I have always been influenced by something Lewis Thomas, the American polymath writer-physician once said at a lecture I attended. He felt he would be better served by a doctor who had read Shakespeare than someone who had merely focussed all of his formative years on learning medicine. His point, I think, was that to really help people you had to understand who they were, what they thought, how they lived. We are all more than our bodies.
Me? I have always loved philosophy, cherished its Greek etymological roots: love of wisdom, and at least pretended I understood how it might help me to interact with my patients: to accept all points of view with equanimity –or to spell it as Sir William Osler did in his famous essay, Aequanimitas –imperturbability.
Philosophy helps you to do that, but only if you don’t get too enmeshed in the details. Only if you don’t privilege one tenet over another. Only if you never accept that you are at the end of the journey. Or meet someone who is…
My conversations with patients have changed over the years from that of an expert trying to impress, to a teacher trying to listen -the difference between an encyclopedia and a manual, I suppose. Part of it is age, I’m sure, but a better part is the belief that, as Osler put it: “Listen to your patient, he is telling you the diagnosis.” And although directive listening works best, sometimes the topic turns an unexpected corner and a tangent is entered. I like tangents but not in the office -they can terminally entangle the discussion. They are like blackberry bushes in a field: I try to stay away from them.
There was a patient who wouldn’t let me, though. A PhD candidate in Philosophy, she had come to see me because of pelvic pain. And while she readily conceded that she was under considerable stress writing her dissertation, she felt that her problem was reality-based. I should have just written it down; I shouldn’t have asked what she meant…
“Reality is the sum total of all that is,” she said, settling back all too comfortably in her chair. “The question, of course, is does it include potentiality –all that might be, or could be imagined to be?”
She closed her eyes, for a moment as if digesting the profundity of what she had just said, and then opened them suddenly and stared at the ceiling. “But our realities differ, don’t they? I mean, you inhabit a different mental world than me; you can no more apprehend my sensations than I can yours. We are on different sides of a wall.”
She had to be kidding; I didn’t ask anything like that. But nonetheless, I felt it incumbent upon me to defend my profession –my humanity, for that matter. I decided to sit back in my chair as well- fight opaque answer with precise question. “But surely if you really believed that I couldn’t appreciate your pain, you wouldn’t have come here.” I then pasted on my most innocent smile. “And anyway, I don’t have to feel your pain, just accept that you are experiencing it and take it from there.” I put on a more contemplative, but satisfied smile.
My answer didn’t faze her in the slightest. I think she had her rebuttal ready before my smile had even fully blossomed. It started with a deep theatrical sigh. “Do you ever wonder if we define the world, doctor –our own world, that is?” She was sitting on the opposite side of the desk from me, but suddenly she leaned forward and put her elbows on it to fix me with a stare that would have done Medusa proud. I even stiffened reflexively.
“Don’t we all define our worlds?” I said, rather proud of my response.
“Yes, but differently.” She looked as intense as her words. “Pain has a different meaning to each of us: a different feeling, a different impact… it is only an If to anybody but myself: If, as you say, you have pain; if as you assert, the pain is seven out of ten… If all of these things are as you tell me, I have only your word to go on. There is no objective way of demonstrating your thesis. So aren’t you left with the same undefinable as you started..?”
Wow. And to think I was only going to ask her how long she’d had the pain. She ended her explanation rather tentatively, thank god, because I had lost her shortly after her first attempt at clarification. I began to wonder if this dissemblage was a PhD syndrome: full of sound and fury, yet signifying nothing –practice for the defence of her thesis. Equivocation. Obfuscation. Playing with words like others play with cards.
Sometimes, however, it is necessary to find out more about the pain than its meaning. I wanted to pin her down on the more mundane aspects of her symptoms: more like where than why. Or when, not if. It occurred to me that her road to if was not the road to solution and I was trying to figure out how to phrase it more philosophically when she straightened in her chair as if she’d suddenly received an electric jolt and stabbed me with her eyes.
“I realize that my approach to pain is different from yours, doctor, but the reason just occurred to me: I have defined it that way. Not you; not your reality. Mine… I am the one at fault.”
I tended to agree with her, although I probably wouldn’t have put it that way. “So…” -I sensed an opportunity when her face wrinkled as she thought through the ramifications of her enlightenment… A word-gap- “Where, exactly does…”
But she saw through my plan, and the door closed again. “You see I create the reality in which I suffer…” She paused, but not long enough for me to remember what I was going to ask, let alone to say it. “And so by coming here, I define you in a way… Both you and your response… Do you see what I mean?” She said it with such hope in her face that I almost said yes.
And then, just as suddenly, her face fell on hard times and the intensity disappeared. “But despite my solopsism, I still have pain.” Gradually, her expression refocussed like a magnifying glass and I could see her deep brown eyes dissolve in tears. “Can you help me even from your side of the wall?”
Solopsism? I smiled a real smile and nodded. I looked up the word as soon as I got home.