In the late 1970s, I practiced internal medicine at a Community Health Center in the Hill District of Pittsburgh. Many of my patients were poor, elderly and chronically ill. They lived in a housing project called Terrace Village, which was somewhat of a misnomer since the place had no terraces and the drab, cracked streets and institutional buildings looked nothing like a village. In fact, in Terrace Village there were no shops at all and very few gathering places because it was unsafe to loiter outside one's apartment any longer than was absolutely necessary. Because of this, the clinic, which occupied an open area beside the devastated playground was an ideal place for older people to socialize. Thus, having a doctor's appointment was often an occasion to get out and hobnob with friends in the waiting room. I was young then and had a long, scraggly beard that amused my patients to no end. But the thing they found most strange about me was that I spent so much time listening to their stories.
I was also a junior faculty member at the University Hospital a few blocks down the hill. Even then, tertiary care hospitals were places that relied mostly on numbers and machines and avoided stories as much as possible. Students and residents learned that, in order to be a "real" doctor they had to learn detachment and objectivity. When students tried to tell their patients' stories during rounds, the resident would caution them to stick to the point. Sometimes an attending doctor might say, "What do you think you are, a social worker?"
Often, my Terrace Village patients would find themselves hospitalized for exacerbations of their emphysema, cardiac disease, or diabetes. When I visited them in the hospital, I found that a major transformation had taken place. A woman whom I knew to be a wise and capable grandmother whose daughter had died from an overdose of crack, had suddenly become an old black lady lying in bed. In the hospital she had turned into an object, rather than a subject; a case of uncontrolled diabetes, rather than a person caring for three children while grieving for their dead mother. Another of my patients, a paraplegic from polio since childhood, was a teetotaler and self-educated expert on the history of Pittsburgh . In the hospital, because he had a big red nose and constantly expressed himself in four letter words, the doctors had labeled my patient an alcoholic. They had converted him into another object, a zombie who couldn't think straight because they were 'covering' him for alcohol withdrawal symptoms with sedatives.
This personal experience of two types of medicine captures a serious problem in American medical care, a problem that has become even more pronounced in the last 30 years. How can we respect our patients' stories, while getting on with the technical business of identifying and treating their diseases? At a more basic level, how can we open ourselves to their pain and suffering without being weighed down by their problems, or allowing our hearts to be swayed from sound medical judgment? Indeed, this dichotomy between connection and detachment, listening and categorizing, compassion and objectivity has a long history in medicine.
But rather than considering these presumed oppositions to be dichotomies or conflicts, perhaps it is wiser to accept them as tensions (or perhaps insights?) that arise from the nature of healing itself. In 1803, an English physician named Thomas Percival published a book on medical ethics, in which he enjoined physicians to "unite tenderness with steadiness" in their care of patients (1). Under "steadiness" Percival included objectivity and reason, along with courage and integrity. By "tenderness" he meant humanity, compassion, fellow feeling, and sympathy. In his letters, Percival contrasts the "coldness of heart" that often develops in practitioners who do not cultivate such virtues with the "tender charity" that the moral practice of medicine requires (1, 2). I believe our failure to respect patient narrative and our anxiety to suppress fellow feeling through detachment, leads directly to the "coldness of heart" that Percival referred to.
There is a schizophrenic dimension to all this, resulting from the mixed messages that medical students receive. On the one hand, we teach students that narrative constitutes the heart of medical practice; and that respect and empathy are the basis for healing relationships. Yet when these young women and men reach the hospital, they encounter an extremely powerful anti-narrative culture that teaches them that stories—subjective and mutable as they are--may actually obscure the problem. Very quickly stories degenerate into "hard" data, like lab values and computer scans. In a surprisingly short time, students learn to avoid speaking (to themselves, as well as their patients) about meaning, suffering, value, and belief. Rather, they devote their energy to body parts, machines, and biochemical processes. Hence, they develop the "coldness of heart" that 200 years ago Thomas Percival predicted.
I don't want to exaggerate. There are plenty of good doctors who respect patients and listen to their stories. Throughout the country, medical schools have begun to teach communication skills, narrative competence, self-awareness, professionalism, and, in general, to develop a greater sensitivity patients' needs (3). Some doctors are taking this movement a step further and encouraging patients to assist in their own healing by writing about the experience of illness (and often also about their negative interactions with health care professionals) in their own journals and poem (4). A small but growing body of medical evidence demonstrates the efficacy of writing about one's feelings about, and responses to, illness, as an important adjunct to healing (5).
I want to end with a poem about one of my patients from the clinic in Terrace Village so many years ago. She was an elderly woman with arthritis ravaging many of her joints. But the worst problem of all was her exquisitely painful hand, the result of many years of carpal tunnel syndrome (eventually treated too late) combined with arthritis. She comes into my office and dumps her hand on my desk as if it were an intransigent villain. "It's worthless," she tells me. No matter how hard I try, I cannot render this patient invisible. I cannot simply ignore her, make another referral, or fool with her medications. This lady is too tough, too opaque.
The Knitted Glove
You come into my office wearing a blue
knitted glove with a ribbon at the wrist.
You remove the glove slowly, painfully
and dump out the contents, a worthless hand.
What a specimen! It looks much like a regular hand,
warm, pliable, soft. You can move the fingers.
If it's not one thing, it's another.
Last month the fire in your hips had you down,
or up mincing across the room with a cane.
When I ask about the hips today, you pass them off
so I can't tell if only your pain
or the memory is gone. Your knitted hand
is the long and short of it. Pain doesn't exist
in the past any more than this morning does.
This thing, the name for your solitary days,
for the hips, the hand, for the walk of your eyes
away from mine, this thing is coyote, the trickster.
I want to call, Come out, you son of a dog!
and wrestle that thing to the ground for you,
I want to take its neck between my hands.
But in this world I don't know how to find
the bastard, so we sit. We talk about the pain (6).
One part of medical practice is trying to learn the trickster's name, but often coyote's lair remains hidden, not matter how much we try to find it. We have no idea who or what he is. But we can learn how much coyote damages our patient's life by listening to her narrative. We can stand with her in a respectful, non-judgmental way. WE can offer compassion. Yes, I do want to grapple with coyote; I want to wrestle him to the ground; I want "to take his neck between my hands." But in this case, as in the case of so much human suffering, "I don't know how to find / the bastard, so we sit. We talk about the pain/"
- Leake CD (ed.) Percival's Medical Ethics. New York , Williams and Wilkins, 1927. Quoted in Baker R. Deciphering Percival's code. In: Baker R, Porter D, Porter R (eds.) The Codification of Medical Morality. Netherlands , Kluwer Academic Publishers, 1993, p. 196.
- Coulehan JL Tenderness and steadiness: Emotions in medical practice. Lit Med. 1996; 14: 222-236.
- Stephenson A, Higgs R, Sugarman. Teaching professional development in medical schools. The Lancet. 2001; 357: 867-870.
- Fox J. Poetic Medicine. The Healing Art of Poem Making.. New York , Putnam, 1997
- Bolton G. The Therapeutic Potential of Creative Writing. Writing Myself. London , Jessica Kingsley Publishers, 1999
- Reynolds R, Stone J. (Eds.) On Doctoring. Simon & Schuster, 3rd edition, 2001, p. 321