Words that heal

Blessed are they that mourn, for they shall be comforted.

There once was a physician who had twin daughters. One grew up to become a psychiatrist. The other developed schizophrenia as an undergraduate. She poured out her anguish through words with pen on paper. Eventually, she became a published poet. Of the two daughters, which one was the healer?

In order to diagnose, a psychiatrist must learn to listen to the patient. Now there are many practicing psychiatrists who base their pharmacological treatments on symptoms alone. Medication regimens are adjusted based upon the patient’s response to the drug. Sometimes the dose is increased to enhance the effect of the drug; other times the drug is discontinued because of untoward side effects. Much of pharmacological treatment comes down to trial and error. Many times medication can help, but in the end a pill cannot heal a soul.

Freud, regarded by many as the father of psychiatry, once wrote: “Wherever I go, I find a poet has been there first.”

Throughout the centuries poets have pursued the art of crying out, of putting pen to paper (or stylus to papyrus), crafting words as conduits to transmit their anguish, their deepest longings, their joys, their sorrows. Many have written in part to help themselves to heal. When we read their words, we enter in to their anguish, their longings, their joy and their sorrow; and when we do, we ourselves may experience some degree of healing as well.

It doesn’t take a college degree to become a poet. One must only open oneself up to the suffering of the soul, to face one’s demons, to record the emotional truth of the spiritual state, to capture the passion (and in this instance I refer to the root meaning of that word: to suffer) in a few brief lines which may, if one is lucky, last for an eternity.

Listeners and healers

At the end of a recent afternoon session at the office an informal discussion on the relative merits of the physical examination arose among the members of the clinical staff. The junior PA, an astute practitioner with three years of experience in the field, argued that quality medical care centers on careful physical examination of the patient. “It’s so important to develop your observational skills,” she said. “If you want to clinch the diagnosis, you’ve got to know what you’re looking for, regardless of whether it’s a heart murmur, a deviated eye, an enlarged spleen or a skin lesion.”

“That’s what they tell us in PA school,” the student piped up. “It’s all about learning clinical signs and symptoms.”

One of the older pediatricians had a different take. “So much of what we diagnose is actually brought to our attention by the patients themselves,” he said. “And with our modern technological advances, we can readily detect physical maladies. For instance, much of what we used to refer to as congenital heart disease is now diagnosed by ultrasound in utero. As clinicians, we would do much better to ask a few open-ended questions in the patient interview and then sit back and listen to what the patient has to say.”

This impromptu discussion got me to thinking: What does it mean to care for the patient in our age of accelerated technological practice, where computer driven devices allow us to glean volumes of lab values from minute specimens of body fluids; where sophisticated scans enable us to peer inside the living body and tag its idiosyncratic pathologies; where our modern pharmacological armamentarium allows us to treat previously universally fatal diseases with effective drugs and transplanted tissues and organs? Surely, there has never been a time in the history of medicine where the benefits of diagnosis and treatment have shown greater promise than now.

And yet, as we surge ahead toward more and greater technological expertise, might we be in danger of losing something in the process? Are we in fact overlooking the whole point of the practice of medicine — to cure sometimes, to relieve often, to comfort always? Have we in fact forgotten that first and foremost the art of medicine rests upon our ability to listen to the patient — and thus impart some degree of healing in the process?

A hospitalist colleague e-mailed me his observations on this topic.

“Soon computer capability may exist to diagnose and recommend treatment to a degree unimaginable right now. Such advances may ease the burden on the clinician and improve the quality of care. But without a human connection, such a medical encounter falls short of providing a healing environment.”

Doctors are now debating the relative merits of continuing to teach students the art of cardiac auscultation. In 2012 New York’s Mt. Sinai Hospital provided medical students with hand-held ultrasound devices capable of generating real-time images of the heart at the bedside. Such devices have proven to be superior to the physical examination, nearly doubling the likelihood of accurate cardiac diagnoses. There are those who would have us discard the archaic, inaccurate stethoscope for such sophisticated technological tools.

In a recent New England Journal of Medicine essay Dr. Elazer Edelman writes that “auscultation is a fading art.” Yet he makes a case for continuing to teach clinical medicine at the bedside, albeit by the use of an electronic stethoscope linked to a speaker. The projected sounds allow “everyone in the room to hear and understand what the patient is experiencing.”

“In teaching at the bedside,” Dr. Edelman writes, “explanations of the finer elements of auscultation are less important than what the sounds tell us.”

