Some of my encounters with patients are so shocking that they remain etched on my mind as lessons that have altered the way I practice.
It was 1994 and I was still working as a gastroenterologist but training to be a psychotherapist. Therese arrived in my clinic in a wheelchair, her face creased with misery and pain. Breathing heavily and holding her abdomen, she told me that she had been suffering from what she described as a dreadful pain in the pit of her stomach for years. It was associated with some difficulty in defaecation, but the pain was the dominant feature.
She had seen several specialists before pitching up in my clinic. She had had many tests and numerous trials of treatment. None of the tests had revealed any obvious disease or injury. And none of the medications relieved the pain.
I asked if I could examine her. She got up with great difficulty and walked slowly to the couch, bent forwards with her hands clasped over the lower part of her abdomen. She needed my nurse’s help to get her on the couch.
When she was settled, I gently put a hand on her abdomen and it instantly went into spasm. She groaned and turned pale. I did not persist, but just mentioned the obvious.
‘Your stomach is very painful’.
I observed the long scar below the belly button to her pelvis. ‘What was the operation?’ ‘It was a hysterectomy – for fibroids, but the gynaecologist told me everything was alright down there.’
‘When was that?’
‘Eight years ago’.
‘And you’ve had the pain ever since?’
‘So tell me, did anything happen at that time?’ I enquired.
At that, she looked frightened, then put her hands over her eyes and, between sobs, told me that her twin sister had been murdered. My stomach turned over. I felt nauseated and light headed. I sat down on a chair, transfixed, while Therese told me her story.
‘My sister was married to a soldier. They were stationed in Germany. She was seven months pregnant. They had a fight and he kicked her so hard in the stomach that her uterus ruptured and she bled to death. I was in hospital in England, recovering from a hysterectomy. I could not attend the funeral and have never visited her grave in Germany. Her husband was tried and given a jail sentence for manslaughter on the grounds of diminished responsibility. He was discharged from the army, but has now been released from prison and is back in England. He wants to see me.’
Not all illness is accompanied by any definitive pathology: tumour, infection, inflammation or injury. Instead, many unexplained illnesses can be brought on by trauma. They represent the feeling of what happened. Therese’s symptoms made perfect sense when viewed from the perspective of the awful tragedy that befell her twin. Therese had needed to tell her story, She had wanted somebody to understand and validate what her body knew.
When she had finished, I allowed the silence to settle and then asked if I could examine her tummy again. This time, it was soft and she allowed me to gently feel for any lumps or swelling or localised tenderness. I held her hand and let my other hand rest on her tummy for a few minutes while we maintained eye contact and chatted. Then I asked her to move back to her chair. This time she completed the manoeuvre with no obvious discomfort.
It was a start. There had been a therapeutic connection. I saw her for several more times after that. During the first few sessions, I asked to examine her again, and, with my hand resting on her tummy, she talked more about what had happened. She also told me she had met her brother-in-law. ‘He was so upset about it all and so apologetic. I just listened, understood and forgave him. That’s all he wanted. We both agreed to get on with our lives and never meet again.’
Healing is not just a matter of doing the right test and applying the right medicine. It is also a feeling connection between mind and body, often facilitated by the body/mind of another person, who may or may not be a doctor. There is nothing clever about it. It is more about intuition than education. I had no idea how to treat Theresa. I was only guided by what felt right and trusted that gut feeling. It was not even necessary to say anything very much. Listening, eye contact, acknowledgement, posture and a ‘laying on of hands’ is enough to engage a person’s trust and create a healing space where feeling can be transferred, confidence attained and thought facilitated.
Many illnesses, especially those that upset the gut, do not have an obvious cause and do not respond to a specific treatment. They tend to come and go depending on how the patient feels and what is happening in their lives.
Doctors are extensively trained in the ‘knowledge’ of medicine, the aetiology, diagnosis and pharmacology, but they receive little guidance in the skills of healing. How can GPs connect with their patients if they only have 8 minutes per appointment and spend most of it scanning through the test results on their computer screen? Lacking attention and eye contact, offered a diagnosis they don’t understand and prescribed treatments they have no confidence in, patients often complain that ‘my doctor never listens to me’. With nowhere else to go, they invariably return frustrated and in pain to face a similar encounter. Healing requires eye contact, understanding, empathy and some physical touch.
50 years ago, before the advent of ‘tests for everything’, the practice of medicine prioritised the taking of a careful history and physical examination. The examination was not only there to elicit the signs of disease, it was also a means of making a connection with the patient – a laying on of hands. Careful palpation could discern the emotional climate, the temperature and moistness of the skin, the quality of the pulse, muscle tone, tremor or lack of movement. The therapeutic connection with an attentive and unhurried doctor often dispelled anxiety and built trust.
Symptoms are communications. They not only provide clues as to the disease process, they also convey what the illness means for the patient and what they want from the doctor. The patient may not only be ill, they are often frightened, lonely, depressed and frustrated. By attentive listening, acute observation and careful physical examination, a doctor can discern the dread of disability or disfigurement, the threat of unemployment and poverty, the terror of pain, and the fear of death. For the patient, he or she might represent a healer but is also a counsellor, priest, friend or father figure. So, by adjusting their response to match the patient’s expectations, doctors might more readily establish a therapeutic relationship and thereby optimise prognosis.
Unfortunately, there is not enough time within nationalised health services for doctors to represent all of those roles. The patients’ need for more time and health care system’s insistence on cost efficiency leaves their doctors in a cleft stick. They can rarely do more than order another test, write another prescription and, often in desperation, arrange a referral to a counsellor, who may have more time to become engaged.