The Doctor's Dilemma
Returning Service, Grace, and Meaning to the Art of Healing
An interview with Peter Warshall

Rachel Naomi Remen is one of my closest friends. She is a life partner in our work at Commonweal, a small health and environmental research institute in West Marin. She serves as medical director of the Cancer Help Program, our week-long residential program for cancer patients, and director of the Institute for Health and Illness, our training program for physicians and health professionals who work with people with life-threatening illnesses. From fifteen years of work together with people facing cancer, I have a deep sense of Rachel's life project. Rachel's specials genius - no lesser word will do - is to uncover the great wisdom in life stories that point us toward the enlargement of the soul. Her unique gift for this work has its source in her triple identity as a person who has lived with a life-threatening illness for many years, a physician, and a healer steeped in the traditions of the healer's art. So Rachel lives and writes with uncommon access to that place within us where life and death meet, where all pretense dissolves, where a deeper knowing and caring can be found. - Michael Lerner

Rachel Naomi Remen: Every culture has its shadow, and represses the wholeness of its people in some way. It persuades us to diminish ourselves, by disapproving of certain parts of our wholeness. It is a very natural thing to give up wholeness for approval. We don't even realize we're doing this, though we do it all the time in a lot of relationships and within the culture. Until fairly recently, our culture edited people very severely - the heart, the soul, the intuition were not acceptable; all that was respected was the intellect, the facts.

Any medical culture intensifies the values of the larger culture it tries to serve. Medical culture intensifies the shadow of the culture as well. Possibly this is why medical people are looked up to in the culture, seen as successful people. In my experience, those who are perceived as successful usually bear the cultural wound most deeply.

Physicians have been wounded by their training. We are taught that objectivity is an invulnerable stance. But objectivity actually makes us vulnerable. From an objective stance, no one has access to his or her human strengths. You cannot cry or grieve or even pray. You don't even know that you're loved by the people you are serving. Objectivity makes physicians vulnerable to burnout. It prevents us from finding meaning. If the heart is a way of seeing, meaning is found when you see though the heart. The objective stance, distancing yourself, holding yourself apart, makes it impossible to find meaning. We find meaning only in the things we touch and that touch us deeply. Meaning is found only through genuine relationship.

The third-party payer system has created a crisis in medicine. It has invaded the integrity of the doctor/patient relationship. Ninety-five percent of California physicians really work for two people. They work for the organization that pays their salary, and they also work for the patient. What may be absolutely the best for the patient may not be economically the best for the organization. So there is this constant pull. There is now a certain lack of trust in these relationships. Malpractice suits started that - the doctor did not trust the patient. Now the patient does not trust the doctor, because he can never be sure whether what's being done is what's best for him or what best serves the company the doctor works for.

The third-party payer system has imposed a "business value system" on medicine. This can violate the deepest values of medical practitioners. Doctors are dropping out. Young, well-trained doctors are going elsewhere. It's not a question of money. Its' about the violation of core individual values. It's about being asked on a daily basis to do your work at a level far below your capacity for excellence. It would be as if I said to you, "Now look, you're a good writer, a good editor. You've come here and talked with me for an hour. You could really have done it in fifteen minutes, you'll save tape. And you really don't need a pen - use a pencil." If you're a good editor, you can do something passable, even with all those constraints. But if you do this day in and day out, something dies within you.

Peter Warshall: My goddaughter is pregnant. She can have one obstetrician for the nine months, but suddenly, at the moment of birth, it's whoever is on call, any one of nine obstetricians on call.

RNR: Talk about violation of a relationship! And yet people accept this because they feel that this is how it's supposed to be.

In your father's generation [Peter's father was a pediatrician from 1945 to the late 1960s], doctors had the freedom to do things according to what was best. If they wished to spend more time with someone, they could. But when relationship starts getting mandated, and you have only your eight or ten minutes of every person, no matter how frightened, how sick, or what their needs are... Well, it violates the very reason you went into this work. Many doctors have lost their sense of the meaning of their work, and they cannot go on.