“Projected sounds … engage our patients, for they hear what we hear (often for the first time), and appreciate what we are doing (also often for the first time), which binds them to us and us to them.”

In the practice of clinical medicine Dr. Edelman opines: “We must in a sense become part of our patients — physically engaging them so that we can feel what they feel, sense how they suffer, and fully comprehend what they are trying to tell us.”

“It is not only the teaching of auscultation that is improved when physician and patient are tethered to one another, but also the teaching of patient care and the practice of clinical medicine.”

Dr. Edelman concludes: “The stethoscope can help us diagnose and teach, but above all it ties us to our patients.”

I agree with much of what Dr. Edelman has to say. When we as clinicians distance ourselves from the patient — either physically or empathetically — something of the caring aspect of the art of medicine is lost. But I would take it one step further.

If we wish to become true healers in our chosen vocation, we must take the time to train ourselves to listen, not only with our ears, but with our hearts as well. For it is only when we listen with the heart that we can truly hope to provide a measure of healing to the patient.

Edelman, ER, Weber, BN. Tenuous Tether. NEJM 2015;373:2199–2201 (December 3, 2015)

A tapestry of song

My life has been a tapestry of rich and royal hue
An everlasting vision of the ever-changing view
A wondrous woven magic in bits of blue and gold
A tapestry to feel and see, impossible to hold.

—Carole King, Tapestry

When we arrived home from the Tapestry Singers annual Valentine’s Day cabaret concert, I counted up the musical numbers listed in the program. There were exactly twenty — a full musical score.

The songs ranged from Broadway hits to country ballads, patriotic medleys to spiritual worship songs. For two hours we were treated to poignant arrangements of pieces like Leonard Cohen’s “Hallelujah” and Enya’s “Only Time,” Jerry Herman’s “Ribbons Down My Back” and Irving Berlin’s “Anything You Can Do, I Can Do Better,” Mark Hayes’ “Consecration” and Marie Barnett’s “Breathe.” For the grand finale there was a special rendition of “Over the Rainbow.”

This annual event was the brainchild of Jana Pivácek-Cole, a talented vocalist and voice teacher, who succumbed to cancer at the close of last year. Since 1998, Jana’s Tapestry Singers, composed of former voice students of all ages,  has offered public performances to raise financial support for the Kateri Medical Clinic in the Kaduna province of northern Nigeria.

Without the benefit of Kateri Medical Clinic, thousands of Nigerians who reside in the region would have no access to medical care. Last year over 14,000 people received care at Kateri for the amazingly low cost of $5 per encounter.

As I sat through this moving musical repertoire, I reflected on our medical mission to Nigeria last summer. We saw nearly 6,000 patients in a 2-week stretch. Many more were unable to access care during our stay; although the needs were great, the workers were relatively few.

When my eyes began to water, I wasn’t entirely certain why. It might have been the poignant pieces of music I heard — or perhaps the memories of those Nigerian patients I had seen. Both sets of voices were certainly present, and together they sounded sweet and low in my ear.

In a Paris Review interview literary critic George Steiner opined:

The next Copernicus may have something to tell us about what music does inside us and how it is created. Above all, music illustrates for me that order of meaning that you can’t translate, can’t paraphrase, can’t put in any other terms, and yet which is intensely meaningful.

Some say that music can heal the heart; I know it can heal the soul. Perhaps it is even capable of moving beyond the borders of space and time to touch the lives of others in need, continents away.

Show me the way to go home

Like ghosts, late-morning mists hovered momentarily over the mountain, winding their way upward to lose themselves in the low-lying clouds. Up on the ridge the old tower stood stately firm, a shell of its former glory. We wound our way along the river road, the pavement still glazed from morning rains.

Down the interstate we flew, making the Pennsylvania border in record time, then coasted into Milford, where we turned southwest to begin the descent through the long green valley. Off to our left through the trees we caught glimpses of the grey Delaware. A wild turkey strutted through the brush; an oriole darted across the road into the trees. A short detour twisted through a stand of dense forest.

We turned off at Smithfield, picking up the shortcut that my uncle had told us about decades ago. Shortly, we glided over the crest of the hill and dropped down into the old town. We pulled into a parking space, crossed the street and slipped inside the church just in time to catch my cousin’s eulogy, the prayers, the creed, and a few familiar hymns from long ago.

The graveside interment was brief. The hillside lay dotted with flags freshly planted for the Memorial Day remembrance. We returned to our cars and headed out to the banquet facility on the hill.

I met my cousin at the entrance. “It was a good talk,” I told him.

