THE FORTUNATE PHYSICIAN:
LEARNING FROM OUR PATIENTS
(now complete version of paper)
Fred L. Griffin, M.D.
John Berger’s book, A Fortunate Man, tells the story of the life of a physician who, through thoughtful work with patients and dedicated self-inquiry, created a set of circumstances where he constantly learned from his patients. Not only does he learn how to be a more skillful clinician; through the physician-patient relationship, he came to learn more about himself. In this paper the author will explore how the marriage of the development of professional proficiency with the achievement of deeper self-understanding was achieved by Dr. John Sassall.
The nature of the physician-patient relationship created by Sassall has much in common with the two-person clinical relationship as it is viewed from the perspectives of both psychoanalysis and narrative medicine. A Fortunate Man may therefore be employed to introduce the shared elements of psychoanalytic practice and narrative medicine to the practicing physician and to demonstrate how these approaches to medical practice may lead to meaningful and satisfying clinical work .
Near the end of John Berger's (1967) remarkable book, A Fortunate Man, the author says this about the professional life created by Dr. John Sassall, the country doctor about whom the book was written:
Sassall, with the cunning intuition that any fortunate man requires today
in order to go on working at what he believes in, has established the
situation he needs. Not without cost, but on the whole satisfactorily. In
it he is working...hoping to learn more, learning more. (F.M., p. 158)
The "situation" to which Berger refers is the set of circumstances where—by dint of his experience within the physician-patient relationship—Dr. Sassall was able to satisfy his need to learn more about the humanity of his patients and to learn more about himself as a physician and as a man.
As a psychoanalyst in my thirtieth year as a physician, I have been reflecting upon how fortunate I am to be engaged in a process with my patients that, while constantly challenging me to become a more effective clinician, provides the dual opportunities to learn to better grasp the stories of my patients and to comprehend more about myself.. My training has taught me to focus closely on what is "written" intersubjectively within the two-person relationship between analyst and patient as a path to "reading" what my patients are trying to communicate about their lives. In order to do so, I must constantly confront my limited self-understanding and engage in self-inquiry in order to make full use of the clinical situation to explore my patients' experience. This, to my mind, is a fortunate set of circumstances.
Primary care physicians at the frontlines of patient care are also afforded moments in the physician-patient relationship whereby they can achieve such a partnering of self-reflection and self-inquiry with engaged, attuned clinical work on their patients' behalf. However, the training of physicians that has devalued the physician’s subjective experience with his or her patients does not prepare the practicing physician to fully grasp what their patients are attempting to communicate to them about their illnesses. An appreciation for the intersubjectivity of the doctor-patient relationship—the unique experience that is shared and created by this doctor with this patient at this particular moment in time—may better bring to life an understanding of the experience their patients are trying to convey.
The contemporary movement of narrative medicine provides a way of viewing the doctor-patient relationship in a more comprehensive and illuminating manner, and it offers tools to the practicing physician for the achievement of the narrative competence (Charon, 2001a) that is essential for a better understanding of the patient’s experience in the face of illness. As I recognized my own good fortune to have “established the situation” I need for satisfying professional work (Horowitz et al, 2003), I sought a way to communicate what I have found in my clinical experience as a psychoanalyst that may be of value to both the practicing physician and to the growing body of literature on narrative medicine.
However, the terminology and frames of reference that psychoanalysts use when they speak about their work often seem off-putting, if not irrelevant, to the practicing physician. I knew that I must find a way to enter the world of the physician and to engage in a conversation with them that, while being informed by my experience as a psychoanalyst, communicates something that is real about their own experience in words that are meaningful to them..
When I discovered A Fortunate Man, I knew that I had found a medium through which I could convey elements of my training and experience as an analyst in a form that would be accessible to my physician colleagues. This book-length essay captures the life of one practicing physician, Dr. John Sassall. It demonstrates how he uses himself to heal his patients and how he employs the doctor-patient relationship to foster his own professional and personal development. Berger beautifully describes how Sassall matured as a physician over time as a result of his encounters with his patients. In this paper I will use Berger’s words—language that captures so much of the life of the practicing physician—to speak to doctors in a voice that communicates something about the physician-patient relationship and about the development of the physician as seen through the eyes of a psychoanalyst. I believe that this is also a voice that will ring true to those who are exploring the approaches of narrative medicine.
This paper is largely based upon my experience with physicians in a series of evening discussions where I used A Fortunate Man as a stimulus for explorations about the physician-patient relationship, about the professional and personal development of the physician, and about the practice of narrative medicine. The book presents clinical vignettes showing Sassall at work and commentary on his professional and personal development. Conversations that were stimulated by the text provided many opportunities for me to introduce psychoanalytic perspectives—freed from psychoanalytic terminology—about the physician’s encounter with the patient. Concepts such as unconscious motivation, transference-countertransference, the intersubjectivity of clinical experience, empathy and intuition, clinical process, therapeutic alliance, self-inquiry, and the use of the self as a clinical tool were illustrated through our explorations of this text and by the discussions of the physicians’ own clinical experience evoked by our conversations. Moreover, the clinical vignettes that Berger so beautifully writes in A Fortunate Man demonstrate how encounters with patients may be transformed into stories, into narratives, through the practice of narrative medicine.
As a part of this class, some physicians engaged in narrative writing, which, they came to discover, stimulated self-reflection and led to even deeper insight into their encounters with patients. Thus, A Fortunate Man becomes a vehicle for demonstrating both the principles of psychoanalytic practice and of narrative medicine, and in so doing, brings these two disciplines into a “conversation” with one another.
