Healing Our Healthcare System and Culture: Our Humanity is More Powerful Than Our Expertise
Medicine and healing is as close to love as it is to science. There’s no question that we live better through science and what we can measure. Yet to live well is going to take something more than that. Life is filled with mystery, miracles, courage, heroism, love — all these things that we can witness but not measure or even understand, but they make our lives valuable anyway. ~ Rachel Naomi Remen
Dear PEERS subscribers,
Recall a time of grief, loss, or deep hardship.
Think about someone who helped you through those times. What did that person do and say? What message did they deliver, and how did they deliver the message?
As you moved through these difficult life situations, what did you call upon for your strength?
These are the questions that medical doctor Rachel Naomi Remen asks healthcare professionals to reflect on, in order to better serve their patients. One of the core pioneers of integrative medicine and relationship-centered care, Rachel Naomi Remen has spent decades counseling hundreds of end-of-life people and those dealing with cancer. She is a clinical professor at UCSF School of Medicine and founder of the Institute for the Study of Health and Illness (ISHI). As co-founder of the Commonweal Cancer Help Program, she created one of the first integrative care support groups for cancer patients in America.
In addition to being a physician for 40 years, Dr Remen has been a patient of the medical system for 60 years. Her illness included being diagnosed with Crohn’s Disease at age 15, recovering from a coma after a massive bleed in her mid teens, having eight major surgeries including her large intestine surgically removed, and years of intensive therapy with toxic drugs. She was told by her doctors that there was no cure and that she would be dead by age 40. “My doctors had an excellent sense of my disease. Yet what they didn’t have was any real sense of me.”
Stories, not facts, are what holds a culture together. She suggests that sometimes we need a meaningful and powerful story more than food in order to live.
“Stories heal when they are more about who we are, not what we have done. About what we have faced to build what we have, what we have drawn upon and risked to do, what we have felt, thought, feared and discovered through the events of our lives. And about where the love that has sustained us comes from. Stories remind us we’re not alone with whatever faces us and that there are resources, both within us and in the larger world and in the unseen world, that may be cooperating with us in our struggle to find a way to deal with challenges ... For example, the facts are that I have had Crohn’s disease for 52 years. I’ve had eight major surgeries. But that doesn’t tell you about my journey and what’s happened to me because of that, and what it means to live with an illness like this and discover the power of being a human being.”
Her creation of the The Healer’s Art curriculum for medical students is now taught in more than half of American Medical schools and medical schools in 7 countries abroad. The Healer’s Art course utilizes principles of humanistic and transpersonal psychology, creative arts, interpersonal and relationship building skills, encounters with awe and mystery, and storytelling to strengthen human dimensions of medicine rarely discussed in medical training. Living well, Remen says, is not about eradicating our wounds and weaknesses but understanding how they complete our identity and equip us to help others. The way we deal with loss shapes our capacity to be present to life more than anything else.
“I think that we all feel that we’re not enough to make a difference; that we need to be more, somehow, either wealthier or more educated or different than the people we are. People ask: how can I make a difference when I’m so wounded and feel so not-enough? I tell them that it’s our very wounds that enable us to make a difference. We are the right people, just as we are. And to just wonder about that a little, what if we were exactly what’s needed? What then? How would I live if I was exactly what’s needed for whatever I am stepping into?”
Remen reminds doctors of their power to make a difference through human response and connection to their patients. People who are physicians have been trained to believe that it is a scientific objectivity that makes them most effective, and a mental distance that protects them from becoming wounded by this difficult work. Yet objectivity can make us far more vulnerable emotionally than compassion and humanity. Objectivity separates us from the life around us and within us. Physicians often pay a huge price for their objectivity.
Below are two powerful essays written by Rachel Naomi Remen: Recovering the Sacred in Medicine and Helping, Fixing, or Serving. Click here to skip to her second essay.
For further exploration of Remen's work, check out her profoundly touching books Kitchen Table Wisdom: Stories that Heal and My Grandfather’s Blessings: Stories of Strength, Refuge and Belonging. These books contain powerful stories of her own personal healing journey as well as stories of the patients, families, and healthcare practitioners she worked with.
