When one of my patients dies, no matter how much it was anticipated, I feel sad. A cleft opens way down in my chest and although in time it mends, there is from that point on a fissure, ragged, chipped, where once the place was smooth. I have been diminished by the death as though a part of me has fallen into eternity and will never be recovered.
Loss is related to love. We cannot feel loss unless we have loved. Therefore I will say it, although it may embarrass the reader: I love my patients, every one of them. They may infuriate or confound me; they may not follow my advice or even agree to collaborate in discussion; I may be tempted to give up on them and walk out. But I love their quirks and foibles, their many particularities.
Doctoring is about love. There is the illusion of distance conferred by professionalism and the white coat, but this love, philanthropos, or "loving other human beings," is the highest form of Eros. In Corinthians it is The Greatest Gift: Though I speak with the tongues of men and of angels, but have not love, I have become a noisy gonger or a clanging cymbal. And though I have the gift of prophecy, and understand all mysteries and all knowledge, and though I have all faith, so that I could remove mountains, but have not love, I am nothing.
Having love is what brings an opening, a pouring out to another. The tools and entrapments of medicine are hopeless without this. A doctor endures with a patient, hearing stories that have never been told to anyone else, bearing with them, waiting in a silence that is completely present. It's important not to protect ourselves from the stress of others. We do this all the time when we say, "I don't have time for this!" or "Other people have the same issue," or "Get your act together!" We may think, "I'm not like that." Sometimes doctors charge patients for being late, or dismiss them from the practice for "noncompliance." These are ways to barricade ourselves from suffering, which after all has a purpose and needs to be borne. The suffering of others reminds us--since we are unconscious much of the time--of our own suffering, which is tangled up in our past, and complicated. It feels dark and unbearable if we get close to it.
Something generative happens in sessions with patients when all I do is listen to what they say. It is almost as if witnessing translates into livingness. The patient talks and talks, then thanks me profusely on the way out, even though I have "done" nothing. I have not ordered tests, found a disease, or written a prescription. Yet there is suddenly a lightness-of-heart in the space between us, and the patient is able to carry on and perhaps to live differently. I don't understand this mystery. It is not outwardly miraculous. "The cure is effected by love," said Plato. It is the mainstay of medical practice.
There are times when a patient's litany of complaints irritates me. I have had patients who unload twenty-six different pains and problems in the taking of their history, as though they were dumping a wheelbarrow full of stones at my feet, saying, "Clean this up." It's overwhelming at first, and my silent reaction is a bit like giving up. "Do you really think I can help you?" I want to cry out. "Give me a break!"
Of course the patient must believe, in the deep recesses of his mind, that I can help or he wouldn't be here. But outwardly there is a presentation of hopelessness, a message waiting to be corroborated, and dreading corroboration: "I cannot be helped," "See what a mess I am," "My father was right, I'll never amount to anything."
In these cases I sit with my own irritation. When I don't know what to do or where to begin, I simply watch and listen, terrible as it feels to hold still. I remind myself that my irritation is a signpost for a problem of my own, and in this way the patient has helped me to diagnose myself. The patient's enumerated sufferings, and my crescendo of irritation, are pointing to a warped part of my past which has pressed like a knot in a tree on my heart. It, too, is in need of attention. If I can attend to this, the patient might also get well. Therefore I wait for the patient to finish speaking, and for my own inner experience to emerge. A wash of sadness signals that I am getting close. I remember a line from Alan Watts: "The transformation of the world is brought about by the transformation of the self." If I can bring light to my dark interior I may eventually be of some use to this patient.
Last month one of my patients died. She was one of those people whose many problems seemed insoluble. My staff would warn me in advance when she was scheduled. I would take a deep breath before entering the exam room. Towards the end of her life she came two or three times a week, urgently needing to commune with me. Over the years she had copied verses from the Bible and brought them wrapped in ribbon as a gift--sometimes many painstakingly handwritten pages. "I can't write my own poetry, but this is better than anything I could write anyway," she'd say. "I wanted to give you something." In the manner about which I have just spoken she helped me a great deal, as though her difficulties were a kind of therapy to me. Most days I could not have understood this and simply wrote her prescriptions, attended to her pain. After the shock of her death I was paging nostalgically through her chart and saw one of her Bible passages. "Love bears all things, believes all things, hopes all things, endures all things." The handwriting was tremulous and childlike, but it adhered obediently to the lines on the wrinkled paper. At that moment I felt a cleft in my chest open, and tears began to flow.