You might say that I’m part of a new breed of physician. When I applied to UBC medical school in 2005, my application was weighted in two parts: 50% of my evaluation score came from my GPA, work and volunteer experience, research, personal letter and references, and the other 50% was based on a 25 minute interview.
Thirty or forty years ago, GPA, research/publication credentials, and high profile references almost exclusively determined entrance into medical school. I personally benefited greatly from this shift; I nearly came below the cut-off to interview based on my paper application alone, and it was only because the interview is so heavily weighted that I was accepted. This is no small change, and I think the implication for what this means for the future of (Western) medicine is worth exploring.
What’s at the heart of this shift towards a focus on the interview (and the accompanying implied importance of communication and interpersonal skills)? What kind of new physician is the medical system attempting to create? What’s the crisis we’re responding to?
I’ve recently been introduced to a term that I think can be helpful for framing this inquiry: iatrogenic suffering.
The word ‘iatrogenic’ derives from iatro, meaning healer or physician, and genic, which means producing. So iatrogenic suffering is suffering caused by the action (or inaction) of the physician towards the patient.
This term was coined by Dr. David Kuhl, a family physician who worked as a palliative care (care of the terminally ill and dying) specialist for more than 10 years, and subsequently obtained his PhD. Dr. Kuhl now works at the Centre for Practitioner Renewal in Vancouver, which seeks to support and sustain health care providers in the work place.
Dr. Kuhl developed this concept during his work as a Soros Faculty Scholar with the Project on Death in America, which involved an exploration of spiritual and psychological issues at the end of life. Through his long and in depth interviews with individuals living with terminal illnesses, he identified several core themes of importance.
One of his key discoveries was that the way physicians communicate with their patients has a profound effect on them, one not to be underestimated. He gives one harrowing example:
"Marjorie, a woman in her late 70s had a different experience. After months of being reassured that the mass in her groin was benign, her doctor gave her another message from the doorway of her room, as she was waking from the general anesthetic. “Oh, by the way, we were wrong; it is cancer. I have made an appointment for you to see the oncologist in a few days.” No interaction, no touch, no discussion, no hope. For Marjorie, “The way the doctor talked to me caused me more pain than the disease itself.”
We can all feel ourselves cringe at this woman’s story. She’s experiencing one of the most vulnerable moments of her life, and is given a remarkably cold, dispassionate and I would say inhuman response. What has happened in our medical system and the training of our “healers” that makes this even possible? What is the responsibility of the physician in this case? How should we respond?
In one sense, I think what we’re witnessing is the loss of interiority on the part of the physician, and a lack of inter-subjective communication in the clinical encounter.
What I mean by interiority is the inner experience of the physician: her emotions, mental state, energetic level… perhaps her reactions to the patient, relationship with death and illness, or her expectations of herself. With this in mind, what does it mean to expect our physicians to be “clinical?” There’s an implied level of detachment, ostensibly in the name of creating distance and clear decision-making (wouldn’t want to let our feelings cloud our judgment). And certainly this is important to some degree – if I’m sobbing uncontrollably while giving my patient his cancer diagnosis, I’m certainly not doing him any favors.
But I also feel that this focus on the removal of our “selves” (our interiority) is a bit of a cop out and potentially really harmful. In the name of remaining “clinical,” we spare ourselves the hard work of recognizing our own fears, judgments, resistances, etc., taking responsibility for them, and finding a way to still serve our patients from that place of awareness. I feel that the detachment we’re encouraged to develop as physicians has gone too far, and at its worst can lead to the kind of disastrous iatrogenic suffering that Marjorie experienced in the example above.
To frame this in explicitly integral terms, what I’m describing is a massive deficit of the upper left quadrant, or the interior of the individual. Conventional (or biomedical) medicine operates from a rational (or modern) stage of development and it’s praxis is profoundly dominated by the upper right quadrant (exterior of the individual). Examples of this abound, and one of my favorites is our approach to depression.
Depression understood through a conventional medical lens is caused by an imbalance or disregulation of three neurotransmitters, dopamine, norepinephrine, and serotonin: the monoamine hypothesis. These chemicals can be seen, touched, measured and represent the upper right quadrant view of depression. We are less willing to consider the aspect of depression that resides in the interior (or inner experience, psyche, mind – UL quadrant)) of the individual. An integrally informed approach would recognize that the neurotransmitters mentioned (real, and very important) represent the exterior correlates of the total human experience of depression, which also includes that oh-so important inner experience (the one you’re having right now reading this).
This over-bearance of the upper right quadrant permeates all aspects of medicine, from how we understand health and illness, our approach to treatment (the default treatment for depression, SSRI’s and other pharmaceuticals, act on the neurotransmitters mentioned above), and the culture and expected behaviours of physicians (and other conventional health care practitioners of course). What was going on in the mind/heart of Marjorie’s doctor that prevented her from communicating more compassionately? Perhaps she has difficulty facing illness and death, perhaps Marjorie reminded her of the pain of losing her own mother to cancer, or perhaps she has simply never been expected to develop her own emotional/spiritual fluency.
A re-invigoration of interiority on the part of the physician begins to create room for what I am calling an inter-subjective clinical encounter. In this vision, there’s the recognition that both the patient and the physician are having a very real, very messy, very real-time inner experience. And that can create lots of friction, disconnect and most importantly, suffering and dissatisfaction on the part of the patient… particularly when it’s unconscious. And conversely, a physician who is conscious of her interiority and holding the encounter with space and caring presence begins to create the conditions for real healing and positive change.
It’s important to remember the profound privilege that it is to be a physician. In my very short career, I’ve already had opportunities to be with people in incredibly vulnerable and tenuous moments in their lives; from the 56 year old mother of three just receiving her diagnosis of metastatic carcinoid bowel cancer, to the woman I met the other day, towards the end of her reproductive years, reckoning with the loss of her third pregnancy. In these moments, their profound openness and tender vulnerability is utterly complete, and so very unlike any other human interaction I’ve ever had. It’s scary, to be honest, and on one level I can understand why many physicians shrink away from the responsibility of trying to hold that experience for people, why they choose to hide behind the clinical.
In his foreword to the anthology Consciousness and Healing, Ken Wilber describes the difference between conventional, integrative and integral medicine like this: conventional medicine treats the illness, integrative medicine treats the whole person, and integral medicine incorporates all of this and also treats the physician.
Physicians need to develop the capacity to be in touch with their own interiority and remain compassionately available to their patients, especially in their most challenging moments. This requires a major shift in how we select those we allow to be physicians in our society, which is a process already in motion. We also need to provide opportunities for current physicians to develop their emotional/spiritual capacities, which inspiring people like Dr. Michael Krasner are undertaking.
The reality is that medicine is alarmingly steeped in a rational-materialist worldview, and the individuals who choose to step outside of that face the recoil of it’s gravitational pull. So it will take time, and coming together in places like Beams to create a new culture. I’m excited though, to put my energy behind this process already deeply underway. I think there are very real opportunities to change the ways we are doing things as a medical community, and to take responsibility for our communication with our patients. By developing our own consciousness and interiority, we can take each clinical encounter as an opportunity to reduce iatrogenic suffering, and perhaps foster healing instead.