With faith in a transforming world,
Amber Yang for PEERS and WantToKnow.info
The Recovery of the Sacred in Medicine
Years ago, I was at a workshop with mythologist Joseph Campbell, and he was showing us pictures of the sacred. He showed us this wonderful bronze statue of the god Shiva, dancing. Inside a ring of flame the god was dancing. He had one foot in the air, and the other foot resting on the back of a little man, who was crouched down in the dust, giving his full, absorbed attention to something he was holding between his hands. I asked Joseph Campbell, "What is that? What is that little guy doing down there?" Campbell said, "That's a little man who is so caught up in the study of the material world that he does not notice that the living god is dancing on his back."
That little man is a health professional. That little man is the whole health care system. Our medical system has become overly focused on the body and the state of the body, but we are not our bodies. We have bodies, but we are not our bodies.
We need to heal the wound inflicted on us and our culture by Descartes - the mind-body split. But this wound goes much deeper; it's also a split between the sacred and the secular. The split between the sacred and the secular is the illusion that continues to permeate our society. It alters our thinking and causes us to ask the wrong questions, and when we ask the wrong questions, our solutions don't serve us.
During the first lecture in the medical school course I'm directing at the University of California-San Francisco, one of the physician graduates of the Institute for the Study of Health and Illness (ISHI) told the class this story from his own life:
His mother had nursed his father for 10 years while his father deteriorated into Alzheimer's disease. His father's brain had died but his body still walked around and ate, and it was fed, clothed, and cared for by his mother. His speech deteriorated and for five years of his life, he was not able to speak.
His mother was eventually persuaded to get some help. One day, when she had gone shopping, her husband had a massive heart attack and fell to the floor in the living room. The caretakers rushed to his side and one said to the other, "Call 911!" But before this could happen a voice said, "Don't call 911. Tell my wife that I am all right. Tell her I love her." And his father died. Looking intently at the medical students, this doctor said to them, "I challenge you to the question: Who spoke? Without wondering about this question, you can be a doctor to disease but not to human beings."
The recovery of the soul may depend not on having the right answers but on asking the right questions and carrying them with us for our whole lives. The medical system may need to relinquish a single-minded quest for mastery and allow for the presence of mystery. "Who spoke?" indeed.
What does it mean to a physician to practice medicine without mystery? When I was a medical student, my school had a large, black-tie retirement dinner for a very famous man on the medical faculty, whose scientific contribution had earned him a Nobel prize. He was 80 years old. The entire school gathered to honor him, and famous medical people came from all over the world.
This doctor gave a wonderful speech describing the progress of scientific knowledge during the 50 years that he had been a physician. We gave him a standing ovation.
After we sat down he remained at the podium. There was a brief silence and then he said, "There's something else important that I want to say. And I especially want to tell the students. I have been a physician for 50 years and I don't know anything more about life now than I did at the beginning. I am no wiser. It slipped through my fingers."
We were stunned into silence. I remember thinking that perhaps he was senile. In retrospect, it was a very remarkable thing he did. He took an opportunity to warn us about the cage of ideas and roles and self-expectations that was closing around us, even as he spoke to us - the cage that would keep us from achieving our good purpose, which is healing. Healing is a matter of wisdom, not of scientific knowledge.
So, what is the task of the medical system? Our modern view of disease is that disease is centered in the body. The older view of disease is that it is soul loss, a loss of connection, of meaning, of purpose, of essence. If this is so, the real task of the medical system is to heal soul loss, to aid in the retrieval of the soul. The entire culture is ill with soul loss.
What is needed is not to bring spirit into our work, to develop more of a spiritual practice or to go to church more. Our task is to recognize that we are always on sacred ground, that there is no split between the sacred and secular. That the living god is dancing on our back. That there is no task that is not sacred in nature and no relationship that is not sacred in nature. Life is a spiritual practice. Health care, which serves life, is a spiritual practice.
Disease is a spiritual path, too. Much illness is caused by the loss of the soul. Many, many people live lives that are empty. This emptiness is caused, in some part, by living without meaning, or with meaning that is much too small, too trivial, or too material for the needs of a human being.