Throughout A Fortunate Man, Berger’s language is complemented by the evocative photographs of Jean Mohr. In the opening pages of the book we find photographs of bucolic scenes: a winding road amidst forest and field, two men in a boat fishing on a calm river. As the photographs turn from crisp, sunny scenes to those that are dark, foggy, and barely discernable, these words are found in the corners of these landscapes:
Landscapes can be deceptive. Sometimes a landscape seems to be less a setting for the life of its inhabitants than a curtain behind which their struggles, achievements and accidents take place. For those who, with the inhabitants are behind the curtain, landmarks are no longer only geographic but also biographical and personal. (F.M., pp. 13-15)
Berger is an essayist of the highest order (most often writing as an art critic). Reading collections of his essays—Ways of Seeing, The Look of Things, The Sense of Sight, About Looking, Toward Reality—may increase one’s sensibilityy and may introduce the reader to more encompassing ways of perceiving and of understanding what he or she is viewing. We know, therefore, that when he speaks of landscapes Berger refers not only to external landscapes but also to the entire universe of the internal, psychological world. The frontispiece of the book shows Sassall at the threshold of his office door, his gaze directed inside (perhaps toward a patient to whom he is listening) and his hand on the outside of the opened door—in the liminal space between inside and outside. This is where the mature clinician knows that he must live, as it relates to both the physical and psychological worlds of the patient (and relates to the territories of inside and outside of the doctor him- or herself).
As a physician, Sassall did not always possess the capacity to see beyond the deceptive external presentation of his patient. Early in Sassall’s career, his rendering of his experience with the patient was simplified by the belief that the physician was an active/objective agent encountering a passive/subjective patient.
He had no patience with anything except emergencies or serious illness. He dealt only with crises in which he was the central character?in which the patient was simplified by the degree of his physical dependence on the doctor?[This] made it impossible and unnecessary for him to examine his own motives. (F.M., p. 55)
As a boy, Sassall constructed a model of what a physician should be through his reading William Conrad’s stories of the sea. Like the mariners in Conrad’s stories who conquered the elements of the weather and sea, when Sassall became a physician he saw himself as a heroic figure: the doctor as master mariner who vanquished disease. Only he and the disease were active participants, while his patients were seen as passive members of the physician-patient relationship. He did not have to consider either how the patient’s total personality shaped the manner in which the patient expressed his or her illness or how his own personality and the approach he took with his patients impacted the sufficiency of his diagnosis and the effectiveness of his treatment.
But there was something more that he brought from Conrad’s vision of the hero to the practice of medicine. For Conrad’s mariners, the dangers of the sea were “unimaginable” and could only be faced by men who were outwardly controlled: those who could encounter the thing of the sea without feeling, without a subjective response. The physician whose life is patterned after these mariners must give up his imagination:
The quality which Conrad constantly warns against is at the same time the very quality to which he appeals: the quality of imagination. It is to the imagination that the sea appeals: but to face the sea in its unimaginable fury, to meet its own challenge, imagination must be abandoned, for it leads to self-isolation and fear?[Sassall] admired physical prowess. He enjoyed being practical and using his hands. He was inquisitive about things rather than feelings. (F.M., p. 52)
Then something happened. A sudden revelation came to Sassall, one that was both obvious and profound: He noticed that the truth of his patients’ lives was not always as it seemed on the surface, on the outside.
They had lived in the Forest for thirty years?The husband said that his wife “was bleeding from down below”?When he [Sassall] went back into the parlour, the wife was lying on the ottoman. Her stockings were rolled down and her dress up. “She” was a man?.Neither he nor the husband referred to the sexual organs which should not have been there? (F.M., p. 56)
Shocked and then perplexed about this experience, Sassall was confronted with
the fact that he had no way to go about understanding how these two males had
sustained a life as man and wife. Here was a compelling example of how external
appearances may be deceptive. Sassall recognized that he must create an approach
to his work that would lead him to an understanding of what motivates people,
of what makes them who they are.
This particular experience was representative of those that required Dr. Sassall to use his imagination to span the distance between the external “landscape” presented by his patients and the internal world of meanings that inform the patient’s relationship with him- or herself and with others. He no longer adopted the Mariners’ denial of their imagination and their method of projecting their inner experience onto the sea.
He had done just that—using illness and medical dangers as they used the sea. He began to realize that he must face his imagination, even explore it. It must no longer lead to the “unimaginable”, as it had with the Master Mariners contemplating the possible fury of the elements—or, as in his case, to his contemplating only fights within the jaws of death itself?He began to realize that imagination had to be lived with on every level: his own imagination first—because otherwise this could distort his observation—and then the imagination of his patients. (F.M., pp. 56-57)
Now it was not only possible for Sassall to explore his own psychology and that of his patients, it was a necessity for him to do so, should he wish to become a more complete physician.
THE DOCTOR’S STORY: THE DEVELOPMENT OF THE PHYSICIAN
Equipped with the capacity for imagination, Sassall began to listen to what his patients told him with better attuned ears and to see them in a new light. Thereby, he became able to create narratives from what he heard and saw. “[He] began to observe himself and others” (F.M., p. 60). In his attempts to be of service to those patients who had become redefined by physical disease or by deforming external circumstances, Sassall now “restories the patient” (Weinstein, 2003, p. 160). And be began to listen to himself in new ways.
Yet it became apparent to Sassall that to more fully understand his patients’ stories and to differentiate them from his own, he must learn more about himself—his character, his motivations, his past, his ways of comprehending the world. He read Freud and found his self-analysis initially so disturbing that he became sexually impotent for a time. He re-emerged from his six months of self-examination with a different approach to his patient and a more comprehensive understanding of the forms in which an illness may manifests itself.
... that the patient should be treated as a total personality, that illness is frequently a form of expression rather than a surrender to natural hazards. (F.M., p. 62)
With these revelations Sassall, now a mature clinician, needed not to create such emotional distance between himself and his patients. His therapeutic relationship with them improved, and he began to see into them with new eyes. For example, he came to understand that illness deforms the patient’s sense of who he or she is. And he began to imagine how he might help to restore the patient’s more coherent sense of self.