There is a growing interest among medical educators and policy makers in helping physicians preserve and recover the meaning of medicine. Freshmen medical students come into medical school on fire with a spirit of service - if you can preserve that, maybe doctors can last longer in these difficult times.

There's a certain concern that medicine may be losing its soul. It's an old soul. I happen to be of a Jewish background, and the only other thing I know that has this kind of lineage is Judaism. It goes back a long, long way. The doctors of generations ago would have been awed by our science and our tools, but they would have understood our commitment perfectly, because they shared it with us. It is an unbroken lineage.

PW: "Meaning" for doctors appears threatened by the technological - the techniques for long life, for fertility. Their tools change so rapidly.

RNR: And the tools are so seductive and so powerful.

PW: Are we messing with the natural law of things?

RNR: Of course we are. We messed with the natural law of things the minute a human first took an herb. The natural law of things has been altered very significantly of r along time. There are numerous ways of looking at this. Obviously, when we alter natural law, we do harm. We are not wise enough to recognize the interconnectedness of our actions. No human being could be wise enough.

Doctors feel burdened and overwhelmed by the decisions that are now expected of them. There are so many decisions we make now that used to be in the hands of fate. It used to be that somebody simply died. Now people have a cardiac arrest and they're resuscitated. When do we resuscitate and when do we not? Or do we give a woman (who would otherwise not be pregnant) fertility drugs - and terminate the lives of three fetuses in her seven-fetus pregnancy? And which three? And how about euthanasia? I don't believe that anyone wants to make these kinds of decisions. Anyone who's ever had to put a dog or a cat to sleep - even when the dog or cat is old and suffering - knows how difficult it is. Imaging putting a human being to sleep. Could you do it? Yet these decisions sort of come with the turf. Nobody asked the doctor, "Do you want to make these decisions?" They're being forced to make these decisions by the nature of the technology. It's not a very comfortable place. I think most practitioners feel unprepared.

Technology has changed medical education into a "training." It has been said that our technology is always fifty years ahead of our wisdom. And in that lag time, we may destroy ourselves. Do we act because we can or because we should? People are afraid, for instance, of genetically altered vegetables. But when in doubt, we generally go forward instead of waiting.

PW: The courts are being asked to judge. Like that recent decision about a woman who got divorced. She still wanted to use eggs fertilized by her former husband, and he said, "No, we're now divorced." But she said, "Well, you signed a legal document that we could do this." The court ruled that he has the right to refuse, since it would be his child. It begins a strange techno materialist decision-making, reminiscent of King Solomon.

RNR: We so easily outrun our headlights. We're very technically capable, but we're not very wise. In a recent situation, seven babies were born through "the miracle of science" and, at the age of two, two of them are obviously retarded. I have yet to see this actually written up in a newspaper. Reporters covering the second birthday simply said, "Oh, this one can't sit up yet," "This one has poor head support."

PW: What can a culture do to change that kind of attitude? Most people I meet just accept that medical miracles are there for them. How do you work with medical students and doctors, given the dilemmas we've hashed over?

RNR: I work with doctors on two levels. I run a course called Continuing Medical Education (CME) at the Institute for the Study of Health and Illness at Commonweal. And I run a class called "The Healer's Art" for freshmen medical students at the University of California, San Francisco. The physician graduates of the CME program teach with me in the medical school course. Both of these courses are about recovering, strengthening, and preserving the meaning in this work.

The medical school course is preventive, because meaning seems to function inversely as expertise. The freshman students are on fire with the meaning of their work; by the time they are seniors, this is gone. It's as if they now know what they need to do, but have forgotten why they came. "The Healer's Art" is an elective. An elective usually draws eight to twelve students, but we get somewhere between fifty and sixty every year. That means that almost one out of every two students in the school has chosen to take this course.