How did we lose the soul? What happened, I think, is that we entered into a culture that devalued the yin, or the feminine principle. We lost a way of seeing. Yeats says this wonderful thing: "The voyage of discovery lies not in seeking new vistas but in having new eyes."
The yin is a way of seeing, a way of understanding the world, a way of formulating solutions, and a very powerful way of acting. Access to sacred experience requires us to reclaim our yin capacity, to value the subjective, the intuitive, the qualitative, to not limit our focus to the surfaces of things.
We all know the power of the yang masculine principle, especially in health care. There are many people who would have died long before today without the powerful, life-saving interventions of masculine-principle oriented medicine. I am one of them. So it is not about throwing away the masculine principle; it is about reclaiming wholeness, integrity.
What does it mean to perceive subjectively as well as objectively? When I started the poetry writing workshops with people with cancer, I was amazed that a poem came to me because I don't think of myself as a poet. My poem goes like this:
O
body!
for 35 years
1,573 experts with
14,372 combined years of training
have failed
to
cure your
wounds.Deep inside
I
am
whole
Reclaiming the sacred requires this kind of a double vision - the cultivation of a double vision that experiences the objective and the subjective worlds simultaneously.
The imbalance in the medical system, the emphasis on yang-principle approaches and perceptions that pervades our entire culture, diminishes everybody. It diminishes the people who work within the system, and it diminishes the people who seek out the system for their healing. When you leave the doctor's office you may feel diminished, even though you have been given the right diagnosis and the right pills. If someone relates to you in a predominantly yang-principle style, you experience their strength, their capacity. You get rescued, as it were, and you feel smaller.
What is it like, then, to relate to someone who is relating to you in a predominantly yin feminine-principle style? This symbol is called Venus's mirror. When someone relates to you from the feminine side of themselves, what you see reflected in Venus's mirror is your own strength, your own capacity, your own uniqueness. What would the medical system be like if it could do that for us, as well as providing the right diagnosis, the right pills?
The yin is about comfort in the world of relationship, the world of connection, the interdependence of things. We have had a disease-centered medical care. We have moved to a more patient-centered form of care. What we need is a medicine based on right relationship.
What we have now is a medicine of isolation. The shadow side of the yang, or masculine principle, is isolation. We have actually institutionalized isolation in medicine. We even have a language that nobody can understand. There is no reason why true things cannot be said in little words.
What does it look like when you start healing professional isolation?
At the end of our ISHI curriculum workshop at Commonweal we do a healing circle, a ritual we also do with people with cancer. The first time we did this, the eight doctors, all men, were sitting in a circle with their eyes closed. I have a little Zen gong, and when I strike the gong, the man to my left says his name aloud. The others then meditate on this man, pray for him, dream his dream with him, hope for his well being, believe in him, all in total silence, of course, for about two minutes. When I strike the gong again, the next man says his name aloud and everybody meditates on him for two minutes. And we go around the entire group this way.
Just before the end of this exercise, I opened my eyes and saw that some of the men were crying. At the end I asked about this, and one physician said, "I have never been wished well by another doctor before." The others just nodded. Medicine is a culture of competition, independence, isolation.
What we are building at ISHI is a healing community, physicians who are in relationship to each other in a way that is healing so that they can endure the difficult work of being a health professional without burning out, people who know about healing through personal experience. The yang cures. The yin heals.
At the close of each workshop we ask, "What did you learn? What are you taking home with you?" A cancer specialist said, "I just realized that I was numb. I was so numb that I didn't know that I was numb. Here, for the first time, I have found silence - silence in the woods, silence in the yoga. I didn't know I needed silence, I didn't know how to get silence, so I made myself numb instead." This man might have been talking for the entire culture. All of us are numb because we do not allow silence. Silence is a quality of the yin.
Because the medical system does not yet understand the full range of human needs it wounds people - both doctors and patients. It does not recognize the full range of human strengths, either. What is needed for the healing of the medical system is what is needed for the healing of the culture. Because we are wounded in the same way as our institutions, when you are trained by an institution your wounds increase. In our training we are actually rewarded for our woundedness and punished for our wholeness. Medical training at the moment is like a disease. We have to recover from it, and many people never do. I am a recovering physician.