Illness separates and encourages a distorted, fragmented form of self-consciousness. The doctor, through his relationship with the invalid and by means of the special intimacy he is allowed, has to compensate for these broken connections? (F.M., p. 69)
Sassall began to realize that the nature of the physician-patient relationship is much more complex than he had envisioned. Not only do his patients experience feelings about their encounters with disease, his intimate contact with his patients evoke his own feelings. He discovered that his subjective reactions to his patients and to their diseases affect his view of the patient, impact the diagnoses he makes, and, to a significant degree, determine how he goes about treating them. Sassall had to develop his imagination whereby he could look inside his patients and inside himself to be more cognizant of what was occurring between him and his patients. He now knew that he was dealing with more three-dimensional characters in this physician-patient drama.
This revised model of the physician-patient relationship that Sassall created is worlds apart from that of the less developed one constituted of the active doctor with the passive patient. This new kind of relationship is a living, breathing two-person relationship that takes into account the subjectivity of both doctor and patient. Rather than denying the patient’s emotional impact upon the physician, this more developed physician may make fuller use of all his imaginative senses to understand his patient and the manner in which the patient’s disease (the biological or physiological event) may present itself in the form of an illness (the social and existential dilemma posed by the disease in the context of the individual’s personality and network)..
It is here that Sassall was beginning to be fortunate. This is because he had recognized that his earlier model—that of being the hero, the protagonist of the story, who was there to conquer disease—limited his capacities to be a physician in the fuller sense of being a physician: a healer. He had to listen to his patient’s stories and understand who they were as people. He could then grasp how disease expressed itself in unique ways, ways that were shaped by the patient’s personal psychology and by the social and interpersonal context.
And Sassall was fortunate because he was forced to look into himself and to grow. His work with his patients fostered his own emotional development, allowing him to become more of a human being in the unfolding doctor-patient relationship. He therefore became, shall we say, a better man, as he became a better doctor. Sassall achieved better connections with his own emotional life and better connections with his patients. Through his increasing capacity to discern his own feelings and to reflect upon personal meanings, he became more competent to find words of understanding with which to communicate to his patients what he grasped of their experience.
Once he was putting a syringe deep into a man’s chest: there was little question of pain but it made the man feel bad: the man tried to explain his revulsion: “That’s where I live, where you’re putting that needle in.” “I know,” Sassall said, “I know what it feels like. I can’t bear anything done near my eyes, I can’t bear to be touched there. I think that is where I live, just under and behind my eyes.” (F.M., pp. 47-50)
The patient was telling Sassall what it meant to be penetrated by a needle in that part of his body. Because Sassall now had better access to his own feelings and to his own world of meanings, he was able to make a meaningful connection with his patient. He found that by developing his own sensibility, he possessed a clinical instrument that was just as powerful as the stethoscope and medication that address what lies in the patient’s interior.
A FAILED CONNECTION
Early in A Fortunate Man, Berger beautifully describes how this more mature, more fully developed, physician made use of himself in his work with his patients. Placed among the vignettes describing Dr. Sassall at his best is one case that illustrates his experience with a case that “failed”—where he felt that his approach was inadequate to the problem that his patient presented. It is a cautionary tale that demonstrates that the physician—even when his intention to help is most operative—may not always connect with his patient, should he not use his experience and clinical intuition to create a trusting relationship. The following vignette also reminds physicians that there are powerful psychological and social forces that may stand in the way of the best therapeutic efforts.
A thirty-seven year old unmarried woman now living with her ill mother, this woman was first seen by Sassall ten years earlier when she consulted him for a cough and a sense of weakness. Her chest film at that time had been normal. Sassall felt that she wanted to talk about something, yet she refused to look at him directly, “casting him quick anxious glances as though somehow by these to bring him closer. He questioned her but could not gain her confidence.” (F.M., p. 21). A few months later she returned to see Sassall, complaining of insomnia and asthmatic symptoms. He could see the change that was taking place in his patient and now in the physician-patient relationship, a change that Berger describes, as follows:
Now when he saw her, she smiled at him through her illness. Her eyes were round like a rabbit’s. She was timid of anything outside the cage of her illness. If anybody approached too near, her eyes twitched like the skin round a rabbit’s nose. He was convinced that her condition was the result of extreme emotional stress. Both she and her mother insisted, however, that she had no worries. (F.M., p. 21)
It was two years later that Sassall discovered the cause of her problem through a chance conversation with a woman who had worked with the patient at a dairy. He was told that the manager there—a member of the Salvation Army—had an affair with the patient and had promised to marry her. Overcome with religious scruples, he abandoned her. On what must been a house call to see her ailing mother, Sassall, armed with this information, tried again to reach his patient:
The doctor once again questioned the girl’s mother. Had her daughter been happy at that dairy? Yes, perfectly. He asked the girl if she had been happy there. She smiled in her cage and nodded her head. He then asked outright whether the manager had made a pass at her. She froze—like an animal who realizes that it is impossible to bolt. Her hands stopped moving. Her head remained averted. Her breathing became inaudible. She never answered him. (F.M., p. 21)
Thereafter, her asthma worsened, causing structural damage to her lungs. She lived by taking steroids, her face left moon-shaped. This woman rarely left the cottage where she lived with her mother. Her life had devolved into life in the cage of her illness. Somehow, she gave up on life. Sassall knew that the manner in which she resigned her life to the role of one-who-is-sick must somehow be an expression of how she felt about herself, of how she saw herself, and of what life she felt she deserved. This is Berger’s commentary:
Before, the water was deep. Then the torrent of God and the man. And afterwards, the shallows, clear but constantly disturbed, endlessly irritated by their shallowness as though by an allergy. There is a bend in the river which often reminds the doctor of his failure. (F.M., p. 23)
It is clear that Dr. Sassall was also “constantly disturbed” by
the course that his patient’s life had taken. And that he blamed himself
for it. I suspect that he did not fully appreciate that there are times when,
even in the hands of the most experienced, the best attuned practitioner, a
patient may fall into his or her own angle of repose.. That is, there are elements
of character and of motivation that powerfully—even irrevocably—determine
one’s psychological response to trauma. These are forces that may not
be overcome by the most seasoned clinician. Thus, this case is also a cautionary
tale that may remind physicians that they are not able to rescue the patient
from the impact of traumatic external events in concert with limitations of
the patient’s personal psychology and social environment.
