MD Program

  • Healing in a Scientific Age: Finding Meaning in Medicine

    Presentation at the
    White Coat Ceremony
    University of Iowa

    Roy J. and Lucille A. Carver College of Medicine

    Friday August 19, 2005

    by
    Paul A. James
    Professor and Head, Department of Family Medicine

    Introduction

    Thank you Dr. Ephgrave. Dean Robillard, Mrs. Katen-Bahensky, Provost Hogan, colleagues, future physicians, families and friends, I am sincerely grateful for the opportunity to share this day with you.

    I can hardly contain my enthusiasm for you because you have chosen the greatest profession. I feel your excitement and understand well your thirst for knowledge. And on Monday, Dean Robillard will open the floodgates of knowledge, and a wave of information will not only quench your thirst, but will perhaps have you searching for a life boat.

    Each of you is here today because of unique circumstances and they relate (I hope) to your desire to help someone in need. Not to frighten anyone, but think about it, at this moment, there is an individual out there, who is on a course that will intersect with your life. This person will call you doctor and will come to you with the expectation of healing. That person’s story has begun, and you will become part of it.

    Later, you will recite the Hippocratic Oath and you will “swear by that which you hold most sacred”. Now that sounds like serious business. Sacred is a difficult word in today’s lexicon signifying, depending on your world view, something very important to be treated with respect, or something to reverence signifying oneness with God, holiness. When one deals in life and death, sacred becomes an important word.

    It was 25 years this week when I walked your path, and I have decided to provide you glimpses into the profession of medicine and these sacred moments. I will share with you the doctor’s perspective, but I also hope that you see a very human perspective in three stories. Like the poet Muriel Rukeyser, I have the suspicion that “the universe is made of stories, not of atoms.” These experiences represent lessons that honor the purpose of the White Coat Ceremony. They are to teach you about the importance of humility, hope and something stronger than death itself, the healing power of love. Perhaps you already know these things, but I want you to experience them as a physician with me guiding you in this protected place. Imagine then, that you wear the white coat of the healer.

    A Profession in Need of Humility

    I wanted this story to be about humility, but it’s really about physician hubris- my own inflated sense of what being a physician meant. I was completing my second year of residency, finally becoming confident in my knowledge and skills. I was on call that evening and had just returned from the emergency room at about 11 p.m. I was now taking call from home and it was wonderful. I was awakened a little after midnight by my pager. I dialed the offending phone number.

    A lady answered the phone and was somewhat frantic in her request that I come to her home and make a house call on her husband. She relayed to me that he had a fever of 104 degrees, was clammy, having difficulty breathing and “making gurgling noises.” My mind raced through the differential diagnosis. I surmised that this man was sick.

    “It sounds like your husband is very ill, he could even die,” I said. “You'll need to take him to the emergency room and I will meet you there.”

    “No,” she replied. “I need a doctor to come to our home.”

    I felt resistance to my generous recommendation. She clearly did not understand that I was the physician. This pushback caused me to question her motives. My mind raced to other questions and possibilities. Why was she so accepting of the possibility that her husband might die? This lady's voice sounded young, perhaps in her 30s or 40s. A man who is gurgling certainly must be in his 80s. Perhaps this was a May-December marriage, and she married him for his money. The headlines would read, “Widow Inherits Millions with the aid of a young Doctor.”

    I really couldn’t hear her explanations for why she thought I should come to her home, because of my preoccupation and frustration with her inability to listen.

    “So, Dr. James, will you now come to see my husband?” she asked as my attention returned to the phone call.

    Now I was definitely worrying about me. What will my colleagues say if I make a house call on a deathly ill gentleman? How will I explain this to my attending staff in the morning? I'll be the laughing stock of the residency.

    I returned to the matter at hand. Perhaps I needed more history. I reiterated to her that it sounded like her husband might die. Was she really willing to accept that he might die at home?

    “Well, yes,” she said, “of course.”

    I regained my sanity and returned to the basics. Her husband was 43 years old. He had multiple sclerosis and had been hospitalized too many times to count. Four months ago, he made his wife promise that she would never take him back to the hospital.

    “Dr. James, do you understand that I need you to come see him because I'm very worried about him,” she reiterated.

    I went to the home, scared to death. Upon entrance to the small home, I noticed the patient over on the right side of the living room in a hospital bed. He was diaphoretic, pulse was 120 and his temperature was indeed 104 degrees. His lungs were terribly congested with rales on both sides half way up the chest. An indwelling Foley catheter showed that his urine was very cloudy. I finished my exam, noting how the patient had no evidence of skin breakdown, his skin care the best I had seen for a bedridden patient.

