These days, the label “attending” is attached to “physician” as a matter of course, obscuring the possibility that it might once have meant something beyond a job description.
Jacob Needleman, in The Way of the Physician, has suggested that the role of the physician “was the last as well as the first great and honorable passion of man, the fusion of the search for understanding and the impulse to help and serve suffering humanity.”
Like many of my colleagues, I was moved to become a doctor by just such an ideal — however dimly I perceived it. Without wanting to blame anyone, I’m sorry to say that I didn’t find any commanding models among my medical school teachers. Even those who approximated such a “fusion” — one might call it wisdom — seemed unable to convey how they’d come by it. Competence, cleverness, even great kindness, yes, these in abundance; but wisdom? Precious little.
Without doubt, many fledgling professionals — attorneys, ministers, teachers — have experienced precisely the same aspirations and disappointments. For that reason, I believe my musings are not merely those of a physician in the making, but rather, describe the more universal search to be of service in the world while at the same time remaining open to something beyond it.
If a certain kind of attention — an active attention — is the key to this effort, then perhaps we should not be surprised that modern education has failed to produce it. With its emphasis on memorization and regurgitative examinations, modern professional training almost totally neglects the development of the student’s inner life — especially the questions “Who am I?” and “What am I doing?” Indeed, competition for admission to professional schools is now so intense that one who pauses to reflect on such questions risks failure.
The dehumanizing quality of modern medicine has not gone unnoticed by medical school faculties. Nor has there been a shortage of ideas for counteracting it. Still, the problem worsens. Who does not now dread illness partly out of fear of being subjected to “the health care system” itself?
Reluctantly, I have come to the conclusion that efforts to fix things by tinkering with the system are doomed to failure. In part, I speak from having failed many years ago in a simple group effort in this direction, but these days I speak also from a deeper understanding of the problem.
After the first month of medical school, it became clear to a group of campus “radicals” (fellow first-year students) that we were not going to be able to “change the system.” Indeed, we felt we’d be lucky to graduate with any idealism intact. So instead of railing against it, we decided simply to keep a collective journal of our training — the events that turned so many into cynical careerists. We felt we were almost powerless, but we thought there was some value in keeping a record. Within a few months, the more restless among us had invited other “health care workers” into our enterprise (so as not to be “elitist”), and not long thereafter, the group took a decidedly Maoist turn. After protesting the group’s change in direction, I was told to get off my “self-perfection trip,” or get out, so I left. Somehow, hating didn’t go with being a doctor.
Partly as a result of this failure, I retreated into the world of research to make my peace with the medical establishment — surely Mother Science would lead me to wisdom (and a little fame wouldn’t be unappreciated!). But after sacrificing twenty-nine mice to the god of my personal ambition, I let the thirtieth go free, dropped out of the research rat race, and became a practicing physician.
I wasn’t able then to articulate exactly what the problem was, but it had something to do with being trapped in a whole series of crazy causal loops. For example, the manufacture of the plastic dishes in which I was growing cancer cells probably produced toxic wastes, wastes which in turn caused the cancer for which I was trying to find the cure by growing cells in plastic dishes. I later discovered that my intuitive discontent was a bit of what David Ehrenfeld, in his brilliant essay, “The Arrogance Of Humanism,” has called “end-product analysis.” His end-product analysis of the war on cancer (and it could be repeated for all our altruistic “wars”) is much clearer than mine:
The society clever enough to perform sophisticated research on cancer is the society clever enough to invent the sugar substitutes, children’s sleepwear ingredients, food-coloring agents, and swimming-pool test kits that may cause it.
The point is that many of our proposed solutions to the dehumanization of medicine have been made necessary by earlier solutions to earlier problems which in turn were earlier solutions. Ehrenfeld exposes the set of assumptions underlying this apparently endless spiral — assumptions upon which the work of most professionals rests:
Humanists are fond of attacking religion for its untestable assumptions, but humanism contains untestable assumptions of its own. These are the givens, the things that are unconsciously assumed and rarely or never debated. If they occurred in others, humanists would call them superstitions, or, more politely, articles of faith. . . .
All problems are soluble by people. Many problems are soluble by technology. Those problems that are not soluble by technology, or by technology alone, have solutions in the social world (of politics, economics, etc.). When the chips are down, we will apply ourselves and work together for a solution before it is too late.
If Ehrenfeld is right, then the loss of the myth/ideal of “The Great Physician” is but a reflection of a much deeper dilemma for which most solutions are just more of the same. His comments on modern medicine have an unmistakable ring of truth:
Our civilization is coming to equate the value of life with the mere avoidance of death. An empty and impossible goal, a fool’s quest for nothingness, has been substituted for a delight in living that lies latent in all of us. When death is once again accepted as one of many important parts of life, then life may recover its old thrill, and the efforts of good physicians will not be wasted. But I do not see how this can come to pass in a humanistic world.
In the meantime, people will still become ill and call a physician. What shall I do? As Krishna instructs Arjuna in the Bhagavad-Gita, refusal to participate is not a solution. And yet, if the answers to these problems — for me, the problems of attending illness and death — lie outside the realm of humanism, then where? In something beyond human beings? But here is a paradox, for if I choose to believe in something greater than myself, what is greater? Something truly higher should compel my faith, not request it. The way out of this intellectual quagmire is to recognize that the mind alone cannot provide the precision I need: the necessary clarity can come only from direct experience — in my case from the practice of medicine.
