I was sweating by the end of my speech. Everybody stared at me. The chief resident said nothing. He turned to Tim, and asked when the tests would be scheduled.
Tim said the tests would be scheduled all during the coming week.
The chief resident said, Fine. Go ahead.
And that was that.
We went on to the next patient.
“What do you people think is wrong with me?” Emily said later, when she and I were alone.
“We’re not sure,” I said.
“Nothing is wrong with me,” Emily said. “I feel fine. I don’t want any more tests.”
“I can understand that feeling,” I said.
“Well, then, why do I have to have them? He hurt me,” she said, pointing to her bandaged hip.
I was on dangerous ground now. I had to choose my words carefully. “If you want to leave the hospital,” I said, “no one can stop you.”
“You mean I can just walk out of here?”
“No, you have to be discharged. But if you insist on it, they have to discharge you.”
“They do?”
“They’ll try to talk you out of leaving, but they can’t make you stay.”
“Good,” Emily said. “I’m sick of all you fucking doctors and your fucking tests.”
“Guess who checked out?” Tim said that night in the cafeteria. “Emily.”
“Oh yes?”
“Yeah. Discharged herself against physicians’ advice.”
“When?”
“Tonight. Screaming and swearing, nobody could talk any sense to her. They had to let her go. I think somebody put the idea into her head.”
“Oh, really?”
“Yeah. Somebody talked to her.”
“I wonder who?”
“I think somebody from Accounting. They’re not sure if she’s covered by Medicare, you know, and I think Accounting got nervous about the expense and decided to get her out.” He sighed. “But you wait. She’ll be back in a few weeks, covered in lice, just like before. Crazy old bitch.”
* * *
Two months later, I was walking through the lobby of the outpatient department when I felt a pain in the ribs. Somebody had banged into me. I grunted and kept going.
“Hey! Doctor!”
I stopped and turned. A rather elegant woman stood there, wearing a green cape and a beret set at a rakish angle. She smoked a cigarette from a long ivory holder. She carried a cane in one hand. She was staring at me expectantly.
“Don’t you say hello, Doctor?”
Patients never understand how many people you see, how many faces pass before you, particularly in the outpatient clinic. You may see fifty in an afternoon. “I’m sorry,” I said, “but do I know you?”
She cocked her head, and seemed amused. “Miss Vincent.”
I hadn’t a clue. “Miss Vincent?”
“Emily.”
I stared, still not recognizing her. I tried to dredge up anybody named Emily Vincent. And suddenly it all fell together. Emily! The lady who was lousy on admission!
Seeing her now, her stance, her dress, her manner, I understood. Emily was a bohemian. In the 1920s, she had been one of those rebellious, independent, artsy women. Of course she knew all about artists and writers. Of course she had never married. Of course she swore and smoked and was fiercely independent and advanced. Of course she was contemptuous of the doctors around her. Of course she liked to say shocking and outrageous things. As the years went on, Emily would have been in turn a flapper, then a wartime riveter, then an aging beatnik. Of course she said things like “Daddy-oh.” Emily was a hipster.
“Emily,” I said, “how are you?”
“Quite well, Dottore. You may call me Miss Vincent.”
“You’re coming to the clinic?”
“They say I have a little something with my thyroid, and I take pills,” she said, puffing on her cigarette. “Frankly, I think it’s crap, but my doctor is so handsome, I indulge him.”
“You look wonderful, Miss Vincent,” I said, still trying to adjust to what I was seeing.
“You, too,” she said. “Well, I must be off. Ciao.”
And, with a dramatic wave, she turned, cape flying, and was gone.
Heart Attack!
A major disaster befell the medical wards of the Beth Israel Hospital. All the interns and residents went around shaking their heads. The disaster was that, by some quirk of fate or statistics, two-thirds of the patients on the ward had the same illness. Heart attack.