“I almost didn’t get through it,” he said.

“You did fine. I liked your description of what it was like when your dad would get home at the end of the day, pulling into the driveway, jingling the change in his pocket, humming some old tune.”

“It was the best part of the day for him—and for us.”

We filed inside and found our seats at one of the long tables. It had been years—fourteen, in fact—since I had sat down to break bread with my extended family, the remnant of aunts, uncles and cousins I had grown up with. I shook hands and exchanged hugs, recalling snatches of their personal histories, knowing that they knew mine. Collectively, a family grows, breaks, gathers together to bind up its wounds and moves on.

We ate and reminisced, stood and shook hands, introducing ourselves to the younger set we hadn’t seen in years. Finally, before dessert, we sat to sing my uncle’s favorite, “Show me the way to go home.”

It was a shorter drive back up the valley to the interstate. Despite patches of heavy fog and steady rain along the extensive stretch of darkened highway, we navigated our way through the night back home.

Recommended reading

In preparation for a routine medical checkup, a good friend of mine drafted a list of concerns to discuss with his physician.

Even though my friend’s life now spans seven decades, he remains in reasonably good health.  Like most of us, he’s got some minor issues related to the wear and tear of his body over time, but nothing insurmountable.

He sat and thought and jotted a few items down on paper.  First he listed his current medications.  Then he wrote a short note to remind himself to mention the problem of his ongoing knee pain.  After that he recorded his concern about his recent inability to remember where he puts things.  Lastly, he added a particularly worrisome problem—inability to rest at night because of recurring bad dreams.

My friend enjoys talking with his doctor, because, as he puts it, his doctor always takes the time to listen.

Whenever my friend checks in with the receptionist for his scheduled appointment, he always inquires just how far behind the doctor is running.  The usual answer falls somewhere between one to two hours.  Undaunted, my friend takes a seat and opens whatever reading material he has brought along to pass the time until the nurse calls his name.

One recent morning over breakfast my friend shared the notes he had taken down during this latest doctor visit.  One by one we reviewed the issues.  When it came to the sleep problem, I asked him what his doctor had advised.

“Oh, he said I should read Thoreau’s Walden,” he told me.  “He feels that it’s a good book to cleanse the mind.”

On hearing this advice, I smiled.  I re-read Walden every spring.  Perhaps that’s why I haven’t been plagued with disturbing dreams for years.

Walden is melting apace. There is a canal two rods wide along the northerly and westerly sides, and wider still at the east end. A great field of ice has cracked off from the main body. I hear a song sparrow singing from the bushes on the shore,—olit, olit, olit,chip, chip, chip, che char,che wiss, wiss, wiss. He too is helping to crack it. How handsome the great sweeping curves in the edge of the ice, answering somewhat to those of the shore, but more regular! It is unusually hard, owing to the recent severe but transient cold, and all watered or waved like a palace floor. But the wind slides eastward over its opaque surface in vain, till it reaches the living surface beyond. It is glorious to behold this ribbon of water sparkling in the sun, the bare face of the pond full of glee and youth, as if it spoke the joy of the fishes within it, and the sands on its shore,—a silvery sheen as from the scales of a leuciscus, as it were all one active fish. Such is the contrast between winter and spring. Walden was dead and is alive again. (“Spring” in Walden)

Precious Stone

“We are all fixing what is broken.  It is the task of a lifetime.”     —Verghese

By chance, when I was a boy searching for rocks to add to my growing collection, I found my first piece of pyrite — “fool’s gold.”  This particular nugget was big, certainly much bigger than any crystalline mineral I had previously encountered.  As I turned it over in my hand, it reflected a tarnished brassy light.

This treasure turned out to be nothing next to the tiny flakes of real gold that later, as an adolescent, I panned from the mountain streams of New Mexico.  That brilliant yellow sparkle was unmistakable.  Once you encounter the real thing, you never forget; it burns itself into your memory and you guard its image forever.

For me, now a seasoned clinician, Abraham Verghese’s 2009 novel Cutting for Stone is the real thing.

Against the backdrop of Ethiopia, a country so beautifully depicted that his descriptions can hurt, Verghese crafts the timeless narrative of two brothers, twins joined at the head by a mysterious cord identified at birth.  In an emergency caesarean section the obstetrician who will become their surrogate mother clamps and divides this tube, uncertain if it contains meninges, gray matter or aberrant blood vessels.  Thus separated at birth, the twins retain a mysterious bond between them throughout the rest of their lives.