Although I’d always felt that it was a privilege to attend the ill, I didn’t begin to understand what it meant until the death of a dear friend. After exploratory abdominal surgery confirmed the diagnosis of inoperable cancer, this accomplished actress called me to her bedside to discuss her choices. Should she undergo chemotherapy and radiation? I described the side effects of the treatments — the hair loss, nausea, bone marrow suppression — as well as the hoped-for benefits: prolongation of life for another six months to a year. After listening carefully, she said, “I haven’t devoted all this time and energy to awakening [referring to a long path of inner work] to die like that. Can you help me die at home?”
I can’t say I did much actual work of tending her at home. Another physician and I arranged for her to have a hospital bed installed; we also made sure that a bottle of morphine syrup was available when she felt she needed it (she didn’t use much). Many other friends did the nursing — bathing her, feeding her, and changing her bedclothes. I simply watched, held her hand, talked with her, and waited. Gradually, she ate less and less, stopped taking water, and in time, almost imperceptibly, ceased to breathe.
Her death was all the more staggering to me because I had never seen anyone die naturally before. I also became acutely aware of having been denied such an experience with my father, himself a physician, who had died of leukemia six months earlier. At his end, by horrible contrast, our family had had to force the attending physician to stop the “life-saving” measures that were only prolonging his agony.
The lesson of these deaths is not, as the medical schools so often propose, that physicians need more seminars in medical ethics, or advanced training courses in social skills development. We need instead to recognize that our deepest assumptions have led us to a gross misunderstanding of the place of human beings in the world. In summary, we have been taught that life emerges out of a dead universe.
One of the most damaging consequences of our failure to understand who and what we are is reflected in the belief that the very means by which we know anything, our consciousness, can itself be understood rationally. It’s as though that analysis itself weren’t a function of the very kind of awareness in which it took place! Yet it is precisely from this attitude that humanists either ignore consciousness or regard it as some sort of “stuff” secreted, as it were, from the brain. Translated into the education of professionals, it’s an assumption that regards “the facts” as far more important than the state of mind which receives them.
It is much more intelligent to take the position that the universe is alive, and that “my” consciousness is not mine at all, but rather the appearance in me of something which already exists. As C. Daly King proposed in The States of Human Consciousness, we should conceive of consciousness not as a thing, but as the relation between knower and known. Attention, especially insofar as it can be directed by will, is the element of this consciousness over which we have some direct control. But in the usual, so-called “waking” state of consciousness, our attention is essentially passive. Once our basic impulses are satisfied, our attention is attracted here and there and retained for various lengths of time as a result of fascination, enthusiasm, and the like.
In this state our perceptions become habituated and our actions automatic. We become, at best, bored; at worst, cynical. Without questioning whether this passive attention and the state it reflects is our only possibility, there is simply no escape from the endless cycle of desperate solutions begetting even more agonizing problems. It is not that we have left ourselves out of the solution to our miseries; it is that we have left out the potential for anything higher.
It seems to me that if there is anything unique about being an attending physician, it is the force with which one’s daily work demands some vision of genuine inner development. Confronted with another human being who is in pain, chasing after altered states of consciousness for their own sake is simply unconscionable. And here the direction appears: the search for a higher consciousness must have for its aim the development of conscience. As the French physician Jean Vaysse wrote:
Conscience calls me to be myself. To be myself begins with self-knowledge. Self-knowledge begins with work on myself. Work on myself is based on the sensation of myself.
This “sensation of myself” is perhaps the first function of an active attention — an attention beyond what is given by mere biological drives.
One night many years ago, during a tour of duty in an emergency room, I had an especially lucid experience of the kind of attention that supports conscience in action. The evening had been difficult, and when I did finally manage to get to bed, I fell asleep immediately. A short time later, however, I was awakened by a call to see another patient. While asleep, I had dreamt with such intensity that when I awoke, I seriously questioned which was reality — the previous state or this one? Having had the experience of waking up within a dream on several previous occasions, my doubts weren’t entirely without foundation. Fortunately, I was confident enough in my medical skills to maintain this interesting state of self-wonderment while I dressed and made my way to the emergency room to see a mother and her eight-year-old son.
Before I could say a word, the woman informed me that her boy needed “a shot of penicillin right now.” In a flash I took in the whole scene, reading their faces and postures as though they, and I, were written into the script of a play.
The woman was tired, frightened, and angry. Her son had been complaining of a sore throat, and she, suspicious that he was simply using a minor problem to get her attention, had threatened him with “getting a shot” if he didn’t quiet down. The poor boy had forgotten himself and complained once again, forcing his mother to make good on her threat.
I saw all this in a flash in my state of questioning, and I also saw that my role as the doctor in this drama was not restricted to treating the illness. Examination of the boy suggested a mild viral infection. I ordered a blood count and a throat culture, and while waiting for the results, asked his mother how she was — from a real interest in knowing. Tearfully, she described the difficulties of raising her son alone and maintaining a full-time job — her husband had abandoned them a couple of years previously. In this new state of awareness, we seemed in a dance: her need to speak matched by my need to listen. As we talked, she edged closer to her son and began rubbing his back as he lay on the gurney. The lab tests confirmed the diagnosis. I reassured her that her son would be fine, prescribed a mild decongestant, and set up a follow-up appointment.
It was a small scene, neither dramatic nor unusual — in all respects insignificant in the larger scheme of things; nevertheless, it has remained alive in my memory for many years. For on that occasion, perhaps for the first time, I truly attended — acting not from what I imagined a physician to be, but rather, from a state of unencumbered attention. Astonishingly, I discovered that what I’d been longing for had been with me all along.
This essay originally appeared in the Summer 1990 issue of Parabola, The Magazine of Myth and Tradition, and is reprinted with permission.
— Ed.
