Suffering, Meaning, and Healing: Challenges of Contemporary Medicine

It has been a great pleasure to read the essays by Thomas R. Egnew on healing throughout the years. His most recent essay on Suffering, Meaning, and Healing: Challenges of Contemporary Medicine, is again one of those pleasures. As they say, Dr. Egnew has “a way with words.”

One of the key issues around healing is its definition, assessment, and measurement. If, as family physicians, we are serious about bringing healing back into contemporary medicine, we need to make a concerted effort to developing the tools for understanding, measuring, and enhancing how healing happens.

Since healing is an “emergent property of the whole person,” it involves a complex set of characteristics that enhance the likelihood of this emergence. The total environment from the inner personal - to the interpersonal - to the outer, need to be considered. Only then can we truly construct an optimal healing environment.

One of these components of healing is helping an individual to become more whole – to attain the “experience of wholeness.” To do that, of course, we must understand what a “whole person” actually is. In Dr. Egnew’s description, one of those components is healing connections and how narrative can help attain that provides a wonderful grounding. But what is a “whole person?” I think of a whole person a having at least three- if not four dimensions. First, becoming whole means the integration of the self in space. This is the more traditional concept of mind-body-spirit integration. Practices such as, meditation, breathing the Relaxation Response, yoga, and others help one feel connected in the heart and in the head.

An equally important area is the integration of the self. This means the integration of one’s past, present, and future self. So often when tramatic events occur in our life, we cut ourselves off from feeling, experiencing, and reconciling with our reactions to those traumas. Thus, we become disengaged or separated from our past self. Reintegration with that past self can be very healing as illustrated by the numerous studies examining the therapeutic effect of storytelling and narrative about traumatic past experiences. Equally relevant is the integration with our future self. Serious illness disrupts that sense of future and the patient often asks, “Where do I go from here, Doc?” “Will I ever get to the … (fill in the blank - wedding, school, job, etc.)” One reason that individuals are discharged from the hospital faster when seated near a window, may be because they can see out the window and so imagine themselves in the future outside, and no longer ill. Chris Feudtner has said that in the context of terminal childhood illness that healing is “the attainment of hope.” The process of the physician healer is to help the child and their families identify hopes that can be obtained. Becoming whole as a person also means being connected to others and Dr. Egnew so eloquently describes this process. It has been well documented, that those who are isolated and do not have social support – that is not connected with others - are less resilient – and more likely to die prematurely and more likely to get ill. From the perspective of the whole person, they are less whole because a person is defined in their relationship to others. Otherwise, they are simply individuals and not whole persons. Thus, a core role of the physician healer should be to assist in individuals becoming socially whole by decreasing their social isolation. Finally, the person has a spiritual core and thus, is not whole unless they are connected to the “Other.” That is something greater than themselves that touches at or reaches for ultimate meaning - beyond their ego. From this perspective, then spiritual practices are reintegration with one’s “Self” and thus, also involve the process for becoming “whole.” One can conceptualize healing is attaining this experience of wholeness in all four of these dimensions - space, time, person, and other. As those who aspire to be healer/physician/scientists, we should design and explore research that helps to disentangle, understand, and facilitate this process of wholeness in more effective and more efficient ways.

Competing interests:   None declared

Dr. Egnew makes a powerful and eloquent argument for doctors needing to learn to become healers. Despite cultural obstacles, progress is being made.

Our culture is focused on controlling and shaping the environment to our personal benefit. The existential realities of suffering from constant change, aging, sickness and death are relegated to the dark shadows of our life narratives. Hence the shock when we must face these universal facts of life. Even then, we hope for a cure, so we can resume a life narrative in which we “live happily ever after.”

Patients’ emotional well-being relies heavily on a “sense of control over disease.” They demand to be cured, and resist psychosocial approaches. The dominance of biomedicine has inadvertently helped create “intolerance and increased sensitivity to pain” and suffering. (1)

Clinicians are equally attached to this sense of agency over disease. Not surprisingly, a majority of physicians support the cure-focused biomedical, and resist the biopsychosocial model (2) which includes healing. Changing the orientation of one’s life narrative from exclusively controlling, to one that includes acceptance of illness, seems to be as daunting for most physicians as it is for patients. Yet, physicians, if they are to be healers, need to undergo this transformation and acquire an additional skill set, somewhat like that of a traditional healer.