The medical system does not trust process. The whole concept of "fixing" and "broken" suggests an insensitivity to the process nature of the world. The essential word of process is "yet." "Yet" is seeing with yin/feminine eyes. We are all "works in process." That means that judgment is really inappropriate, or premature, because none of us are finished ... yet.
When I began to be interested in the spiritual, I remember literally praying that I could stop seeing people's faults so that I could release myself from my habit of critical judgment. I still see what I saw then, but I now recognize that what I am seeing is not deficit but the growing edge in every human being. I am seeing the "yet," the place where God is present, the place where the work happens.
Our medical system needs to see human beings as a process. Moreover, it needs to recognize that human process is purposeful. It is a process that involves movement toward greater meaning. People who report near-death experiences also report an ineffable knowing about the purpose of life. According to these reports, the purpose of life is to grow in wisdom and to learn how to love better. It is so simple and general a purpose that we are each free to find our own way to do it. To more fully serve life, medicine needs to help people to grow in wisdom and to learn to love better.
The challenge for us is to shift from being the fixers of the broken to the holders of the "yet" for people who have lost sight of the "yet" and those who do not believe in it. A stanza from a poem written by psychologist Dorian Ross, PhD, after her surgery supports the power of this position.
Mother bathing me each morning
with hospital rough washclothes
but with such tenderness and wish
for warm water
that my skin did not hurt, it moved
out towards her,
recognizing at last its own
a trust that went deeper than peril,
her force becoming mine
but in surprising ways . . .
It was the cream she put under my eyes
each morning,
believing that there would be a time
again that I would
care about beauty
believing in this body when I could not.
Is there a way to practice medicine, such that we are grateful for the opportunity to practice medicine? Is there a way to practice life, such that we are grateful for the opportunity to practice life? So that at the end of many years of such practice, we might feel that we had been privileged and had not let the opportunity slip through our fingers? The healing of a system and the healing of the world happens one heart at a time.
Helping, Fixing, or Serving
Helping, fixing and serving represent three different ways of seeing life. When you help, you see life as weak. When you fix, you see life as broken. When you serve, you see life as whole. Fixing and helping may be the work of the ego, and service the work of the soul.
Service rests on the premise that the nature of life is sacred, that life is a holy mystery which has an unknown purpose. When we serve, we know that we belong to life and to that purpose. From the perspective of service, we are all connected: All suffering is like my suffering and all joy is like my joy. The impulse to serve emerges naturally and inevitably from this way of seeing.
Serving is different from helping. Helping is not a relationship between equals. A helper may see others as weaker than they are, needier than they are, and people often feel this inequality. The danger in helping is that we may inadvertently take away from people more than we could ever give them; we may diminish their self-esteem, their sense of worth, integrity or even wholeness.
When we help, we become aware of our own strength. But when we serve, we don’t serve with our strength; we serve with ourselves, and we draw from all of our experiences. Our limitations serve; our wounds serve; even our darkness can serve. My pain is the source of my compassion; my woundedness is the key to my empathy.
Serving makes us aware of our wholeness and its power. The wholeness in us serves the wholeness in others and the wholeness in life. The wholeness in you is the same as the wholeness in me. Service is a relationship between equals: our service strengthens us as well as others. Fixing and helping are draining, and over time we may burn out, but service is renewing. When we serve, our work itself will renew us. In helping we may find a sense of satisfaction; in serving we find a sense of gratitude.
Harry, an emergency physician, tells a story about discovering this. One evening on his shift in a busy emergency room, a woman was brought in about to give birth. When he examined her, Harry realized immediately that her obstetrician would not be able to get there in time and he was going to deliver this baby himself. Harry likes the technical challenge of delivering babies, and he was pleased. The team swung into action, one nurse hastily opening the instrument packs and two others standing at the foot of the table on either side of Harry, supporting the woman’s legs on their shoulders and murmuring reassurance. The baby was born almost immediately.