Among other things, we develop an atmosphere of safety between students, and between students and faculty. A harmless space between health professionals is rare. Doctors are competitive and isolated. It is rare to hear anyone admit vulnerability or pain. Creating harmless space, and having that experience of acceptance of other people, is, I think, the absolute model of the doctor/patient relationship. We start by helping them to be harmless with their colleagues. The first session, "Survival Skills for Medical Students," starts with a simple exercise that enables students to recognized and reclaim a part of themselves that they fear may be changing in this process of becoming an expert. This is everyone's hidden fear. Students are working fourteen-hour days, seven days a week. Nobody has any idea what this is like beforehand. It's easy not to feed parts of yourself that aren't immediately involved in the workaday tasks.

We start by talking about the cultural shadow, explaining it. Just simply tell stories about it. We ask them to close their eyes and allow an image to come for the part of themselves that they are afraid may change in this process of becoming an expert. We give them big pieces of paper and little boxes of crayons that smell just like the ones in kindergarten. And they draw a picture of this part of themselves. Often the picture is a symbol, like a candle or a lighthouse. We ask them to name the quality at its core...and we get words like compassion, fidelity, wisdom, trust of life, and the like. These are the parts that are threatened by the pressure of the training.

Cultural shadow is hard to heal. It's not like family shadow. Family shadow has more opportunity for healing, because when you become an adult you leave your family and you get validated by other people for things that were not validated by your family. Or you are accepted in ways that you never got accepted in your family. You have an opportunity to reclaim wholeness.

But cultural shadow is reinforced everywhere. There are no nonparticipants. So how do you heal the shadow of the medical culture? What occurred to me is that as culture wounds, so culture can heal. You heal a dominant culture by forming a subculture of credible people, in the middle of it, who value something new, who reinforce and reward something that the dominant culture represses.

So this class might be considered such a subculture, a community that helps those who participate to heal the shadow of medicine. It's not didactic or theoretical. It's experiential. It's a discovery model. It involves taking off masks and showing others both your highest aspirations and your deepest fears. It also involves finding acceptance for who you authentically are.

After we draw, we go into small groups, a doctor and four or five students. The doctor is a facilitator but not a teacher. It's a level playing field. Doctors share their own struggles, their own doubts, their own dreams in the groups, and do the same exercises that the students do. In these small groups, the students share their pictures and discover that they are not alone: others who seemed confident and self-assured have the same inner concerns.

We talk about all sorts of ways to self-remember. We teach ways to feed the parts that matter. There's a special journal we teach them to keep. We teach about ritual, about prayer; we talk about imagery. We close the session with a five-minute meditation - but we can't call it that. We just spend five minutes in supportive community. If I am the doctor in the group, I ask the person on my left to say his name aloud. And in absolute silence, everybody thinks about what that person has shared here tonight, what his dream is for himself and his medicine. And everyone sends strength to that person in any way they care to. You might want to pray for him, if that's your way, or believe in him, or experience that his struggle is important. This is done in silence for about forty-five seconds. Then the next person to the left says her name and the group focuses its attention on her in just the same way, for forty-five seconds. Finally, the doctor says her name, and receives the support of the group as well. And for the first time, we come into right relationship with our fellow professionals.

Medical School is a marginalizing experience. So is medicine. In the next session, students often find that they are able to share things they many not be able to share elsewhere, because not only do they feel safe, they are with other people who can really understand these highly unusual experience they're having, this highly unusual life they're leading.

We open the course with a drawing and we close the course with a drawing. In the final session, which is called "The Care of the Soul," we let the students rewrite the Hippocratic oath for themselves. The oath is about a commitment to befriend life. It is also a way of life. I think of it as a spiritual path. The qualities embodied in it - compassion, harmlessness, covenant, service, reverence for all life - are not the qualities of an expert or a technician. They are soul qualities.

You have to understand that nobody, absolutely no human being, can be harmless. In order to be a truly harmless person you would have to have a vision of the infinite, a chain of events that goes on forever, in order to know that any single action is truly a harmless action. So harmlessness is an aspiration, not something that anyone who is a human being could truly embody.

