You see her in the clinic, in the emergency assessment room, on the ward. She’s had pain for several years now. Many fruitless investigations have been done. The vital signs, the blood work and the imaging give no cause for alarm. Still, she’s in pain, and certain something is wrong. Everyone is frustrated. She wants to see the Consultant; the one who will fix the pain.
In Child Psychiatry, I learnt a few things. One was that psychosomatic illness is unique in that it hardly ever presents to the appropriate specialty for management. You see the masquerade everywhere else. Functional abdominal pain. Recurrent headaches. Pseudoseizures. Chronic pelvic pain. We hunt endlessly for causative agents in the body, but neglect the mind. Why? Perhaps because, of all the things that make us who we are, the mind is the least understood.
‘To be honest’, I say, ‘I don’t know why you’re in pain. We haven’t found anything to worry about. Sometimes, we never find a cause for pain, but as long as we rule out everything that would cause concern, then we can shift our focus to alleviating it.’
The sad fact is that nobody can fix pain. You treat the underlying cause. You give medication to control the symptoms. You wait for it to go away. Sometimes, you have a hunch that the underlying cause originates primarily in the environmental rather than organic, and the history you take bears witness to the suffering you suspected.
We physicians are not very good at dealing with people’s suffering. By and large, we ignore it, even when it is directly impacting their health. I’m trying to be different. So far, I am still on the baby step of acknowledging that the patient is suffering. ‘You must be very worried’, I say, or ‘are you scared?’ ‘How are things?’ ‘That must be difficult’.
I figure that as the medical provider I am a part of the system she finds herself in, and so my response is inextricably linked to her symptoms. I cannot change her perception of her experiences, but by changing my own behaviour I can induce a dynamic change in the system which might have a positive effect on her. It’s a theory I picked up from systemic family therapy. The evidence behind it is uncertain, but if it makes the patient feel better, then I’m all for it. And often it does make them feel a bit better; knowing that somebody believes their pain is real.
We see a lot of pain in Obstetrics & Gynaecology. Most of it is organic in origin. Labour pain. Post-operative pain. Some of it is functional. Some of it is both, but the underlying cause is unlikely ever to be delineated. For example, a significant number of chronic pelvic pain cases are due to pelvic inflammatory disease. Most of these aren’t diagnosed previously because the initial sexually transmitted infection was clinically silent.
What can we do when we’ve reached the limit of our medical abilities? Are we doomed to perpetuate the cycle of despair? Virchow said that only those who regard healing as the ultimate goal of their efforts can be designated physicians. Is this still the case? When our idealism wanes, and we focus more on the treatment than its effect on the person, what then? Is there a place for miracles.
The answer, I think, lies in another question: without our humanity, what do we have? I believe there is always room for the miracle, for compassion, for the higher power. This transformation takes place in acts of love. The physician is not God. To disabuse our patients of their illusions of our omnipotence is difficult, but necessary. It takes humility to admit that we don’t have all the answers; that we are still learning. Where is the room for faith in this reimagined therapeutic relationship? I would argue that such powerful honesty fosters an even deeper trust that is more firmly rooted in reality. It is ultimately a more hopeful way of being, shedding the pretence of what we do not have in order to nurture what lies dormant within us. We all have the capacity to love.
In his epic Les Miserables, Victor Hugo wrote that to love another person is to see the face of God. If this is true, then we can always bring the divine into our work, fallible though we are. How do we love? By being kind. The everyday miracle, when it is too late for anything else and the suffering is right in front of us, and we fear our best efforts just aren’t good enough, lies in our ability to honestly say:
‘Here is a glass of water from my well.
It tastes of rock and root and earth and rain;
It is the best I have, my only spell,
And it is cold, and better than champagne.’
(May Sarton, ‘A glass of water’)