A Life in Medicine

by Robert Coles

  However, right now I think our most pressing concern is less the matter of our work than the manner of ourselves. For the individual psychiatrist, the institutional rigidities affect his thoughts and attitudes, taint his words and feelings, and thereby his ability to treat patients. We become victims of what we most dread; our sensibilities die, and we no longer care or notice. We dread death of the heart—any heart under any moon. Yet I see Organization Men in psychiatry, with all the problems of deathlike conformity. Independent thinking by the adventurous has declined; psychiatric training has become more formal, more preoccupied with certificates and diplomas, more hierarchical. Some of the finest people in early dynamic psychiatry were artists, like Erik Erikson, schoolteachers, like August Aichhorn, or those, like Anna Freud, who had no formal training or occupation but motivations as personal as those of a brilliant and loyal daughter. Today we are obsessed with accreditation, recognition, levels of training, with status as scientists. These are the preoccupations of young psychiatrists. There are more lectures, more supervision, more examinations for specialty status, and thus the profession soon attracts people who take to these practices. Once there were the curious and bold; now there are the carefully well-adjusted and certified.

  When the heart dies, we slip into wordy and doctrinaire caricatures of life. Our journals, our habits of talk become cluttered with jargon or the trivial. There are negative cathects, libido quanta, “presymbiotic, normal-autistic phases of mother-infant unity,” and “a hierarchically stratified, firmly cathected organization of self-representations.” Such dross is excused as a short cut to understanding a complicated message by those versed in the trade; its practitioners call on the authority of symbolic communication in the sciences. But the real test is whether we best understand by this strange proliferation of language the worries, fears, or loves in individual people. As the words grow longer and the concepts more intricate and tedious, human sorrows and temptations disappear, loves move away, envies and jealousies, revenge and terror dissolve. Gone are strong, sensible words with good meaning and the flavor of the real. Freud called Dostoevski the greatest psychologist of all time, and long ago Euripides described in Medea the hurt of the mentally ill. Perhaps we cannot expect to describe our patients with the touching accuracy and poetry used for Lady Macbeth or Hamlet or King Lear, but surely there are sparks to be kindled, cries to be heard, from people who are individuals.

  If we become cold, and our language frosty, then our estrangement is complete. Living in an unreliable world, often lonely, and for this reason attracted to psychiatry as a job with human contacts, we embrace icy reasoning and abstractions, a desperate shadow of the real friendships which we once desired. Estrangement may, indeed, thread through the entire fabric of our professional lives in America. Cartoons show us pre-empted by the wealthy. A recent study from Yale by Doctor Redlich shows how few people are reached by psychiatrists, how much a part of the class and caste system in America we are. Separated from us are all the troubled people in villages and farms from Winesburg to Yoknapatawpha. Away from us are the wretched drunks and the youthful gangs in the wilderness of our cities. Removed from us are most of the poor, the criminal, the drug addicts. Though there are some low-cost clinics, their waiting lists are long, and we are all too easily and too often available to the select few of certain streets and certain neighborhoods.

  Whereas in Europe the theologian or artist shares intimately with psychiatrists, we stand apart from them, afraid to recognize our common heritage. European psychiatry mingles with philosophers; produces Karl Jaspers, a psychiatrist who is a theologian, or Sartre, a novelist and philosopher who writes freely and profoundly about psychiatry. After four years of psychiatric training in a not uncultured city, I begin to wonder whether young psychiatrists in America are becoming isolated by an arbitrary definition of what is, in fact, our work. Our work is the human condition, and we might do well to talk with Reinhold Niebuhr about the “nature and destiny of man,” or with J. D. Salinger about our Holden Caulfields. Perhaps we are too frightened and too insecure to recognize our very brothers. This is a symptom of the estranged.