Cultivating “healing presence” entails a life-long commitment to personal growth, through practices such as meditation. (3) Mindfulness training helps cultivate the ability to face existential reality unselfishly, nonjudgmentally, with acceptance and even joy. (4) Increasingly, healthcare professionals are training to embody these allocentric / ecocentric qualities, enabling them to more effectively help patients do likewise. (5)

1. Dahl J, Lundgren T. Acceptance and commitment therapy (ACT) in the treatment of chronic pain. In: Baer RA, ed. Mindfulness-based treatment approaches: Clinician's guide to evidence base and applications. San Diego, CA: Elsevier Academic Press, 2006:285-305.
2. Astin JA, Soeken K, Sierpina VS, Clarridge BR. Barriers to the integration of psychosocial factors in medicine: results of a national survey of physicians. J Am Board Fam Med 2006:19(6):557-65.
3. Phelon CR. Healing Presence in the Psychotherapist. The Humanistic Psychologist 2004:32(4):342-56.
4. Lovas JG, Lovas DA, Lovas PM. Mindfulness and professionalism in dentistry. J Dent Educ 2008:72(9):998-1009.
5. Hassed C, de Lisle S, Sullivan G, Pier C. Enhancing the health of medical students: outcomes of an integrated mindfulness and lifestyle program. Adv Health Sci Educ Theory Pract 2008.

Competing interests:   None declared

Dr Tom Egnew’s most recent article is an excellent addition to an important theme in clinical practice first initiated by Dr Eric Cassell; that of suffering and how to respond to it.(1) Dr Egnew’s thesis is that doctors need to become ‘healers’ as well as being trained in how to ‘cure’, and that becoming a healer may be an antidote to cynicism and burnout in the profession.

Two possible implications are that 1. existing doctors can re- envisage their approach to medical care, and 2. that medical students could be trained to become healers.

There is a certainly a significant number of doctors who are thinking along these lines and who illustrate that transformation towards a more healing orientation is possible. Two examples are The Institute for the Study of Health and Illness, initiated by Dr. Rachel Naomi Remen (see http://www.meaninginmedicine.org), and Compassion in Healthcare, a New Zealand group that is “dedicated to restoring caring and compassion as core values and daily lived practices for all our health professionals and institutions” (see http://www.compassioninhealthcare.org).

With regard to teaching undergraduate students, the problem is not that they are not compassionate or caring by nature, but more that over the course of their training, their orientation tends to shift towards a rather narrow disease-centred or curative model. Clinical training somehow undermines certain dimensions of patient centredness such as awareness of the biopsychosocial perspective, doctor patient relationship, patient-as- person, and doctor-as-person.(2)

These are difficult issues to address. Undergraduate curriculum reform has made some progress in reducing the well documented decline in student’s capacity for empathy, but there is still a long way to go. Dr Egnew’s article is a timely reminder of the long term goals of both training and future practice.

1. Cassell EJ. The nature of suffering and the goals of medicine. N Engl J Med. 1982;306(11):639–645.

2. Wilson H. Becoming ‘patient centred’: a review. NZ Fam Phys 2008; 35(3): 164-70.

Competing interests:   None declared

While working to serve a chronically ill population – individuals and families with Rare Disorders – I was given the wonderful opportunity and permission to incorporate many of Dr. Egnew's theories on healing and suffering into my presentations.

This community, isolated by small numbers and lack of research/funding, were often forced into an emotionally lonely journey that contributed to their physical suffering. By encouraging those who attended our workshops to share their illness story, and then present to them a “different” definition of healing, one which was reached through a change in their perception, I was given the amazing experience of witnessing very emotional and powerful transformations! To use the expression “knowledge is power” is an understatement in this case.