    This gentleman had the clinical signs of sepsis. My struggles over the next few hours were to learn how to get labs, antibiotics and IV fluids from a University hospital. I told his wife that I would draw blood cultures and other blood test. As I was drawing blood, she asked me if it would help to have a sputum sample. I responded that it would be wonderful but I did not think the patient could cough anything up in his weakened condition. She told me that she would get the sputum for me and performed deep endotracheal suctioning. I recognized at that moment that this gentleman was perhaps far wiser than I suspected with wonderful care like this in his home.

    The following day I heard good reports from my colleagues that he was responding to the intravenous fluids and antibiotics that I had started the evening before.

    I learned a valuable lesson- in order to listen to patients and understand their goals; I would need to empty myself of my preconceptions. Humility is your greatest ally as you attempt to listen to your patients. Humility is not a product from thinking poorly of oneself, but of thinking highly of others - value patients and their opinions.

    Humility is important to our humanity, but also hope is important. You may not be aware of the hope you bring as a physician, but follow me into another night, five years later. Students, remember that when you wear the white coat, expectations can sometimes seem too great.

    A Profession of Hope

    It is a Friday night and I’m now the family doctor in a small-town. It had been a busy week and I was tired. My brother convinced me to go to the high school football game with him since I was the team physician, but the cold rain of that November night made this outing seem burdensome.

    We were a couple of miles from the school along a dark stretch of wet rural road, when we came upon the bright flashing lights of rescue vehicles and Highway patrol indicating an accident ahead. My brother pulled over and jumped out of the car. I sat there, tired. I comforted myself with the notion that EMTs are well trained for emergencies such as this. What could I really do all sopping wet?

    I saw the highway patrolman return to his car in front of me, so I stepped out to ask him a question.

    He recognized me immediately, calling me by name and hurriedly told me that they needed my assistance. A 16 year-old high school student had turned onto the highway from his driveway and was struck head-on by a drunk driver. He was trapped in the wreckage. I surmised the other driver was already on his way to the hospital but did not really grasp what lay before me in the cold rain.

    I stepped into the bright lights and a second later, I heard a voice whisper to a distraught mother and father, “Its okay, Dr. James is here now.”

    It was not okay. Despite my anger at this person for making such a hopeful statement in such a desperate situation, I focused on the tasks at hand. ABC's, that's it - airway, breathing and circulation. I was pleased that the young man could respond to my questions and that gave me hope. The technician was fumbling to get IV access and was poking everywhere except in the vein. I held his hand steady, pushed the catheter a little, and he was in. He smiled at me.

    OK: Intravenous fluids are running, the patient is responding verbally. Within the next few moments, the “jaws of life” finally did their work and the young man was released. I was somewhat surprised when everyone at the scene demanded that I ride with the young man to the hospital.

    Despite serious injuries, the young man lived. Everywhere I went in town; there were pleasant smiles and knowing glances of appreciation for the fine young doctor in the community who heroically saved that student from death. However, I felt guilty about this undue adulation. I was even a reluctant volunteer. Really, I adjusted one technician’s intravenous attempt. I did not want the community to have unrealistic expectations, that’s the recipe for disaster. I suspected the source of this misinformation was the mother of the student and resolved to speak to her. I would explain to her that chance was the reason that her son had lived - not me.

    She asked me what I knew of chance. Is that like being lucky, or unlucky? My whole notion was absurd to her. There was no chance like that in her world. She had seen her son at the brink of death. She knew about chance. In fact, that's what she prayed for. She and her husband had prayed in those moments before my arrival that their son might have a chance to live- they knew that their son would fight hard if given the opportunity to be under the care of a knowledgeable physician. Their prayer had been answered. If their son had that chance, they could accept his death because everything possible would have been done.

    The mother then explained to me her view of what happened that night. She had seen the despair and hopelessness of those trying to help her son. She had even felt that same despair herself. But with the arrival of the physician, the one person in the community with training, knowledge and skill, came hope. And while I may not have been aware of how others responded including her son, she was.

    The physician gave hope in the midst of suffering even though he thought he could do nothing. Sometimes, it is enough simply for the physician to be the splint that holds a fractured life.