The residents acted as if all the theaters in town were playing the same movie, and they’d seen it. Furthermore, most of these patients would be here for two weeks, so the movie wasn’t going to change soon. The home staff was gloomy and bored, because, from a medical standpoint, heart attacks aren’t terribly interesting. They are dangerous and life-threatening, and you worry about your patients, because they may die suddenly. But the diagnostic procedures were well worked out, and there were clear methods for following the progress of recovery.
By now I was in my final year of medical school, and I had decided I would quit at the end of the year. So my three months at the Beth Israel were going to be all the internal medicine I would ever learn; I had to make the best of this time.
I decided to learn something about the feelings the patients had about their disease. Because, although doctors were bored by myocardial infarcts, the patients certainly weren’t. The patients were mostly men in their forties and fifties, and the meaning of this illness was clear to them—they were getting older; this was a reminder of their impending mortality; and they would have to change their lives: work habits, diets, perhaps even their pattern of sexual relations.
So there was plenty of interest for me in these patients. But how to approach them?
Some time earlier, I had read about the experiences of a Swiss physician who, in the 1930s, had taken a medical post in the Alps because it allowed him to ski, which was his great passion. Naturally, this doctor ended up treating many skiing accidents. The cause of the accidents interested him, since he was himself a skier. He asked his patients why they had had their accidents, expecting to hear that they had taken a turn too quickly, or hit a patch of rock, or some other skiing explanation. To his surprise, everyone gave a psychological reason for the accident. They were upset about something, they were distracted, and so on. This doctor learned that the bald question “Why did you break your leg?” yielded interesting answers.
So I decided to try that. I went around and asked patients, “Why did you have a heart attack?”
From a medical standpoint, the question was not so nonsensical as it sounded. During the Korean War, post-mortems on young men had shown that the American diet produced advanced arteriosclerosis by the age of seventeen. You had to assume that all these patients had been walking around with severely clogged arteries since they were teenagers. A heart attack could happen any time. Why had they waited twenty or thirty years to develop a heart attack? Why had their heart attack happened this year and not next, this week and not last week?
But my question “Why did you have a heart attack?” also implied that the patients had some choice in the matter, and therefore some control over their disease. I feared they might respond with anger. So I started with the most easygoing patient on the ward, a man in his forties who had had a mild attack.
“Why did you have a heart attack?”
“You really want to know?”
“Yes, I do.”
“I got a promotion. The company wants me to move to Cincinnati. But my wife doesn’t want to go. She has all her family here in Boston, and she doesn’t want to go with me. That’s why.”
He reported this in a completely straightforward manner, without a trace of anger. Encouraged, I asked other patients.
“My wife is talking about leaving me.”
“My daughter wants to marry a Negro man.”
“My son won’t go to law school.”
“I didn’t get the
raise.”
“I want to get a divorce and feel guilty.”
“My wife wants another baby and I don’t think we can afford it.”
No one was ever angry that I had asked the question. On the contrary, most nodded and said, “You know, I’ve been thinking about that.…” And no one ever mentioned the standard medical causes of arteriosclerosis, such as smoking or diet or getting too little exercise.
Now, I hesitated to jump to conclusions. I knew all patients tended to review their lives when they got really sick, and to draw some conclusion about why the illness had happened. Sometimes the explanations seemed pretty irrelevant. I’d seen a cancer patient who blamed her disease on a lifelong fondness for Boston cream pie, and an arthritis patient who blamed his mother-in-law.
On the other hand, it was accepted in a vague way that there was a relationship between mental processes and disease. One clue came from timing of certain illnesses. For example, the traditional season for duodenal ulcers was mid-January, just after the Christmas holidays. No one knew why this should be, but a psychological factor in the timing of the disease seemed likely.
Another clue came from the association of some physical illnesses with a characteristic personality. For example, a significant percentage of patients with ulcerative bowel disease had extremely irritating personalities. Since the disease itself was hard to live with, some doctors wondered if the disease caused the personality. But many suspected that it was the other way around: the personality caused the disease. Or at least whatever caused the bowel disease also caused the personality.
Third, there was a small group of physical diseases that could be successfully treated with psychotherapy. Warts, goiter, and parathyroid disease responded to both surgery and psychotherapy, suggesting that these illnesses might have direct mental causes.