We may invite others - sometimes the hospital chaplaincy training program - to come, so we have the students, and the physicians who are the faculty, and a group of rabbis and ministers and priests. We remind those present that your medicine isn't something that tells you how to live, what to wear, what to say, when to sleep, what to read, how to spend your time. We invite them to imagine what it could be - a vehicle for the expression of their highest values - and to draw a picture of this vision.

All the drawings are different. They're all unique. I like to think of them as soul drawings. Uniqueness, for me, is one of the qualities of the soul. Then we invite them to ask for help in bringing more of this vision into their daily work. They write three or four sentences, in the "language of help": Help me, show me, may I, give me," etc. And then, for about two hours, everyone reads aloud to each other.

This is a very powerful moment for everyone, including me. If you close your eyes while people are reading, you can't tell who is a medical student, a surgeon, a minister, or a nurse. Somehow, through this simple exercise, we go past the divisiveness of our expertise, and inhabit the unity of our commitment. It always make me wonder if there really isn't only one role and one profession - and that is service. We each do this with our own skills or gifts or expertise, but it is the same work. We befriend life. We become a blessing.

One year, a young woman stood up after reading, looked around at her classmates, and said, "I had no idea that's who you guys were. I thought I was here all alone." Just as there is an isolation in the American culture, there is extreme isolation in the medical culture.

I run a drop-in evening group for doctors who, like myself, are recovering from their training. Sometimes I think that medicine is like a disease: you have to recover from it. "I'm a recovering doctor." Each evening has a topic related to the practice of medicine...like compassion, or suffering, or listening. It's a discovery model. As the "price of admission" to the evening, each person brings a story from his personal life, his professional life, from the world literature, or a poem, or an exercise to help people explore the evening's topic more deeply.

During a session on listening, an oncologist brought a shopping bag with her. In the shopping bag were twelve stethoscopes she had liberated from Kaiser for the evening. She gave everyone a stethoscope and said, "Let's listen to our own hearts for about eight or nine minutes." So me started listening. We're middle-aged, and for the first few minutes you could see that everyone was diagnosing himself. But eight minutes is a long time. And we all went beyond this and found something ineffable...an experience of profound mystery. There were two cardiologists in the room; both of them were blown away. So were we all. My experience was that I had never heard a heart before. I had auscultated thousands of hearts but I had never heard a heart before. It's very, very moving. Talk about an experience of reverence and awe.

I think we have made a trade between mastery and mystery, between information and wisdom. Mystery used to occupy the same place in medicine that science does now, and I truly believe that it still does - except we often do not notice. We often tell ourselves stories to cover up the places where we encounter something that we cannot understand.

I sometimes think that medicine is a front-row seat on mystery. There is so much that happens that we can't explain. A physician once told me the story of the time when he was 18 and his brother was dying of leukemia. About a day before his brother died, he was reading to him in his bedroom. His brother was lying in bed, eyes closed. He couldn't tell if he was awake or not, but he did not know what else to do, so he kept going. As he was reading, he suddenly felt his brother's hand on his arm. His brother's eyes were open and he was looking at a blank wall. "Look, George, look," his brother said. "There is someone there. Someone has come for me, George. Look. Can you see him?"

So George closed the book and looked at the blank wall and he couldn't see a thing... "But I could feel it. There was something in the room with us. It was completely benign, totally good." And he says that in this moment he knew that he was supposed to become a doctor. When his brother died, he went back to school and changed his major from engineering to medicine.

When I asked him to say more about it, he told me that he actually knew in that moment that he was a doctor and had always been a doctor. That he had been born with a doctor's soul in him. Very mysterious! He says that it was like a moment of healing, "coming to my true self. Whatever it was that came for my brother, it came for me too. Perhaps this was a moment of healing for him as well."

Once you get a group of doctors talking about mystery, it's often hard to get them to stop. So much of what we see just doesn't make sense. Sometimes it's a small thing, sometimes it's a large thing. But there's a lot that just does not fit into the box.