It is likely that Dr. Sassall had not completely given up his fantasy of being the hero who could “conquer” disease, that he could not accept the limitations that all physicians have in their attempts to heal. Sassall never ceased looking into himself to find what it was—or might have been—within him that interfered with his reaching this patient. To whatever degree that his technique may have contributed to the progression of her illness (or at least did not reverse its course), we can only speculate that it may lie in his not having established a solid, trusting therapeutic relationship with her. It was a failed connection.
Could it have been that, in his therapeutic zeal to help her, Dr. Sassall underestimated the extraordinary guilt and shame that she felt about the affair with the man? That when he raised the question as to whether the man had made a pass at her, he did so by exposing her in front of her mother, thus making it virtually impossible for her to confide in him? We may imagine that Sassall discovered in his self-inquiry about his experience with this patient that it is not sufficient for the doctor to be “armed” with the “facts” about a patient. The physician must create an alliance where the patient can trust that he or she will not be assaulted by this information. One must know who the patient is as a person and where he or she is emotionally at the moment of encounter in order for the physician to have a sense of how his words may be received. And that for some patients this kind of trust can only develop over time, if at all. It is fortunate that our patients can teach us how to be better doctors—how to become more attuned human beings—even through our failures with them. And fortunate, though always painful and humbling, that they can remind us of our own human limitations.
RECOGNIZING THE PATIENT
Dr. Sassall spent more time listening to his patients—and observing, observing his patients and observing himself. He found that he could now better recognize his patients as the unique human beings they are. He was able to see that the forms in which disease is expressed are largely determined by the total personality of the patient. Then Sassall began to understand the special character and depth of the doctor-patient relationship. He was now able to view each patient as a human being and to engage him or her in a relationship that would bring about healing, a more comprehensive type of healing than that of only conquering disease. This is a kind of healing of the patient’s illness that may take place even if he cannot cure the patient’s disease, a kind of healing that can take place even as the patient lies dying.
Berger describes Dr. Sassall’s experience with the mother of the patient I just described, a woman whose congestive heart failure has forced her to live in her bed. As Sassall enters the house, he find her with pneumonia. He gave her an injection, after which the old woman said, “It’s not your fault” (F.M., p. 26). The following is how Berger captures who this woman is, who she had been, and what the doctor saw and thought as he examined her:
He listened to her chest. Her overworked brown arms, her deeply lined face, her creased, strained neck were suddenly denied by the soft whiteness of her breast. The grey-haired son down in the yard with the cows, the daughter at the foot of the bed in carpet slippers with swollen ankles, had both once clambered and fed there, and yet the soft whiteness of her breast was like a young girl’s. This she had preserved. (F.M., p. 26)
This passage beautifully demonstrates how Sassall came to recognize his patient by viewing the patient and her environment as a narrative to be “read.” This woman’s story was “written” not only by the presence of her children and husband that demonstrates her life as mother and wife. Sassall could read what was written on her body—“overworked brown arms, her deeply lined face, her creased, strained neck”—that illustrated her life of toil. The “soft whiteness of her breast” also reminded him that the young woman that she had been was still a living part of her narrative. Her past and present life was contained in this very moment.
Sassall spoke to the old woman’s husband and said he would come back that evening. When he returned, what he saw disturbed him:
[T]he parlour was in darkness?He called out and receiving no answer felt his way up the stairs?
The room smelt now of sickness?The old woman was paler and a piece of damp rag was laid over her forehead”
The doctor listened once more to her chest. She lay back exhausted. “I’m sorry,” she said, not as though it were an apology but simply a fact. He took her temperature and blood pressure. “I know,” he said, “but you’ll sleep soon and be rested. (F.M., p. 27).
“I’m sorry.” The old woman knew that he and she had done their best, but the end was now near. “I’m sorry” was in part an apology, for she knew that her physician had a personal need to heal and that he would be somehow disappointed in himself for not saving her.
“I know.” Dr. Sassall’s words, “I know,” were ones that he used to communicate many things at once: “I understand how you feel; I know the place, the inner and outer landscape where you now live in your illness; I have been here many times before; I will not let you suffer unnecessarily: I am here with you.”
Sassall told the daughter and the husband that his patient had pneumonia. He instructed them about the medication. The old man who was her husband was silent, yet his hands—“clutching and unclutching the heavy material of the overcoat across his knees” (p. 28)—spoke what he thought, how he felt. Then, as the doctor was leaving, the old man began to cry. As the tears began to well up in the husband’s eyes, the doctor put his bag down, leaned back in the chair, and said, “Can you make us a cup of tea?” Sassall spoke with him about the apple orchard and with the daughter about her father’s rheumatism.
The next morning the old woman died—quickly—after a second attack. Berger reports the scene:
In the parlour the old man rocked on his feet. The doctor deliberately did not put out his hand to steady him. Instead he faced him [and said]. ‘It would have been worse for her if she had lived. It would have been worse.’ (F.M., p. 29)
Here Sassall is a fortunate man—the fortunate physician. He could see
how the individual elements—physical/emotional, individual/family, external/internal,
past/present—fit in with the larger biopsychosocial world of his patient
and with his role in his patient’s world. As he “read” the
old woman’s “story” (that he was now a part of), he saw that
she was part of a larger story that included her husband and her daughter (and
now himself) as the unfolding narrative was being written/created in the present.
Sassall was attuned and responsive to the old woman, and he engaged the husband
and daughter as a part of the totality of the “illness” that lived
in this home. He could perceive and respond to dimensions of the illness in
its broader context.
