Blog | Friday, August 16, 2013

Bearing witness

I was naive when I decided to enter medicine. My impressions then were that doctors always "did" stuff--for patients, and to patients. We would do stuff to you (examinations, blood tests, scans, surgeries) in order to help you.

A lot of time and education later, I've learned that that straightforward paradigm is far from the only way that doctors help people. In fact, following that mostly simple formula (you come to us, we do stuff to you) is sometimes more harmful than helpful.

Good doctoring involves understanding the limits of medicine's capabilities. It involves being able to reckon with uncertainty, to be able to put one's self in patients' shoes, to see that sometimes doing nothing is the best medicine.

This is challenging for all of us. People, as patients, want answers. We want stuff done. It's part of American culture to expect results. On a fundamental level, the doctor-patient relationship has a transactional nature: You want help, we provide expertise, you (or your health insurance) pay us. Somehow, there's a sense of non-value when "nothing" is given in return for your visit.

A wise mentor once taught me something that has stuck with me over many years. Sometimes there is nothing we can do for patients. Times when we simply have no more tools to offer. Rather than see this as failure, he suggested, see this as profound help: Doctors are there to bear witness.

In a "do-it-all" culture, this can seem anathema. Especially to doctors-in-training, who must grapple with finding their own limits after years in training being taught the state of the art in many fields—always with the implicit message of doing, doing, doing in every phase. It creates cognitive dissonance.

When I was an intern and faced this barrier ("There's so much I can't do," I felt, dejectedly), I thought very hard about switching fields. That wise mentorship helped me to re-frame the sense of powerlessness and vulnerability I felt.

Bearing witness is incredibly powerful. Listening to others share their stories of illness and suffering is enriching–for the subject and the listener. Generous listening is a skill in which the listener simply and humbly listens; without judgment or assessment or interjection. It's incredibly hard for physicians to engage in generous listening; we are continually taught to move toward a conclusion, to move faster, to see more patients.

I came across an example of generous listening that is so moving I feel the need to share it: Alice Dreger, a Professor of Clinical Medical Humanities and Bioethics at Northwestern, has become engaged for some time in providing what she calls pro bono medical histories, or, "Taking the History and Giving it Back." [Read her account of it here.]

To put it simply: There are many people that have been traumatized by their interactions with the health care system--made to feel abnormal, inhuman, warped, different. Dr. Dreger listens to their stories, and integrates them with 'official' medical records. She humbly uses her knowledge to let people unburden themselves, and to interpret their records in a way that people can make sense of them.

She charges nothing for her service. Of this work, she writes:

Providing these histories to individuals--work that remains almost completely invisible to the outside world--has been the most consistently satisfying aspect of my professional life.

Dr. Dreger has a PhD in the history and philosophy of science. She doesn't order CT scans or write prescriptions for the people whom she helps. But her act of bearing witness, of helping to make sense of individual's trauma, is profoundly moving for her and her pro bono clients. How does she know it's helpful?

"... [M]aybe this work helps just because I'm somebody (anybody "outside") taking seriously the harm these people have experienced. Maybe what's going on is partly just a validation, a witnessin--saying, essentially, "I believe you. And yes, this really did happen to you." (Some people have told me that they keep handy what I've written for them, so that when they have one of those moments of uncertainty, they can pull it out and say, "Yeah, that really did happen.")

"In any case, I'm convinced it does help people. The "thank you's" these people have given me are like no others in tone and depth. The gratitude feels so deep that I find myself engulfed in my own sense of profound gratitude."

Just knowing about work like Dr. Dreger's nourishes my soul.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.