While the infant was still attached to her mother, Harry laid her along his left forearm. Holding the back of her head in his left hand, he took a suction bulb in his right and began to clear her mouth and nose of mucous. Suddenly, the baby opened her eyes and looked directly at him. In that instant, Harry stepped past all of his training and realized a very simple thing: that he was the first human being this baby girl had ever seen. He felt his heart go out to her in welcome from all people everywhere, and tears came to his eyes.
Harry has delivered hundreds of babies, and has always enjoyed the excitement of making rapid decisions and testing his own competency. But he says that he had never let himself experience the meaning of what he was doing before, or recognize what he was serving with his expertise. In that flash of recognition he felt years of cynicism and fatigue fall away and remembered why he had chosen this work in the first place. All his hard work and personal sacrifice suddenly seemed to him to be worth it.
He feels now that, in a certain sense, this was the first baby he ever delivered. In the past he had been preoccupied with his expertise, assessing and responding to needs and dangers. He had been there many times as an expert, but never before as a human being. He wonders how many other such moments of connection to life he has missed. He suspects there have been many.
As Harry discovered, serving is different from fixing. In fixing, we see others as broken, and respond to this perception with our expertise. Fixers trust their own expertise but may not see the wholeness in another person or trust the integrity of the life in them. When we serve we see and trust that wholeness. We respond to it and collaborate with it. And when we see the wholeness in another, we strengthen it. They may then be able to see it for themselves for the first time.
One woman who served me profoundly is probably unaware of the difference she made in my life. In fact, I do not even know her last name and I am sure she has long forgotten mine.
At twenty-nine, because of Crohn’s Disease, much of my intestine was removed surgically and I was left with an ileostomy. A loop of bowel opens on my abdomen and an ingeniously designed plastic appliance which I remove and replace every few days covers it. Not an easy thing for a young woman to live with, and I was not at all sure that I would be able to do this. While this surgery had given me back much of my vitality, the appliance and the profound change in my body made me feel hopelessly different, permanently shut out of the world of femininity and elegance.
At the beginning, before I could change my appliance myself, it was changed for me by nurse specialists called enterostomal therapists. These white-coated experts were women my own age. They would enter my hospital room, put on an apron, a mask and gloves, and then remove and replace my appliance. The task completed, they would strip off all their protective clothing. Then they would carefully wash their hands. This elaborate ritual made it harder for me. I felt shamed.
One day a woman I had never met before came to do this task. It was late in the day and she was dressed not in a white coat but in a silk dress, heels and stockings. She looked as if she was about to meet someone for dinner. In a friendly way she told me her first name and asked if I wished to have my ileostomy changed. When I nodded, she pulled back my covers, produced a new appliance, and in the most simple and natural way imaginable removed my old one and replaced it, without putting on gloves. I remember watching her hands. She had washed them carefully before she touched me. They were soft and gentle and beautifully cared for. She was wearing a pale pink nail polish and her delicate rings were gold.
At first, I was stunned by this break in professional procedure. But as she laughed and spoke with me in the most ordinary and easy way, I suddenly felt a great wave of unsuspected strength come up from someplace deep in me, and I knew without the slightest doubt that I could do this. I could find a way. It was going to be all right.
I doubt that she ever knew what her willingness to touch me in such a natural way meant to me. In ten minutes she not only tended my body, but healed my wounds. What is most professional is not always what best serves and strengthens the wholeness in others. Fixing and helping create a distance between people, an experience of difference. We cannot serve at a distance. We can only serve that to which we are profoundly connected, that which we are willing to touch. Fixing and helping are strategies to repair life. We serve life not because it is broken but because it is holy.
Serving requires us to know that our humanity is more powerful than our expertise. In forty-five years of chronic illness I have been helped by a great number of people, and fixed by a great many others who did not recognize my wholeness. All that fixing and helping left me wounded in some important and fundamental ways. Only service heals.
Service is not an experience of strength or expertise; service is an experience of mystery, surrender and awe. Helpers and fixers feel causal. Servers may experience from time to time a sense of being used by larger unknown forces. Those who serve have traded a sense of mastery for an experience of mystery, and in doing so have transformed their work and their lives into practice.
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