But this was Sassall as a more experienced, more developed, physician. His perceptions extended beyond the signs of congestive heart failure he saw, beyond the sounds of pneumonia he heard through his stethoscope and , beyond evaluating her color, counting her pulse and respiration, measuring her temperature. Now, because Sassall could use his own feelings—as the particular medical situation emotionally impacted him—through his clinical intuition he could sense what was going on. He could see the pain that her family felt. And because he could do so, his medical treatment exceeded the reach of the injections he administered and the pills he prescribed. It extended beyond treating this old, dying woman to treating her family. Perhaps this eased her dying by letting her see that he would tend to the anguish that her family was feeling. Through all of these activities, he too found some modicum of comfort.
Sassall was fortunate because his years of experience had led him to use himself as an instrument in his physicianly duties. He was now a healer and a communicator. The communication went both ways—between doctor and patient and between patient and doctor. And both ways with members of the patient’s family. Sassall could use these skills in a way that pleased him, fulfilled him—actualized him. From such experiences he learned more of what he could provide his patients.
In the 1960’s Berger, though not a physician, was writing about the stories he saw as he followed Dr. Sassall on home and office visits with his patients. He demonsrated that Sassall had achieved a kind of narrative competence that allowed him to envision his patients’ lives as coherent stories and to recognize them as the human beings they are. He created a physician-patient relationship that generated rich and authentic connections with them. Berger speaks about the physician’s capacity for recognition and for making connections that heal:
In illness many connexions are severed. Illness separates and encourages a distorted form of self-consciousness. The doctor, through his relationship with the invalid and by means of the special intimacy he is allowed, has to compensate for these broken connections? (F.M., p. 69)
[This requires of the doctor the function of] recognition. This individual recognition is required on both a physical and psychological level. On the [physical level] it constitutes the art of diagnosis. Good general diagnosticians are rare, not because most doctors lack medical knowledge, but because most are incapable of taking in all the possible relevant facts—emotional, historical, environmental as well as physical. They are searching for specific conditions instead of the truth about a man which may then suggest various conditions? (F.M., pp.69-72, my italics)
On the psychological level recognition means support. As soon as we are ill we fear that our illness is unique?The illness, as an undefined force, is a potential threat to our very being? (F.M., p. 73)
Charon (2001b) describes the recognition of the patient within his or her own life story as a “therapeutically central act” (p. 1898). She likens it to the clinical process found in psychoanalysis:
As in psychoanalysis, in all of medical practice the narrating of the patient’s story is a therapeutically central act, because to find words to contain the disorder and its attendant worries gives shape to and control over the chaos of illness. (Charon 2001b, p. 1898)
And the physician must recognize his patient as a person—one not so unlike him- or herself—in order to be an effective doctor. As if in conversation with the practice of narrative medicine and clinical psychoanalysis in the twenty-first century, Berger continues:
The doctor in order to recognize the illness fully?must first recognize the patient as a person? (F.M., p. 74)
Clearly the task of the doctor—unless he merely accepts the illness on its face value and incidentally guarantees for himself a “difficult” patient—is to recognize the man? (F.M., p. 75)
How is it that Sassall is acknowledged as a good doctor? By his cures??I doubt it?No, he is acknowledged as a good doctor because he meets the deep but unformulated expectation of the sick for a sense of fraternity. He recognizes them. Sometimes he fails—often because he has missed a critical opportunity and the patient’s suppressed resentment becomes too hard to break through—but there is about him the constant will of a man trying recognize. (F.M., p. 76)
This “constant will of a man trying to recognize” is something that I call intention: the physician intends to recognize the patient as a person and intends to find the place of the patient’s disease within the context of his or her larger life situation: He intends to discover the illness. And he intends to be helpful. Whatever we choose to call it, patients can identify the presence or absence of this trait in the physician—this trait of intention. The success or failure of a doctor’s treatment of an individual patient often hinges on the presence of intention in the physician-patient relationship that is palpable to the patient..
Berger describes the kind of physician-patient relationship that Dr. Sassall creates through his recognition of his patient, his intention to understand and to be helpful, and his capacity to communicate physically and psychologically with his patients:
It is as though when he talks or listens to a patient, he is also touching them with his hands so as to be less likely to misunderstand; and it is as though, when he is physically examining a patient, they were also conversing. (F.M., p. 77)
This is the physician as communicator and as healer.
What motivates a physician to engage in such relationships with his or her patients? Yes, of course, there is the wish for excellence and the wish to be fully actualized as a practitioner of the art and science of medicine. There is a love and respect for humankind, and the wish to be helpful to others. But Berger hits upon another set of traits—attributes of Sassall’s character that he believes are part of the engine that drives him to such excellence: It is his curiosity and his imagination. Here Sassall is especially a fortunate man. This is what Berger has to say about these traits:
He has an appetite for experience which keeps pace with his imagination and which has not been suppressed. It is the knowledge of the impossibility of satisfying any such appetite for new experience which kills the imagination of most people over thirty in our society. (F.M., p. 78)
This is an openness, even hunger, for new experience that is expressed in the form of Sassall’s powerful intention to use all of his skills to diagnose and to treat his patients’ illnesses. He wants to know. He is driven by what Berger describes as “the spirit of enquiry.” Sassall is quoted as saying, “The essential tragedy of the human situation is not knowing.” (F.M., p. 79)
When patients are describing their conditions or worries to Sassall, instead of nodding his head or murmuring “yes”, he says again and again “I know”, “I know”. He says it with genuine sympathy. Yet it is what he says whilst he is waiting to know more. He already knows what it is like to be this patient in a certain condition: but he does not yet know the full explanation of that condition, nor the extent of his own power? (F.M., p. 81)
THE USE OF IMAGINATION IN THE CLINICAL SITUATION
As Dr. Sassall reconceived his role in the physician-patient relationship and created less emotional distance between him and his patient, he could now use his imagination to envision who his patient is and where he or she “lives” in the unfolding narrative of the patient’s life. He could do so by imagining what it would be like to be his patient in the context of the physical/psychological/social/existential set of circumstances in which he or she lives. He was then able to employ his “imaginative ‘proliferation’ of himself in ‘becoming’ one patient after another” (F.M., p. 143).
