Can a Doctor Live From the Heart?An Interview with Rachel Naomi Remen, MDBy Christina Tucker Dr. Remen, a clinical professor of family and community medicine at UC San Francisco, is the cofounder of the Commonweal Cancer Help Program in Bolinas and the author of two bestselling books, Kitchen Table Wisdom and My Grandfather's Blessings. Her course The Healer's Art is presented in medical schools nationwide, and she offers frequent workshops for practicing physicians. This interview begins with a story from Kitchen Table Wisdom (©Riverhead Books, 1996). As a pediatric intern, I was a secret baby kisser. This was so flagrantly "unprofessional" I was careful not to be discovered. Late at night under the guise of checking a surgical dressing or an IV, I would make solo rounds on the ward and kiss the children good night. If there was a favorite toy or blanket, I would be sure it was close, and if someone were crying I would even sing a little. I never mentioned this dimension of my health care to anyone. I felt the other residents, mostly men, might think less of me for it. One evening as I was talking to a patient's father in the corridor, I glanced over his shoulder and saw Stan, my chief resident, bend over the crib of a little girl with leukemia and kiss her on the forehead. In that moment, I realized that others too might be struggling to extend themselves beyond an accepted professionalism to express a natural caring. Perhaps there was a way to talk about these things, even to support one another. Some time later when we were waiting to be called to the operating room for a C-Section, I told Stan what I had seen and that it had meant something important to me. Although we were alone in the doctor's lounge, Stan denied the whole thing, and we dropped the subject in embarrassment. For the rest of the year, we worked together, 36 hours on call and 12 hours off. We became trusted colleagues, good friends, and even occasional drinking buddies, but neither of us mentioned the incident again. Stan's integrity was almost legendary. He would never have fudged a piece of lab data or said he had read an article when he hadn't. But he would have had to step past our entire professional image and training to admit his heartfelt reaction to that little girl. It was impossible then. It is barely possible now. Expressing caring directly, rather than through a willingness to work a 36-hour day or spend long evenings keeping up with the medical literature and the newest treatments, transgresses a strong professional code. It was just not professional behavior. I stopped kissing the babies then. It did not seem worth the risk. In many ways, a medical training is like a disease: you may need to recover from it. It would be years before I would fully recover from mine. Q: What does it mean to live from the heart, and why should a physician bother to even think about it? A: There is very little in our professional training that would encourage us to live from the heart. The heart is seen as too subjective, too soft, too unquantifiable to be of serious concern or have credibility in the practice of medicine. And yet, the heart is one of the strongest places from which to live a life, especially a physician's life. The heart is an organ of vision—a way of seeing life that allows you to see below the facts of a situation to its real meaning. Meaning renews you and inspires you to continue doing work you have been doing for years. Q: Why did you become a doctor? I became a doctor originally because everyone else in my family was a doctor. There are nine physicians and three nurses in two generations of my family and I thought at one time that becoming an adult and becoming a physician were part of the same process. Later on, I became a doctor because I saw it as a spiritual path. I saw it as a way of life, characterized by things that were important to me: service, harmlessness, and compassion. I realized that I could live in such a way that my life mattered. I could make a difference to other people. Q: Did the doctors in your family share that same idea about service? They shared the idea about service; but they saw service in a very different way. They saw service as a function of science—a function of curing and eradicating disease. I think that this is very much a part of our service as physicians; but I also know that many diseases can't be cured. There is a growing population of chronically ill people who are living with incurable diseases they would have died of 20 years ago. In order to help people like this, we need to shift our therapeutic goal from curing to healing. That's where the heart comes in. Q: Do people just wake up one day and decide to be of service to fellow humans? How does it happen that the idea of service becomes a focus for some people? That is a mysterious kind of question, because there is such a thing as a "calling" in our field. I think many people are called into this work but don't realize it. We have a tendency to think of "calling" as some kind of miraculous event—a visitation by an angel or a spiritual presence that says, "This is your life work: to be a physician." But actually I suspect that "calling" is much subtler than that. Many physicians from early childhood have responded to the needs of living things because they have this deep intent to make a difference. Most people draw back when they are confronted with the need, pain, or suffering of others, and especially the suffering of strangers. I would define "calling" as realizing that you are made a certain way inside; so that your response to suffering and need is a little different than the average response to suffering and need. I sometimes ask large audiences of physicians, "How old were you when you first realized that the needs of living things mattered to you—the needs of insects, plants, animals or people?" In an audience of physicians usually a little more than a third will tell me that they were under 10 years old when they first realized that making a difference in the suffering mattered to them. Another third would be between 10 and 15. I think this may be what "calling" looks like. In the service workshops that I give, I often ask people to tell stories of their earliest memories of responding to the needs of living things. The people telling these stories are internists, surgeons, clinicians, researchers, and teachers. One doctor remembered that when she was small the members of her family used to swat and kill flies. This reduced her to tears, and everyone would laugh. Then her grandmother taught her how to catch the flies in her hands and