We also provided information and language skills to the participants, on how to better communicate with their many physicians as to their suffering. We encouraged them to do this with the hope they might better “connect” and hopefully form the bond that Dr. Egnew writes of as the “physician-healer” model (using the philosophy of “If you can't take Mohamed to the mountain, then bring the mountain to Mohamed.") The feedback from attendees in years to follow was very positive. Many stated that their doctors welcomed their initiating the discussion and felt that a healthy emotional “bridge” had been built between the patient and physician.

Are these new ideas? Old ideas? Does it really matter to the one who is lifted up by them? I have witnessed patients and caregivers profoundly impacted by the thesis of this essay and with gratitude I applaud Dr. Egnew in his continuing efforts to promote and encourage the role of physician-healer in contemporary medicine.

Competing interests:   None declared

In this thoughtful and provocative essay, Egnew asks physicians to be both excellent technicians, applying the best that technical biomedicine has to offer, and holistic healers, helping patients create meaning in the midst of their suffering. To use his television metaphor, he is asking us to be Marcus Welby and Gregory House at the same time. Presented in this way, the task seems impossible, particularly to physicians in training. The formal curriculum teaches that there are two separate skills, two wholly different ways of being, and a physician must master both. The time devoted to the mastery of biomedical skills versus the time devoted to mastering the art of relationship, however, makes it clear to students which they should consider most important, as Peter Karlin points out in his response to Egnew’s essay. This dichotomous way of thinking (and teaching) will never get us to where Egnew wants us to go.

In my study of healing relationships,[1] I found that physician healers experienced no such dichotomy. Their ability to give full attention to their patients’ experience of illness enhanced their ability to arrive at better diagnoses. Their capacity to “suffer with” their patients led them to be able to tailor treatment to meet the needs of individuals. Their willingness to partner with patients led to better adherence to medicine regimens. In short, relational wisdom and clinical wisdom were inextricably tied together.

How can we teach this integrated way of caring for patients? Boudreaux and colleagues have presented a concept they call “physicianship,” which they argue is “based on the fundamental premise that healing is the doctor’s primary obligation.” They have used this conceptual framework to reorganize the entire undergraduate curriculum at McGill University Medical School.[2] If we wish to train the holistic physician healers that Egnew describes, we would do well to pay attention to the efforts of our Canadian colleagues. Tinkering around the edges of the medical curriculum will not be sufficient.

1. Scott, J.G., et al., Understanding healing relationships in primary care. Ann Fam Med, 2008. 6(4): p. 315-22.

2. Boudreau, J., E.J. Cassell, and A. Fuks, A healing curriculum. Med Educ, 2007. 41(12): p. 1193-201.

Competing interests:   None declared

In his letter of 1549, the great Michelangelo perceived his work as a sculptor to be one of “liberating the figure imprisoned in the marble”; this effect is most dramatically and poignantly seen in his sculptures of slaves.

Egnew’s superb distillation raises issues about how physician-healers can maximise their impact in the healing process. The late theologian Henri Nouwen (quoted in Egnew’s paper) introduced the concept of “emptying oneself” in his discussion of compassion. The term used by Nouwen describes the process and the state of “being there”, fully present, in order to “pay attention to others in such a way that they begin to recognise their own value”. However, in clinical practice we are rarely empty. We are mostly “occupied”. Indeed, as we come to each new consultation we may be in a state of preoccupation, largely distracted by an emphasis on diagnosing, investigating and curing the physical aspects of disease. Nouwen continues “every time we pay attention we become emptier and the more empty we are the more healing space we have to offer”. As a less-attuned oncologist in the past, I recall visiting patients with gifts – a new drug, a new treatment plan, or a new investigation. Now I just bring myself with all its imperfections, and my emptiness. It is also said that patients will mostly heal themselves as long as we provide for them a space for that healing to occur. In Buddhist philosophy, cultivating mental relaxation (“emptiness suffused with compassion”) is seen as vital in actualising our role as healers. Once we have emptied ourself and created an empty space in our busy internal worlds, we connect through listening.

The recent interest in teaching communication skills to young doctors and to other healthcare professionals is both encouraging and overdue. However, the communication which is taught does not necessarily equate to a clinician’s ability nor their desire to “connect” to the person of the patient. Little emphasis has been placed on the fundamental role of “communion before communicating”; the teaching of communication skills alone without true underlying communion, will, predictably been seen by patients as gratuitous and superficial at best, and demeaning at worst.