  In some way our hearts must live. If we truly live, we will talk clearly and avoid the solitary trek. In some way we must manage to blend poetic insight with a craft and unite intimately the rational and the intuitive, the aloof stance of the scholar with the passion and affection of the friend who cares and is moved. It seems to me that this is the oldest summons in the history of Western civilization. We can answer this request only with some capacity for risk, dare, and whim. Thwarting us at every turn of life is the ageless fear of uncertainty; it is hard to risk the unknown. If we see a patient who puzzles us, we can avoid the mystery and challenge of the unique through readily available diagnostic categories. There is no end to classifications and terminologies, but the real end for us may be the soul of man, lost in these words: “Name it and it’s so, or call it and it’s real.” This is the language of children faced with a confusion of the real and unreal, and it is ironic, if human, to see so much of this same habit still among psychiatrists.

  Perhaps, if we dared to be free, more would be revealed than we care to admit. I sometimes wonder why we do not have a journal in our profession which publishes anonymous contributions. We might then hear and feel more of the real give-and-take in all those closed offices, get a fuller flavor of the encounter between the two people, patient and psychiatrist, who are in and of themselves what we call psychotherapy. The answer to the skeptic who questions the worth of psychotherapy is neither the withdrawn posture of the adherent of a closed system who dismisses all inquiry as suspect, nor an eruption of pseudoscientific verbal pyrotechnics. Problems will not be solved by professional arrogance or more guilds and rituals. For it is more by being than by doing that the meaningful and deeply felt communion between us and our patients will emerge. This demands as much honesty and freedom from us as it does from our patients, and as much trust on our part as we would someday hope to receive from them.

  If the patient brings problems that may be understood as similar to those in many others, that may be conceptualized and abstracted, he is still in the midst of a life which is in some ways different from all others. We bring only ourselves; and so each morning in our long working day is different, and our methods of treatment will differ in many subtle ways from those of all of our colleagues. When so much of the world faces the anthill of totalitarian living, it is important for us to affirm proudly the preciously individual in each human being and in ourselves as doctors. When we see patients, the knowledge and wisdom of many intellectual ancestors are in our brains, and, we hope, some life and affection in our hearts. The heart must carry the reasoning across those inches or feet of office room. The psychiatrist, too, has his life and loves, his sorrows and angers. We know that we receive from our patients many of the irrational, misplaced, distorted thoughts and feelings once directed at parents, teachers, brothers, and sisters. We also know that our patients attempt to elicit from us many of the attitudes and responses of these earlier figures. But we must strive for some neutrality, particularly in the beginning of treatment, so that our patients may be offered, through us and their already charged feelings toward us, some idea of past passions presently lived. Yet, so often this neutrality becomes our signal for complete anonymity. We try to hide behind our couches, hide ourselves from our patients. In so doing we prolong the very isolation often responsible for our patients’ troubles, and if we persist, they will derive from the experience many interpretations, but little warmth and trust.

  I think that our own lives and problems are part of the therapeutic process. Our feelings, our own disorders and early sorrows are for us in some fashion what the surgeon’s skilled hands are for his work. His hands are the trained instruments of knowledge, lectures, traditions. Yet they are, even in surgery, responsive to the artistry, the creative and sensitive intuition of the surgeon as a man. The psychiatrist’s hands are himself, his life. We are
educated and prepared, able to see and interpret. But we see, talk, and listen through our minds, our memories, our persons. It is through our emotions that the hands of our healing flex and function, reach out, and finally touch.

  We cannot solve many problems, and there are the world and the stars to dwarf us and give us some humor about ourselves. But we can hope that, with some of the feeling of what Martin Buber calls “I-Thou” quietly and lovingly nurtured in some of our patients, there may be more friendliness about us. This would be no small happening, and it is for this that we must work. Alert against dryness and the stale, smiling with others and occasionally at ourselves, we can read and study; but maybe wince, shout, cry, and love, too. Really, there is much less to say than to affirm by living. I would hope that we would dare to accept ourselves fully and offer ourselves freely to a quizzical and apprehensive time and to uneasy and restless people.