to take them outside and set them free. This teaching was the bond between herself and her grandmother—that they both felt the same way about life in all of its forms. Another doctor's story also happened when she was very young. She and her mother were walking home, and they saw a mouse that had probably been attacked by a cat. It was still alive but badly hurt. The little girl was devastated and wanted to take the mouse home. The only way her mother persuaded her to leave the mouse was by telling her that the mouse needed peace and quiet in order to get better and get well. And so they had gone home without the mouse. I suspect the mother had thought her daughter would forget about it; but the next day she wanted to go back and see how the mouse was doing. The mother once again said that the mouse needed peace and quiet and time to get well. The next day the girl again asked her mother to go back. And the following day as well. It became apparent to the mother that her young daughter wasn't going to forget about this mouse. So, the day afterwards, a letter was passed under the door of their apartment. It was a letter from the mouse thanking the little girl for her love and concern and telling her that he was all better now. She was maybe four years old at the time, and she kept that letter for many years. One of my favorite stories was told by a doctor who remembers being bathed in a bathtub as a child. She had cut her foot on the rim of the drain because it was sharp. Her mother had told her not to step on the rim because it could hurt her. But she noticed that when her mother pulled the plug, the bath water would circle the rim of the drain. She became very concerned that circling the rim would cause the water pain. So she would be careful to put her washcloth on top of the drain after her mother pulled the plug, so the water would not be hurt. She believes she was about two years old at the time. These are all early stories of compassion. The heart is the seat of compassion, and compassion exists in very young children. Many of them carry this forward into a career that is characterized by science and technology but is not driven by science and technology. It's driven by the heart. Q: You talk with many different doctors around the country who are trained in many different specialties. The students that you work with in The Healer's Art and other programs probably have a different perspective from the doctors who are older and have been in practice for a long time. What, if any, are the differences in perspective about service? The Healer's Art is now being taught in 46 medical schools nationwide, and by the end of 2006 we expect it to be taught in 52 or more of America's 120 medical schools. These young first- and second-year medical students have a deep sense of service and the meaning of this work. I sometimes think that meaning varies inversely with expertise. As we become caught up in the details of our work, we may come to see our service as identical with our expertise. We can become more distant from the meaning of the work and the intent that brought us into the work in the first place. The Healer's Art course doesn't actually "teach" anything. It is a discovery model of education, a very experiential curriculum. It is contemplative and reflective. And it allows the student to engage with their own concept of professionalism; to determine for themselves what a good doctor is and what their image of their professional role is. We recently gathered up the evaluations of the 700 students who took the nationwide course in 2004. The interesting thing is that the responses to such questions as "What did you learn about medicine in this course?" are pretty much the same no matter what school they come from. The Harvard students responded in much the same way as students from the University of New Mexico or other schools. The wide range of culture within individual schools didn't seem to have any effect on the responses. A great many students told us the heart played a central role in their choice to become a physician. Let me share some of these responses: "I discovered I'm allowed to feel things and express emotions as a doctor. We're always told to distance ourselves, but allowing ourselves to feel will keep us healthier." These are powerful simple statements by young medical students. I don't think there's a doctor in the United States that in his or her inner secret life does not share these beliefs. But something keeps us from discussing our collective calling: our shared intent to make a difference to other people and our deep heartfelt relationship to the work. This intent goes back to the time before we entered medical school and defines who we are as people. In the writings of Cicero there's a description of the temples of Asclepius, the father of medicine. The temples are in direct lineage to every allopathic medical center. People came to these ancient places to learn medicine, to teach medicine, to be healed or cured from illnesses—very much the way they come to any of our major medical centers today. Cicero tells us that the temples were arranged around a central courtyard, and in this central courtyard stood a statue of Venus, the goddess of love. I pondered this for many years. For a long time, especially with my scientific and technical training, I didn't understand it at all. But now I think it is the essence of our profession. For all its scientific firepower, medicine is not a work of science; medicine is a work of service. And service is a special kind of love. The closer we can come to experiencing this basic intent to serve in our daily professional lives, the stronger we are in standing against external pressures. Service, the deep meaning of our work, defines who we are as individuals and as a profession. It is the foundation of our community. It gives us a place to stand and something to transmit to the young who will follow after us. The loss of the heart in our work puts us at risk of losing the integrity of intent that has allowed our profession to survive over generations and can enable it to survive now. Q: What would you say to a physician who wonders how it is possible to practice heartfelt service in the midst of all of the daily pressures: complications with insurance, overloaded schedules with not enough time with each patient, and seemingly no time to contemplate the meaning of service? Seeing your work through the heart is not time-related. It basically is about seeing familiar things in new ways. Let's say a patient comes in who is in the middle of a challenging chemotherapy: a