    **This mother and father did all they knew to do for their child. That is what people do for those that they love. Your patients will want to know from you whether they did all that they could. Your patients will expect the same from you.

    We have seen the importance of humility for physicians, and how they provide hope. Now let’s return to finish the initial story of the gentleman who was very ill at home and learn how families deal with suffering.
    The Final Story: Honoring Relationships

    Three nights later I was paged at 4 a.m. and dialed the vaguely familiar number. The wife answered the phone and this time, was equally panic stricken.

    “Dr. James, thank God it's you.” She said. “I think my husband is dying. I don't know what to do. Can you help me?”

    This time, I did not do an inquisition. I hurried to her home and entered the doorway. I looked over at her husband who was eerily still with no respirations. I stepped over to him mostly thinking of what I would say to his wife. What was appropriate?

    “Tell me what happened,” I asked. She responded, giving me time to think.

    She told me about all that she had tried to do in the last few hours to sustain her husband. Would my pronouncement in some sense be a judgment on her actions and relationship with her husband? Was her husband's death a defeat for both her and me? Did I share in this outcome?

    “I think you did all you could. No, we did all we could. We tried to abide by your husband's wishes. I believe that he would be very proud of you and what you did for him,” I said.

    The next hour I attempted to find a mortician who would accept credit because of their financial situation. In that time, I found out 4 months ago, her husband had paid off the mortgage with his disability income and felt he had done all he could. I stood up to leave but as I did, she broke into tears.

    “Dr. James, you've helped me some much. But my biggest concern now is about my son.”

    “What do you mean?” I inquired.

    Her son was 13 years old and sleeping in the bedroom adjacent to the living room.

    “Should I awaken my son and allow him to visit with his father before the mortician arrives?” She asked.

    She and I together entered the room and visited with her son. I asked him about his father and their relationship. He told me of his nightly prayers- that God would accept his father into heaven soon. He knew that this was what his father wanted. Yes, he did want to visit with his father. I witnessed at 5:30 a.m. that morning, a son and his mother, holding a departed father and husband in an embrace that was truly sacred.

    Two days later, I read an obituary of a 43 year old pharmacist. It said how he was loved by a devoted son and wife. And I, the physician, knew in greater depth the truth of that sentimental statement.

    I’ve shared with you some of my intimate moments as a physician. While wearing the white coat, you must balance the pride of accomplishments with humility, hope with realism, and understand that death, though it is often framed as our worthy enemy, is one step in the cycle of life where a family’s love can have immeasurable power. So, how does one find meaning in medicine?

    Finding Meaning in Medicine

    Dr. Victor Frankel in his book, In Search of Meaning, describes three avenues by which one may find meaning in life.

    1. “By creating a work or by doing a deed.”
    2. The second is by experiencing something or encountering someone; in other words, meaning can be found not only in work, but also in love.
    3. The third avenue to meaning in life is found in Suffering: a concept poorly understood in scientific terms. Frankel identified within his own life the value of assigning meaning to suffering. You see, he was a world famous psychiatrist imprisoned in Nazi concentration camps and bore witness to the murder of his wife and parents in gas chambers. Science predicts a response based on the known stimuli. The essence for Dr. Frankel of our humanity was that humans could choose a response different from the predicted norm, and that makes us human. He chose not to be bitter in his response to his situation, and thus transcended the depravity of the moment. Physicians have a similar opportunity.

    So now we return to your sacred oath. I have shared with you three of my sacred moments where I learned the power of humility, hope and the defeat of death by a family’s love. In each case, my inspiration for practicing medicine was strengthened, not weakened. Like Victor Frankel, you have a choice; to become cynical and bitter practitioners of a well-paid profession, concerned mostly with your own well being, or to reach out and share your knowledge, skill, but always to act as a caring and compassionate physician.

    To keep my own perspective, I often submit a brief prayer especially when I’m not at my best, to acknowledge my very small role in this world, and I invite God to join me in a sacred moment. In doing so, I am more able to be a vessel of humility and hope, while honoring the loving relationships that my patients have spent a lifetime to build.

    My challenge to you is that you will identify suffering and that you will be moved to act with care and compassion for those in need. Now you begin your stories, I invite each of you to one day share them with me. May God bless you all.

    Reference:

    Viktor E. Frankel, Man’s Search for Meaning: An Introduction to Logotherapy. Printed by Beacon Press, 25 Beacon Street, Boston, Massachusetts. Original publication in 1959. 4th Edition published in 1992.