Those who are called to be physician-healers need to be faithful to their calling, and to act as role models for their colleagues. Unless this initiative is taken, when and where will we ever see role models of true physician-healers? Egnew’s paper issues a challenge for would-be physician-healers to take the lead, to become role models and to set new standards in compassionate patient care.

There is much to discuss about the roles that suffering, meaning and healing played in the life of Michaelangelo and in his works. One can only imagine how the worlds of beauty and imagination might have suffered had Michaelangelo’s sculptures merely reflected the work of those who had come before him.

Competing interests:   None declared

My recent brief encounter with lung cancer made this all too real for me. The physicians I connected to could hear my anxiety, my denial, and my fear of what this meant for me and my family and my surprise at my need to not really face the possible new reality in my life. I was no longer simply a patient. She was no longer the doctor and we became colleagues, on a first name basis. I was a person who had needs for things like how can I reach you at off hours and I was given a phone number. I was shown a picture of the CT scan, my husband was an accepted member of the team so to speak. I was made aware of the physician's needs and what worked for her as well. No one tired of listening to our questions, to reviewing what was involved and what we could do about it. In retrospect I knew how to create a relationship that worked for me, as well as to receive the care I needed. This experience led me to think that in training health care professionals to create a healing relationship they may need to be taught how to teach the ill person, as well as the physician how to be involved in an equitable relationship where everyone is heard. This may involve developing a vocabulary that facilitates participants developing new roles consistent with this new goal.

Phyllis R. Silverman, Ph.D.
Scholar in Residence at Brandeis U. Women’s Studies Research Center
Author with M. Kelly "A parent’s guide to raising grieving children: Rebuilding your family after the loss of a loved one."

Competing interests:   None declared

When physicians think or say, “There is nothing left to do”; or worse, “I have nothing to offer you” they are mistaken. When cure is no longer possible an opportunity for healing emerges. A physician, of course, cannot heal a patient, but s/he can foster healing through her/his own conscious presence. Another term for this quality of presence is mindfulness. A physician’s mindfulness may facilitate healing in the context of medical practice.[1]

The symbol of medicine with two snakes entwined around a staff represents the Hippocratic and Asklepian approaches to medicine. Dr. Egnew’s essay, “Suffering, Meaning, and Healing: Challenges of Contemporary Medicine” highlights the dual and complementary roles of physicians – those who ‘act for’, ‘do to’ the patient (Hippocratic) and those who create the circumstances that support healing in the other person and a sense of safety for the voyage into the unknown space of illness (Asklepian).

How can physicians be supported in this dual role? Novack, Epstein and Paulsen (1999) addressed this question directly by purporting that medical students need to be encouraged to be self-aware (mindful of the self), cultivate personal growth, and preserve their own well-being.[2] This is not a ‘plus’ but a necessity for those who will be exposed to stress, distress, and suffering on a daily basis throughout their careers. Hutchinson, Hutchinson, and Arnaert (In press) compare and contrast physicians’ and patients’ roles when curing or healing are the goals of treatment.[3] Power and responsibility shift from the physician to the patient when healing takes precedence. Yet, the physician has an important role to play; that is one of accompaniment

Rackel (2007) concurs with Egnew (2009) in his correspondence regarding creating expertise in health and healing. He notes that new family doctors wish to be experts in salutogenesis (the creating of health) as well as experts in pathogenesis (the creation of disease).[4] This is possible in the context of the doctor-patient relationship and can be taught as part of the medical curriculum.[5]

References
1. Dobkin PL. Fostering healing through mindfulness in the context of medical practice. Curr Oncol. 2009;16(2):1-3.
2. Novack DH, Epstein RM, Paulsen RH. Toward creating physician- healers: fostering medical students' self-awareness, personal growth, and well-being. Acad Med. 1999;74(5):516-520.
3. Hutchinson TA, Hutchinson N, Arnaert A. Whole Person Care: Encompassing the Two Faces of Medicine. Can Med Assoc J. In press 2009.
4. Rakel D. Creating expertise in health and healing. J Am Board Fam Med. 2007;20(6):611.
5. Boudreau JD, Cassell EJ, Fuks A. A healing curriculum. Med Educ. 2007;41(12):1193-1201.