Berger writes about an experience between Dr. Sassall and a sixteen year old woman who came into his office crying. She did not—really could not—tell him what was the matter. “I just feel sort of miserable” (p. 31). He gently, but persistently, went down his list of possibilities:
‘What’s getting you down?’
‘Water-works all right?’
‘Have you got a temperature?’
She shook her head.
‘When was your last one?’
The doctor paused.
‘’Do you remember that rash that you used to get on your tum? Has it ever come back?”
He leaned forward in his chair towards her.
‘You just feel weepy?’ (F.M., p. 32)
Sassall then asked about her work. “Okay,” she said. As he continued
to explore her feelings about her job—determinedly, for he knew that he
was now on the right track with her—she finally confessed, “It’s
terrible that laundry. I hate it” (F.M., p. 33). She was trapped,
was going nowhere.
Sassall asked what she wanted to do. She had always wanted to be a secretary, not a laundry worker. How much education? She had left school early. He wrote a note to get her off work for a few days and then asked her to come back to explore her possibilities.
“You can come up again on Wednesday and I’ll phone the Labour Exchange and we’ll
talk about what they say.”
“I’m sorry,” she said, beginning to cry again.
“Don’t be sorry. The fact that you’re crying means that you’ve got imagination. If you didn’t have imagination, you wouldn’t feel so bad. Now go to bed and stay there
tomorrow.” (F.M., p. 33).
Consider this exchange between Sassall and his patient. He did not perceive her crying merely as a sign of disease by reducing this human expression of pain to a biological indicator of depression that prompted his writing a prescription for an antidepressant medication. He did not ignore her tears nor run from them. This young woman’s crying had meaning to Sassall in the context of her illness. Her tears meant that she hated the way her life was going, that she wanted more. That she had sufficient imagination to perceive her plight; yet she did not have the capacity to imagine how she might find her way out, nor the resources to do anything about it. Here is how Berger writes her story:
Only her feet betray her. There is something about the way she walks on her feet—a kind of irresponsibility towards them—which is still quite childish. Her figure is 36-25-36? Her face was grubby with tear stains. But around her eyes and on the muzzle of her face which terminates in her full lip-sticked lips there is evidence of the same force that has filled out her bust and her hips. She is nubile in everything except her education and her chances (F.M., pp. 31-32)
While her tears were a sign that she had sufficient imagination to recognize
that something was wrong with her life, she needed Sassall to help her identify
what was wrong and how she could go about remedying it. As with many of his
other patients, he had to use his imagination to formulate and put into words
“some of what they know but cannot think” (F.M., p. 109).
Sassall, knowing his patient and the social and occupational context in which
she lived, had to supply the imagination that she did not possess. He achieved
a depth of understanding of her plight by imagining what it would feel like
to be her in her particular situation.
For Sassall to formulate what his patient was experiencing, he had to consider all of the circumstances impinging upon this young woman that contributed to her illness at this particular stage of her development. If she were not able to imagine herself into a new place in her life and to change her life’s circumstances, he knew she would likely develop in a different direction. And she would return to his office time and again with other sets of symptoms that she could not explain.
By using his imagination, Sassall was able to move beyond viewing the external “landscape”—that of an attractive young woman “with her whole life in front of her”—to exploring her internal world. He first imagined who she was and what her life was like. He then used his imagination to envision who she might become, making it possible for him to assist his patient to take steps toward a new life.
DR. SASSALL’S PRACTICE OF NARRATIVE MEDICINE
In A Fortunate Man, Berger’s commentary about Dr. Sassall at work with his patients captures the substance of narrative medicine. He creates stories out of Sassall’s clinical experience. These are stories about the patient, about Sassall himself, and about the physician-with-his-patient. In writing these stories of experiencee, information is transformed into new knowledge—narrative knowledge—by one who possesses “the human capacity to understand the meaning and significance of stories” (Charon 2001b, p. 83). In the practice of medicine, the achievement of narrative knowledge provides a way for physicians to gain a fuller grasp of their patients’ illnesses beyond the identification of the bioscience of the disease with which they present. This kind of knowledge may not only bestow meaning to what the patient tells the physician, but also to the very practice of medicine.
Charon (2001a) has written extensively on this practice, which she calls narrative medicine—“that is, medicine practiced with the narrative competence to recognize, interpret, and be moved to action by the predicaments of others” (p. 83). As physicians, we best serve our patients if we are able to put the disparate elements of their biopsychosocial illnesses into coherent forms—into narratives—in our minds.
Competent narrative medical practice requires that the physician be emotionally engaged and responsive to patients and attuned to his or her own emotional reactions to them. These are elements of narrative competence:
As the physician listens to the patient, he or she follows the narrative thread of the story, imagines the situation of the teller (the biological, familial, cultural, and existential situation), recognizes the multiple and often contradictory meanings of the words used and the events described, and in some ways enters into and is moved by the narrative world of the patient?[A]cts of diagnostic listening enlist the listener’s interior resources [imagination]?to identify meaning. (Charon 2001b, pp. 1898-1899, my italics)
The following describes how Sassall brings together his curiosity, his imagination, and knowledge of himself to more fully enter into his patient’s world and discover the story that is being presented there. He uses himself as a diagnostic instrument to sound the depths of his patient’s world. Sassall does this through a form of reflective listening that accesses his own emotional experience..
Sassall accepts his innermost feelings and intuitions as clues. His own self is often the most promising starting point. His aim is to find what may be hidden in others (F.M., p. 102)?
He confesses to fear without fear. He finds all impulses natural—or understandable. He remembers what it is like to be a child?His ability to do such things connects his with [his patient’s] experience. (F.M., p. 108)?
He never separates an illness from the total personality of the patient?He does not believe in maintaining his imaginative distance: he must come close enough to recognize the patient fully. (F.M., p. 113)
Sassall employs his subjective experience of the patient diagnostically: He responds to his patient’s story of suffering by imagining himself into it. Thereby, he gains information about his patient that he could not have acquired in any other manner. These are the skills that constitute good narrative medical practice.