Thomas Stone, their surgeon father, normally level-headed and dexterous in the operating theater, flounders on how to proceed with the delivery.  Because of his lack of timely intervention, the mother exsanguinates on the table.  Unable to cope with his perceived incompetence, Stone flees the hospital, the country, and, as we later learn, the continent.  He appears again in the final section of the book where he will be called upon in his brokenness to perform a surgical miracle.

Meantime, the boys are adopted and reared by Hema, the obstetrician gynecologist, and Ghosh, the internist, at Missing (a mispronunciation of “Mission”) Hospital in Addis.  Both boys are introduced to the practice of medicine at an early age.  Each pursues it in his own fashion.  Marion, the first-born, blossoms under the tutelage of Ghosh, the competent and kind clinician; while Shiva, his mother’s favorite, blazes his own unique path, pioneering and perfecting the techniques of fistula surgery that will save thousands of ill-fated young women.

Estranged from Shiva over a fiery young woman, Marion is forced to flee Ethiopia for political asylum.  The paths of the brothers will converge seven years later in America, where, in a manner of speaking, they become reunited again.

In Cutting for Stone, Verghese gives us his best, exploring how the sins of fathers are visited upon subsequent generations, the intricate relationships between broken people, the history of modern medicine from clinical practice to the art of transplantation, the interrelatedness of human existence on this planet.  The narrative is chocked full of medical aphorisms and old saws, a well-stocked larder for the practicing clinician.

Cutting for Stone was placed in my hands by a good friend who thought I might enjoy it.  He and his wife had read it over the course of their recent two-month trek through Australia and New Zealand.  I discovered a bookmark sandwiched between two pages — a dog-eared boarding pass from one of their intercontinental flights.

The read itself turned out to be a fascinating journey, one enriched by precious stone.

Help me to not be afraid

Like all 4-year-olds, Skipper had his likes and dislikes, his favorite activities and things he would rather not do. Like most 4-year-olds, Skipper’s world consisted of family, friends, pre-school and home. And like few 4-year-olds, Skipper’s world came to a grinding halt when his doctor diagnosed him with a brain tumor.

Because of its location, the tumor was operable. The neurosurgical team labored over him for eight hours and succeeded in resecting the growth. Because the pathologist was unable to differentiate the cellular type, the slides were sent out to a world-renowned regional cancer center for review by the experts.  The results came back equivocal.

The parents were given the option of a short course of local radiation, an extended course of chemotherapy, or observation. Because of the side effect profiles, they elected to watch and wait. Unfortunately, the growth recurred.

This time round Skipper was enrolled in a chemotherapeutic protocol. Periodically, he would receive four days of toxic medications. These rounds were scheduled at monthly intervals. The initial treatment regimen knocked him down, but soon he was up and active again. The second round was worse. The morning before the trip to the hospital, Skipper’s grandmother was helping him to put on his socks when he made his small request: “Please, Grandma, help me to not be afraid.”

What do you say to a 4-year-old? What sort of reassurance do you offer? How far out on the limb do you go?

At that age, reassurance takes on the mantel of love. Words help, touch helps, doing an activity together helps. We work with whatever tools we have.

Sometime later after I heard this story, I drove to a local bookstore to browse the shelves in the children’s section. It proved difficult to locate a specific book, because they are categorized under different genres according to the perceptions of the adults who work in these areas. For the young child, a book is a story—nothing more, nothing less. Its category means nothing—it is only the story that holds meaning.

I made my selection and paid at the register. I laid the parcel on the seat beside me as I climbed into my car. I hand carried the book to the house that I had last visited years ago. Tucked in among the towering pines, it was still there, just as I had remembered it: neat and trim, well cared for.

With a short stammer of inadequate words I placed the gift into the hands of the grandmother I had come to know over the past decade. She invited me to come in, and we sat among the plants in the conservatory and talked a long while about children and grandchildren, parenting and grandparenting, love and tough love.

She gifted me a poem by one of her favorite writers, Wendell Berry.

When despair for the world grows in me
And I wake in the night at the least sound
In fear of what my life and my children’s lives may be,
I go and lie down where the wood drake
Rests in his beauty on the water, and the great heron feeds.
I come into the peace of wild things
Who do not tax their lives with forethought of grief.
I come into the presence of still water.
And I feel above me the day-blind stars
Waiting with their light.
For a time I rest in the grace of the world, and am free.

At my age, reassurance takes on the form of caring. We learn to care for one another as best as we can, with whatever tools we can muster.