Competing interests:   None declared

Egnew explores the issue of physician as both curer and healer. He describes a healer as one who helps a patient transcend their suffering but does not necessarily effect a cure for an ailment. When a patient is stricken with an incurable illness, so emerges an opportunity for healing. As a physician, I have had plenty of such opportunities.

How does today's doctor reconcile the dual roles of curer and healer? For example, Jean Jacques Rousseau once said that “The efficient physician is one who successfully entertains the patient while nature effects a cure” At first I laughed at this quote knowing that as physicians our failure rate for effecting a cure is indeed high. After all, in the end, we and all our patients will die. A large part of the difficulty that I and many other physicians have in reconciling our dual roles as curer and healer is that the inability to cure is taken by many as a failure to successfully perform our duty. The message from our society and from our halls of higher education is often this: That we take on the active role as curer and miracle worker and the patient takes on the passive role as recipient, as in the recipient of a healing spell from a beneficent and magnanimous magician. Egnew reminds us that in such cases, our work may have just begun, for our remaining work consists of those elements that he eloquently describes including aiding in the transcendence of their suffering. Thus we are challenged to view our “treatment failures” as not so much personal shortcomings as opportunities to follow through on unfinished work.

Competing interests:   None declared

I enjoyed reading Dr. Egnew's article because he identifies a problem that I have struggled with as a medical student, but have rarely heard articulated. As medical students, we spend the vast majority of our time learning about disease and how to effectively treat it. Understanding disease is important, but the focus on this tends to overshadow what we learn about trying to better understand the patient's illness and how to help alleviate his/her suffering. When we begin clinical rotations in our third year, there are many pressures we experience as we rotate regularly between specialties. We feel the pressure to show competence in managing medical problems, be more efficient, and be able to provide the right answer when asked a question. These are the areas in which we are often evaluated. I believe these pressures and a desire to perform well can lead to a lack of empathy for and development of a therapeutic relationship with the patient. As a student, I have also worked with doctors, nurses, and other providers who are empathetic despite the outside pressures they feel. The relationships they develop with their patients clearly help relieve suffering. Having examples of physician-healers like this are essential to counteracting the sometimes unhealthy pressures we face as students. I appreciated Dr. Egnew's article because it recognizes the importance of developing more of these physician-healers.

Competing interests:   None declared

Dr Egnew’s essay is both timely and timeless. Although his references to antiquity are anchored in the Western tradition, the perspective is just as apropos when considering the traditions of other cultures, particularly the shamans of the East and the “medicine men” of Native American Culture.

I was fortunate in my time with the Crow Nation in Montana as an Indian Health Service physician to be included in a number of healing events. While not scientifically verifiable or, in the current jargon, “evidence-based”, they were undeniably powerful and healing, in the sense that Dr. Egnew elucidated. Interestingly, they also had their own “narrative”, invariably with the goal of reconnecting the patient to their environment, characterized as “the Spirit world”.

It is truly ironic that our increased ability to cure has been accompanied by a decreased ability (or is it inclination?) to heal. In the course of my clinical years I had the privilege of being connected to individuals at birth and death (either their own or their relatives – often children). Despite my relative technical impotence - birth happens well most of the time regardless of what you as a physician do, and the deaths were not preventable – these were the times I felt closest to my patients and were the times of the greatest bonding.

One cannot help but wonder about how the tremendous financial burdens with which our young physicians enter practice and their expectations of an affluent lifestyle impact their ability to assume the role of healer. A generation or two ago, physicians were revered icons in their communities but lived a very modest lifestyle. Today, they are affluent by virtually all community standards, but suffer from the malaise of a loss of identity and prestige. We need to reclaim our own souls, and, in the process, learn to heal again.

Smokey Stover, M.D., MMM, Senior VP MultiCare Medical Associates, Tacoma WA

Competing interests:   None declared