PW: In your book (My Grandfather's Blessings), you say that service, in a sense, was letting the lives that touch yours, touch you. I kept on thinking, was "touch" there a metaphor?

RNR: The very oldest way of healing is touch, a connection between the hand and the heart. But we're trained to diagnose and cure, to connect the hand to the mind. In our CME workshop on healing, we may ask doctors to do hands on healing with each other. At first it feels a little strange to lay your hands on someone and encourage the life in them. But many physicians say they felt as if something in them had always wanted to touch their patients in this way, and they couldn't think of a way to do it without being embarrassed. It's not just physical touch. It's more about the sense of belonging, of occupying a level playing field, a shared vulnerability and a shared strength. The experience I have, is, you greet the life in someone. You accept its present shape, accept it as it is. You recognize its holiness. After hands-on healing, you never see the person you were partnered with in the same way again.

PW: When you were talking about your sense of service, I thought of something. "Service" is a hard word, because another word like it in English is "servitude," and both come from the word for slave. In the Old Testament, you have three sense of service to the land: the manipulator (dominion over), the steward (caretaker), and the servant of the Earth. They keep fighting each other. Are we on a kind of quest for stewardship of the body?

RNR: A very strange idea floated through my head as you said that. I have no idea if the idea is valid or true, but what floated through was that service is much more about celebrating life than it is about dominating it. We don't dominate. We don't "steward." It's more like a celebration.

A long time ago, when I first got interested in this, I asked a number of people whose lives seemed to me to be lives of service to define it. Nobody could. People obviously were living it; they just couldn't talk coherently about it. It was ineffable, in some way. One of the people I asked was my colleague, Marion Weber, who is an artist. Marion is quite remarkable. She's a very, very wise woman. As we were driving somewhere I said to her, "I can't get clear on this article I'm trying to write on service. No one even seems to be able to give me a decent definition for it." And she said, "Oh well, why make it so difficult? Service is belonging." I think the dominion/stewardship/servitude construct has us standing next to something. It feels like a duality. Service doesn't have that distance. It's not a duality. To serve is to make whole in some way. Service...it's more of a grace. It's very close to love, but a very pure kind of love. A befriending of the life in others, unconditionally.

At some level, there's nothing personal in service. It's abstract. Just the same way that unconditional love is impersonal. It goes beyond any individual. So it's a response to the holiness that is at the foundation of all life. It's hard to put that into words. It's the sense that all that life is worthy. And it goes beyond your own preferences in thinking about life, whom you like and whom you don't. Your own preferences are irrelevant. All life is holy. I thin the Hippocratic oath is about a relationship between an individual life and life itself. A person and life itself.

Fixing, helping, and serving are three different ways of experiencing and perceiving. When you experience your work as service, the work itself sustains you. The work itself blesses you. Fixing and helping are ultimately draining; service is renewing. When I fix something, I get satisfaction, pride, all those ego things. When I serve, I get a sense of gratitude for the opportunity to do the work. I feel lucky. Perhaps fixing and helping are the work of the ego...and service is the work of the soul.

My Grandfather's Blessings: Stories of Strength, Refuge, and Belonging When Peter Warshall proposed that I review My Grandfather's Blessings, he said: "There is something to say for friends reviewing books. The longer-term understanding of the author's intent, for instance; and the deeper understanding of their 'project' in life. Also, Whole Earth is about community, and I've always felt that something overflows from one review to another that speaks of intimacy. So if you would like, I would like." That made sense. Rachel's Kitchen Table Wisdom [Riverhead Books, 1997] was a word-of mouth bestseller that has touched people in a way few books ever do. My Grandfather's Blessings takes us another step forward in the unfolding of Rachel's service to the world. The titular reference is to what she learned from her grandfather, a rabbi and scholar of the Kabbalah. The 103 stories explore receiving blessings, becoming a blessing, finding strength and taking refuge, the web of blessings, befriending life, and restoring the world. - Michael J. Lerner

reprinted with permission