the doctor failed to persuade him, I succeeded, by no other art than that of rhetoric.” Plato’s Gorgias 456b-c2
Much of the conversation revolved around issues of modern physician burnout (interestingly, ancient physicians were expected to be healthy and fit as advertisement of their skill) and physician vulnerability. How do doctors protect themselves? was a question. Can physicians be compassionate without becoming mired in the suffering they witness?
This was a week when suffering and modern medicine were much on my mind. My childhood friend’s mother died after a long downward spiral. She was at home, receiving hospice care, but her death was protracted and painful. Here is what my friend wrote me about it:
My Mother is dying. She has not had anything to eat or drink for one week. The MSA completely eradicates the ability to speak OR swallow. Hospice should make allowances for these instances. My beautiful fragile mother now looks like a victim of Dachau or Bergen Belsen. It is not “natural.” It is cruel and sadistic. She is reduced to nothing, begging for relief with her eyes and with the clasp of her hand. Dying pets are treated with more dignity. Her poor, tortured, emaciated body cries out to be put to rest, to be left in peace. Christ on the Cross survived one day. My mother has surpassed him by six.
Another friend writes about her brother’s long illness, resulting from medical error:
My brother had been sick for many years, actually, beginning with a routine root canal in 1986, which wasn’t treated correctly and became infected. The infection had encased his heart by the time he went to the doctor. That simple little thing led to two years of hospitalization and rehab, most of which he doesn’t even remember. The medicine that finally saved his life also made him almost deaf. He eventually recovered from the infection, of course, but his health seemed permanently compromised thereafter. In the last 10 years or so, he was diagnosed with diabetes, rheumatoid arthritis and even at one point was being tested for TB. All the medication he was on had a lot of side effects as well. How much any of these other issues stemmed from problems originating with the root canal I can’t possibly say. He was just never the same after that.
Here are two impassioned reports of suffering. My intention is not to point fingers at medical carelessness or error. Yes, the first heart-wrenching account sounds a clarion call for better pain management for the dying. The second is a tragic story of carelessness that cascaded into a litany of woes. Each case could be attributable to a variety of causes—insufficient monitoring, negligence, judgment errors, red-tape, lack of communication between physicians and patients or families. I bring them to your attention because of the suffering described—suffering for the patient, the families, and one can imagine, the physician themselves. Pain and suffering are an inevitable part of doctoring. Not all patients get well, not all patients survive.
For the sake of argument, I am assuming that these patients’ doctors were the of the same ilk as most of those I’ve encountered in my labyrinthine journey through the medical system: ethical, skilled and for the most part, caring. Most physicians I know are as fed up with the system as their patients. For the physician, there is the added burden that sick people and their families invest him/her with almost shamanic powers, expecting the physician to perform the impossible. As Heinrich von Staden so eloquently relayed last Monday in his talk about physician error recorded in Hippocratic writings, physicians reap a “harvest of sorrows,” by what they must witness. How then do doctors withstand this inevitability? How are young doctors trained to handle suffering?
Is the answer for the physician that he becomes invulnerable (if that is even a possibility) in order to protect himself from the suffering of others? Is the answer to deny his own suffering as well? The position of the physician is both privileged and fraught —she is privy to the most intimate struggles of her patients, and yet she must delimit her involvement in order to maintain her own authority and inner balance.
Perhaps the question of protection needs to be framed differently. Rachel Naomi Remens, a physician who also lives with chronic illness, frames the question this way:
In recent years the question how can I help? has become meaningful to many people. But perhaps there is a deeper question we might consider. Perhaps the real question is not how can I help? but how can I serve?
Serving is different from helping. Helping is based on inequality; it is not a relationship between equals. When you help you use your own strength to help those of lesser strength. If I’m attentive to what’s going on inside of me when I’m helping, I find that I’m always helping someone who’s not as strong as I am, who is needier than I am. People feel this inequality. When we help we may inadvertently take away from people more than we could ever give them; we may diminish their self-esteem, their sense of worth, integrity and wholeness. When I help I am very aware of my own strength. But we don’t serve with our strength, we serve with ourselves. We draw from all of our experiences. Our limitations serve, our wounds serve, even our darkness can serve. The wholeness in us serves the wholeness in others and the wholeness in life. The wholeness in you is the same as the wholeness in me. Service is a relationship between equals.
What Dr. Remens expresses here gets at the most fundamental question for any healthcare provider. We serve with our skill, but we serve first as humans who also suffer. The more whole we are, the more in touch with our own limitations and our own suffering, the more able we will be to be present to those whom we serve. I can tell you that as someone who has a little understood illness and chronic pain, it is not only the physician’s skill I need from him, but also his ability to stand with me in my situation, to acknowledge my pain. This under-standing is an act of imagination, as is the ability to be present. Listening to a patient, standing with her in her predicament, these are acts of healing not to be underestimated.
But you say, isn’t that the sure path to physician burnout? Actually, I think it may be the antidote. The physician can lay down the burden of fixing, of being super-human, when serving. Wouldn’t the physician who can acknowledge that she is not the source of healing, but the midwife to the process of healing, have less stress than the physician who feels the entire outcome rests solely on her?
In the end, the world isn’t divided into the sick and the well, the healer and the healed. We are all sick and well, all healer and in need of healing. If we can stand in our common humanity serving each other, how much pain might be mitigated?