Dr. Sassall began to develop this narrative competence only after he revised his vision of the physician-patient relationship. Remember that he started medical practice as a physician who saw himself as the hero who conquers disease—one who is the protagonist in his own story. Through his many years of practice and through his concerted efforts at self-reflection and self-development, he became a different kind of physician: a physician who came to recognize his patient as a human being experiencing an illness, not an object in possession of a disease. Sassall became capable of seeing the patient’s illness as it arose from the unique personality of the patient in complex interaction with the physical disease and the social context from which it arose. He began to re-envision the physician-patient relationship as one between two human beings—an intersubjective experience where each has his or her own distinct role in the medical transaction. He became attuned to his own subjective emotional responses to his patients and began to reflect upon these reactions. Sassall learned to use his emotional reactions as clues to the nature of his patient’s illness and of the manner in which the patient’s disease alienated the patient from self and others.
Dr. Sassall saw that medical illness may be dehumanizing as it redefines patients, so that they are no longer recognizable to themselves. By using his curiosity, his imagination, and his intention to heal, he engaged in a relationship with his patients that helped to restore their humanity. This is a physician who possesses extraordinary diagnostic skills and who can refine his treatment to fit the human being who comes to him for help. Perhaps this level of competence is sufficient to characterize such a physician as fortunate.
But Dr. Sassall is fortunate in other ways. Physicians who use themselves in this manner to explore the patient’s inner and outer world and to learn what it is like to be the patient before them must engage in a disciplined process of self-inquiry that leads to better self-understanding. It seems to me fortunate that physicians spend their life’s-work engaged in a profession where—hand-in-hand with developing proficiency in helping others—they may deepen self-understanding, increase their own humanity, and learn to better to grapple with the dilemmas that they too must face in life. One physician describes this as a process of being granted “access to knowledge—about the patient and about myself—that would otherwise have remained out of reach”, (Charon 2001, p. 84, my italics). Such experience with patients may be transformative for physicians who avail themselves of the opportunities for professional growth that are brought to life through the physician-patient relationship.
Berger tells us that Dr. Sassall “established the situation” he needed to achieve these ends. Through his life’s work he has created a unique set of circumstances where he has continued to develop as a physician—and as a person. When physicians establish such a situation, they are much more likely to find their work meaningful and are thereby less likely to become “burned out” by the daily impact of the suffering of their patients and of the emotional demands placed upon them by patients and their illnesses. This statement is only apparently paradoxical. The conventional wisdom that doctors must achieve great emotional distance from their patients in order to protect themselves has proven to contribute to a kind of deadening of the physician’s experience where they often feel more like human “doings” than human “beings.” Physicians who are sufficiently emotionally present and attuned—while at the same time maintaining their psychological separateness from their patients—are more likely to find their clinical work satisfying over time (Horowitz et al, 2003). Physicians who engage with their patients in this manner often discover that their experiences within the physician-patient relationship promote deeper understanding of their fellow human beings and encourage a process of self-reflection that may enhance their own self-understanding. This is indeed a unique set of circumstances.
Most physicians enter medicine because they wish to engage in helping relationships with patients. Years of clinical practice as only “objective” participants in the doctor-patient relationship may lead physicians to become robotic in their interactions with patients and may deprive them of opportunities for professional and personal growth. An approach that is marked by engaged, empathetic contact and one that fosters self-reflection and self-inquiry may lead to a more satisfying professional life. Physicians may learn more comprehensively about their patients as they come to understand their patients’ narratives. In so doing, physicians may expand their own universe of the possible ways that lives may be lived. And in the process of learning from patients through the stories that they tell them, physicians may discover more about their own life narratives.
A recent study (Horowitz, et al 2003) describes what physicians who engaged in narrative writing about their clinical experience found most meaningful in the practice of medicine. It reported that these physicians deeply valued their connections with their patients and described how their perspectives had been changed by virtue of engaged clinical contact with patients. What these investigators write is similar to what is demonstrated by Berger’s writing of the life of Dr. John Sassall:
[N]early all the doctors?described a nontechnical, humanstic interaction with patients as experiences that fulfilled them and reaffirmed their commitment to medicine. Rather than recounting tales of diagnostic triumph, they uniformly told stories about crossing from the world of biomedicine into their patient’s world. They described how relationships deepened through recognizing the common ground of each person’s humanity. (Horowitz et al 2003, pp. 773-774)
The physician who spends his or her lifework interacting with patients whose stories they discover and reflect upon can be nothing less than transformative for the physician. How fortunate. Berger states this aspect of Sassall’s professional life very succinctly: “He cures others to cure himself” (p. 77))
THE DOCTOR’S STORY AND THE PATIENT’S STORY
Though written nearly forty years ago, A Fortunate Man affords an extraordinary introduction to elements of contemporary psychoanalytic practice and of narrative medicine that illuminate the physician-patient relationship and demonstrate to today’s practicing physicians an approach to their professional lives that may assist them to create situations in which clinical practice may be meaningful and self-sustaining.
By listening to the patient from the perspective of the narrative that unfolds through the doctor-patient relationship, the physician is granted the capacity to create stories from what may appear to be the disparate elements of the patient’s history and physical examination—as they emerge in the clinical moment. The narrative act transforms facts into knowledge, disease into illness, and an identified patient into a human being. Weinstein (2003) states the necessity for this process in medical practice:
[I]n the crucial arena of doctor-patient relationships, in the diagnostic situation, it seems essential to reinstate listening as a form of medical knowledge every bit as valuable as seeing or prescribing tests. A listening doctor restories the patient. (p. 160)
This vision of the physician-patient relationship is one that is very different
from the one that most practicing physicians were introduced to during their
The model of the detached and objective physician has not equipped doctors to more fully learn from their experience with their patients.
Returning to Berger’s impression of the development of physicians, we are told something of how medical training and experience shape their approaches to patients.