  Abraham Verghese

  from THE TENNIS PARTNER

  David Smith was an Australian tennis player who quit playing the sport in order to become a doctor and study medicine at Texas Tech. There, Smith met Abraham Verghese. The two became friends and played tennis together. But Smith was addicted to cocaine and eventually died. Verghese’s book is an account of their tennis playing, their friendship, and, in this excerpt, a heartfelt warning against the loneliness of the doctor’s world.

  ABRAHAM VERGHESE is a professor of medicine at Texas Tech University. He is also the author of My Own Country, an excerpt from which also appears in this anthology.

  I cannot help but believe that David’s aloneness, his addiction, was worse for being in the medical profession—and not just because of ease of access, or stress, or long hours, but because of the way our profession fosters loneliness.

  Despite all our grand societies, memberships, fellowships, specialty colleges, each with its annual dues and certificates and ceremonials, we are horribly alone. The doctor’s world is one where our own feelings—particularly those of pain, and hurt—are not easily expressed, even though patients are encouraged to express them. We trust our colleagues, we show propriety and reciprocity, we have the scientific knowledge, we learn empathy, but we rarely expose our own emotions.

  There is a silent but terrible collusion to cover up pain, to cover up depression; there is a fear of blushing, a machismo that destroys us. The Citadel quality to medical training, where only the fittest survive, creates the paradox of the humane, empathetic physician, like David, who shows little humanity to himself. The profession is full of “dry drunks,” physicians who use titles, power, prestige, and money just as David used drugs; physicians who are more comfortable with their work identity than with real intimacy. And so it is, when one of our colleagues is whisked away, to treatment, and the particulars emerge, the first response is “I had no idea.”

  It is not individual physicians who are at fault as much as it is the system we have created. So many doctors and medical students came to my office after David’s death, cried with me, expressed concern for me as if I were the grieving widow. Over a hundred people showed up at the funeral home for David’s memorial service, all of them deeply affected by his death, sitting as one body behind his sisters and his father....

  Mine was the only eulogy at the service. I blush to remember how nakedly in that eulogy I expressed my sorrow, my shame. But I am proud too that I celebrated his life, consecrated our friendship. It would have amazed David, but perhaps not have saved him, to know that at the end, even as I stumbled through my last words, my voice breaking, that so many others wept for him.

  David Loxtercamp

  FACING OUR MORALITY: THE VIRTUE OF A COMMON LIFE

  This gentle reflection asks health care practitioners to consider virtue, medical ethics, and the nature of one’s relationships with other people. David Loxtercamp wonders about how physicians respond to patients “in mood and action.” He advocates collaboration not just with other physicians, but with all those one meets in the course of one’s life, and explores the application of medical ethics in everyday practice.

  DAVID LOXTERCAMP is a family practitioner living in Belfast, Maine, and author of A Measure of My Days: The Journal of a Country Doctor.

  Last week I admitted Mr. M. in the predawn hours of an evolving MI [myocardial infarcation]. I had forgotten his name. Erased the particulars of our prickly past until we came face-to-face behind closed curtains in the emergency department. Through sleep-deprived eyes I saw clearly what time had veiled. Thankfully, there was business to conduct, orders to write, and the beat of a clinical guideline to march us along.

  Throughout his uncomplicated recovery, I dwelt in the indigo moods of my inaugural year, the day especially when I botched his outpatient operation. A general surgeon was called to complete it. No lasting harm came except to the doctor’s pride and the prospects for our relationship. Mr. M. saw the surgeon in follow-up. We never again spoke of that afternoon, or my regrets, or the gravitation of his family’s care to my partners.

  Instead, we sank roots into the community. Stayed obliquely aware of the other’s passing through guarded glances in the waiting room or grocery aisle or post office parking lot. Each time our eyes met I flushed with feelings of ineptitude. Patients came and went, other successes and failures blotted the memory, and “complications” became a stubborn but accepted fact.