woman in her late thirties or forties, struggling with breast cancer. You can see her as a task in the adjustment of chemotherapy and management of nausea—but you can also see her in a different way. You might notice that her little daughters are with her, and that they are clean and well-fed and very much loved and happy, despite this powerful, debilitating chemotherapy that their mother is going through. In the blink of an eye, you might see what enables her to endure this difficult treatment or even to choose it; that her will to live is closely related to her deep intent to be there for her children. And so she is able to sustain them despite this enormous physical challenge. You might recognize that not only are you in the presence of a technical problem in the balancing of the chemotherapy, but also in the presence of a hero. It might give you a fuller sense of what you are serving with your expertise—and the privilege that it is to serve people like her. Seeing from the heart does more than just deepen your satisfaction in your work. It gives you a sense of gratitude for the opportunity to do this work, to know people at this depth. Seeing things in this broader way does not take longer than just seeing the lab data. Q: Let me be a devil's advocate for a moment. Is there such a thing as a false sense of service? Someone might form an identity around being a person who serves other people, but it might be a concept instead of something that happens naturally. Our identity is formed around service; but our ego doesn't need to be formed around service. The satisfaction in fulfilling your essential nature, and the strength that it gives you to endure difficulties, cannot be overestimated. I think there is a difference between that and ego gratification. The person who thinks they are better than other people because they are a physician, or the person who feels a sense of arrogance or power over other people because they are a superb surgeon or gifted internist, this is not what I would call service. When the central person in the relationship is the doctor, the relationship is not about service. Service is a relationship between equals, a way of life that has significant meaning to those called into this work. That meaning can sustain them and become their strength. I believe that at depth every physician has the intention to serve and has chosen this profession because of it. When you enable an ego-dominated physician to go deeper, to explore their hidden motivation, it is rare not to discover the wish to make a difference in the lives of others. To the extent we experience fulfillment of that intention in a daily way, we find happiness in this profession. Q: We have been talking about having or developing a sense of service. Are you also really talking about living with a sense of purpose? Well, yes. I've always been fascinated by the literature on near-death experiences, especially the literature that goes back a long way before this concept became part of the culture. In the original interviews of near-death experiences, a number of people reported a realization that there was a purpose to life. The purpose of life was not to become an expert, or to become powerful, or to become wealthy, or even to make a huge contribution to our culture. The purpose of life was to grow in wisdom and learn how to love better. And that is a process. What happens—certainly in the Healer's Art courses—is that young medical students are very close to the intent to serve and are heartfelt. They bring the perspective of the heart into the work. Medical school training, which emphasizes the science and technology, tends to cause them to repress this original impulse, and to believe that their service is their science and their skills and competencies. Then there is a period of time when life teaches you something different. When simply through the experience of caring for and being with many, many people in their struggle with illness and sometimes with death, you discover that you are more than your science; that what you can offer may not only be your medical knowledge. It may be something you learned about life in your garden; or something you learned from your grandmother or grandfather; or something you learned from your own experience of loss and suffering. In offering something beyond your science, you may be able to serve people in ways that your science is incapable of serving them. When I asked one of the students what he had learned in The Healer's Art class, he said he learned that he can heal with his humanity things he could never cure with his science. So recovering the heart of our profession is about recovering the full power of our physicianhood. The suffering of our patients may lie beyond the reach of our science; but never beyond the reach of our caring. Q: How do your CME workshops benefit physicians? Many of the workshops I offer are about reminding people of the perspective of the heart in their profession. It seems to have a powerful impact on what might be called compassion fatigue, or burnout. It also seems to bind people together into a community of service, no matter what their expertise is. Basically, we are a community at the level of intent and calling. There is so much in our work that isolates us from one another. Our training is very isolating, we are habitually competitive, and we find ourselves working with people for years without knowing very much about their motivations and who they are as people. The workshops are really about reminding people why they've come into this work and affirming their purpose in this work, despite all the pressures that are imposed from the outside in contemporary medicine. The workshops enable people to find a sense of professional identity that is stronger and broader and in many ways more powerful than the professional identity they left medical school with. They get a sense that they have belonged to a community of service for most of their lives, a community that is larger than the number of people in the room. Q: You're really talking about lineage, right? Yes, I'm really talking about lineage. Enabling people to explore and discuss the lineage of medicine and to discover that they are a part of a larger community of compassion that spans nations and endures throughout time. I believe that the lineage of medicine is essentially a lineage of the heart. ##### Ms. Tucker, a former talk-show host and announcer for KGO Radio and TV, produces educational video and audio projects. Her special interest is medical education.
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