It is generally assumed that doctors take a professional view of suffering and that the process of professional insulation begins in their second year as medical students when they first start dissecting the human body?Later, other factors are an aid to their self-protection. Doctors use a second, technical, entirely unemotional language?Increasing specialization encourages an increasingly scientific view of illness?The sheer number of their cases discourages self-identification with any individual patient. (F.M., p. 112)
Undoubtedly, primary care physicians are constantly confronted by the emotional impact of their patients’ suffering: “the anguish of dying, of loss, of fear, of loneliness, of being desperately beside oneself, of the sense of futility” (F.M., p. 113).
Anguish arises from a sense of irreparable loss. (The loss may be real or imaginary.) This loss is added to all the other losses sustained during one’s life?Most of these other losses were suffered in childhood. Thus the experience of loss tends to return, redeliver one to one’s childhood?[I]t is the sense of helplessness which leads one back? (F.M., pp. 123-124)
Physicians must find ways to protect themselves from the impact of their patients’ anguish and helplessness. Yet, at the same time, they must assist their patients in the process of transforming the fragmentation of self and the existential despair that often accompany illness into a coherent and meaningful experience that restores a sense of self.
[T]he anguished adult suffers the conviction that what has happened is absurd; or at the best, is without sufficient meaning. (F.M., p. 114)
Such suffering brings the physician dangerously close to his or her own sense of helplessness, inadequacy, and the futility of life:
To encounter a fellow human being in a state of despair compels one to share, at least in imagination, his elemental problems: Is there any meaning in life? Is there any point in his staying alive? (F.M., p. 126; Berger quoting G. M. Carstairs)
[It is] my attempt to define a hidden, subjective experience—the generalized impact on a doctor’s imagination of the suffering which he meets almost daily and which cannot be settled by writing prescriptions. (F.M., p. 126)
In order to be of assistance to the patient who is suffering, the physician must find a way to transform an incomprehensible experience into one that has meaning—for both the patient and the physician. Approaches such as those found in psychoanalytic work and in the practice of narrative medicine are designed to achieve this end. At the same time, physicians must find a way to survive the emotional impact that such encounters with patients engender, because the patient’s story may approach the physician’s own life stories—or to the story that the doctor fears his or her life may become.
In any one physician-patient encounter the past and present experience of the patient (and doctor) are brought together in an instant:
The anguished are trapped in a moment which is born of all that has happened to them. Faced with the rigid irreversibility of events—so terrible for all who are unprepared, and none can be fully prepared—it is their experience which bends in a circle: unable to catch time by the tail, they chase their own, revolving in one moment blindly through all their life. How much then can a moment contain? (F.M., p. 127)
For the physician to creatively make use of such clinical moments with the patient, he or she must be sufficiently acquainted with his or her own story in order to separate it from that of the patient’s. This may be achieved by the disciplined practice of self-reflection and self-inquiry that leads to self-understanding.
Dr. Sassall is described as a physician who became acquainted with his own inner world:
He can enter into other people’s dreams or nightmares. He can lose his temper and then talk about the true reasons, as opposed to the excuse, for why he did so. His ability to do such things connects him with aspects of experience which have to be either ignored or denied by common-sense. (F.M., p. 108)
Sassall’s openness to, and acceptance of, his own sets of feelings allow him to listen less defensively to the feelings that his patients express.
Physicians who are aware of their own feelings are better able to enter into a conversation with themselves about their patients’ emotional lives and about their own: “The feelings that my patient is having is much like my own; yet they are also different in some ways. I can understand this part of what I am being told, but I need to listen further to hear what is unique about this person.” Therefore, physicians’ familiarity with their own internal worlds both fosters their receptivity to the emotional life of patients and makes it more likely they will be better able to separate their own life narratives from those of their patient. When this is so, doctors may better use their own emotional experience as a point of entry to understanding the patient:
Sassall accepts his own innermost feelings and intuitions as clues. His own self is often his most promising starting point. His aim is to find what may be hidden in others? (F.M., p. 102)
His appetite for knowledge is insatiable?experience is, by definition, reflective?[H]e is continually speculating about, extending, and amending his awareness of what is possible?[This is a product of] the cumulative effect of his imaginative ‘proliferation’ of himself in ‘becoming’ one patient after another. (F.M., p. 143)
The physician who enters into encounters with the patient knowing full well that he will be emotionally impacted by the patient is in a much better position to begin to create narratives out of what the patient brings to the clinical situation. The physician-patient relationship is by its very nature an intersubjective experience where meaning is created and discovered by paying attention to both the physician’s and the patient’s subjective emotional experience. The physician who does not deny his or her own emotional reactions to the patient is in a much better place to “feel” his or her way into an understanding of what it means for each individual patient to be faced with illness.
What I have described in this paper—largely by using A Fortunate Man to speak for me—comes mostly from my approach to, and experience within, the physician-patient relationship as a psychoanalyst. To a degree, it also borrows from the literature on narrative medicine. This paper also embodies much of what I have learned from physicians who have been participants in classes that I have taught.
This approach to medical practice demands much of the physician. But it has its rewards. The discipline of self-inquiry is required to use one’s own emotional reactions (feelings, memories, associations to personal experience, recollections of work with other patients) as diagnostic clues. The doctor who is self-aware is capable of remaining present sufficiently to more accurately discern the patient’s unique emotional and existential experience of illness. By engaging in this sort of medical practice, the physician may become a better diagnostician and a more effective healer.
The story of Dr. John Sassall teaches us that medical practice that is constituted of this approach to the physician-patient relationship may create a very fortunate situation for both patient and doctor. It is certainly fortunate that the same process designed to restory the patient’s life may teach the physician ways of being a more complete clinician than could have otherwise been achieved. And it is fortunate that this approach may lead to more meaningful and satisfying clinical work. It may even be true that this process can come to assist the physician in achieving self-understanding by restorying his or her own life.
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Fred L. Griffin, M.D.
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