  But it changed me, this stinging appreciation for the stakes of my authority. Had I really informed Mr. M. before claiming his consent? Did I exceed the bounds of my training? Could I admit to errors and make amends? In the recesses of the physician’s black bag, beneath the armamentarium of drugs and instruments of power and the very best of our intentions, we bear the weight of multitudinous mistakes. They amount to more than misapplication of judgment or fact. We blunder, as William Carlos Williams often reminds us, in our big and hurried ways: a heavy-handed exam, the voltage of our anger, each neglected kindness.

  The ethical dilemmas in medicine are no longer about distributive justice or physician-assisted suicide: these we have surrendered to the stockholders and politicians. For the battle-worn physician, our Waterloo waits in the stack of messages at the end of the day, or in the denied insurance claim we let lapse. We recognize it in unwritten cards of condolence, our cowardice to confront addiction or abuse, the contempt we feel for self-destructive patients, and the encounters we crimp with a blood test or prescription when another five minutes with the doctor would do. How we respond to patients—in mood and action—reflects the core of the physician we are striving to become.

  Recently books on virtue began drifting to my desk like the flotsam and jetsam of a discipline in distress. A thin text by Smith and Churchill was joined by those of Pellegrino and Coles, John Drane and Stanley Hauerwas. Their works flow from an ancient and venerable tradition, one largely neglected in an era of decision making by cookbook and committee. Yet here is ethics in a digestible form, one that appeals to the appetites, whose juices of repulsion and attraction whet the clinical day. In bold type and chapter headings are words like benevolence, compassion, trust, honesty, and justice. These are the elements of a virtuous physician.

  Virtue has a voice, one that whispers (in the words of Abraham Lincoln) to the better angels of our nature and impels us through the drama of lives literary and real, ordinary and heroic. It is neither pious nor Pollyannish but remains largely empiric, always testing the adage that “Virtue has its own reward.” Its attributes are ingrained by repetition until they become habit and attitude and self-image. They press upon everyday acts but withhold judgment until careers draw to a close.

  Virtue has a heart, as Smith and Churchill distill from their commentary on the Gospel story of the good Samaritan. “[He] tends to look like a philanthropist. What usually goes unnoticed is that [he] acts out of compassion. He does not act out of altruism or noblesse oblige, nor does he see his help as fulfillment of a duty or an ideal or even a free and noble act. We are told, rather, that he is ‘moved by compassion’ upon s
eeing the man in the road.”1

  But the heart exposed is also vulnerable, as we know from young love, and equally from John Berger’s classic tale of rural general practice. The protagonist, Dr. Eskell, confronted “far more nakedly than many doctors, the suffering of his patients and the frequent inadequacy of his ability to help them. . . .”2 The price of “facing, trying to understand, hoping to overcome the extreme anguish of other persons five or six times a week” was isolation, cyclical depression, and eventual ruin. It is with irony and truth that Berger entitled his story A Fortunate Man.

  Perhaps this is why doctors are not trained to be tender. We are clinical commandos who target the chief complaint with skill, knowledge, and the force of authority. Patients who refuse to be cured, who remain fundamentally needy, and who return each week unchanged or destined to die, must be bandaged by our welcome. Like Jonah, we enter the whale’s belly of boredom, pain, fantasy, fear. Access is granted to those who dress the leper’s wound, forswear judgment, and peer where others refuse to gaze. We are relief workers in a refugee camp, supplied with an insufficient stockpile of loyalty, friendship, and love. It is ordinary human relationship we engage in, no matter how much is made of the gap in power or degree of intimacy. Differences disappear: we become the patient, and our business is simultaneously the world and a neighbor in need.

  Medical ethics, if it can ever become a practical art, must guide us over the land mines of muddled relationship. It mustn’t be made a bore or the privileged pursuit of specialists. It should hold us accountable, not rarely or remotely like the spectacle of malpractice, but daily in our devotion to patient care. Against the insularity of professionalism, Dickens offers his timeless antidote :