And, finally, it was everybody’s ordinary experience that the minor illnesses in our own lives—colds, sore throats—occurred at times of stress, times when we felt generally weak. This suggested that the ability of the body to resist infection varied with mental attitude.
All this information interested me enormously, but it was pretty fringe stuff in the 1960s in Boston. Curious, yes. Worthy of note, yes. But nothing to pursue in a serious way. The great march of medicine was headed in another direction entirely.
Now, I was getting these data from the heart attack patients. And what I was seeing was that their explanations made sense from the standpoint of the whole organism, as a kind of physical acting-out. These patients were telling me stories of events that had affected their hearts in a metaphorical sense. They were telling me love stories. Sad love stories, which had pained their hearts. Their wives and families and bosses didn’t care for them. Their hearts were attacked.
And pretty soon their hearts were literally attacked. And they experienced physical pain. And that pain, that attack, was going to force a change in their lives, and the lives of those around them. These were men in late middle life, all undergoing a transformation that was signaled by this illness event.
It made almost too much sense.
Finally I brought it up with Herman Gardner. Dr. Gardner was then chief of medicine at the hospital, and a remarkable, extremely thoughtful man. As it happened, he was the attending physician who made rounds with us each day. I said to him that I had been talking with the patients, and I told him their stories.
He listened carefully.
“Yes,” he said. “You know, once I was admitted to the hospital for a slipped disc, and sitting in bed I began to wonder why this had happened to me. And I realized that I had a paper from a colleague that I had to reject, and I didn’t want to face up to it. To postpone it, I got a slipped disc. At the time, I thought it was as good an explanation as any for what had happened to me.”
Here was the chief of medicine himself reporting the same kind of experience. And it opened up all sorts of possibilities. Were psychological factors more important than we were acknowledging? Was it even possible that psychological factors were the most important causes of disease? If so, how far could you push that idea? Could you consider myocardial infarctions to be a brain disease? How would medicine be different if we considered all these people, in all these beds, to be manifesting mental processes through their physical bodies?
Because at the moment we were treating their physical bodies. We acted as if the heart was sick and the brain had nothing to do with it. We treated the heart. Were all these people being treated for the wrong organs?
Such errors were known. For example, some patients with severe abdominal pain actually had glaucoma, a disease of the eye. If you operated on their abdomens, you didn’t cure the disease. But if you treated their eyes, the abdominal pains disappeared.
But to extend that idea more broadly to the brain suggested something quite alarming. It suggested a new conception of medicine, a whole new view of patients and disease.
To take the simplest example, we all believed implicitly the germ theory of disease. Pasteur proposed it one hundred years before, and it had stood the test of time. There were germs—micro-organisms, viruses, parasites—that got into the body and caused infectious disease. That was how it worked.
We all knew that you were more likely to get infected at some times than others, but the basic cause and effect—germs caused disease—was not questioned. To suggest that germs were always out there, a constant factor in the environment, and that the disease process therefore reflected our mental state, was to say something else.
It was to say mental states caused disease.
And if you accepted that concept for infectious disease, where did you draw the line? Did mental states also cause cancer? Did mental states cause heart attacks? Did mental states cause arthritis? What about diseases of old age? Did mental states cause Alzheimer’s? What about children? Did mental states cause leukemia in young children? What about birth defects? Did mental states cause mongolism at birth? If so, whose mental state—the mother’s or the child’s? Or both?
It became clear that at the farther reaches of this idea, you came uncomfortably close to medieval notions that a pregnant woman who suffered a fright would later produce a deformed child. And any consideration of mental states automatically raised the idea of blame. If you caused your illness, weren’t you also to blame? Much medical attention had been devoted to removing ideas of blame from disease. Only a few illnesses, such as alcoholism and other addictions, still had notions of blame attached.
So this idea that mental processes caused disease seemed to have retrogressive aspects. No wonder doctors hesitated to pursue it. I myself backed away from it for many years.
It was Dr. Gardner’s view that both the physical and the mental aspects were important. Even if you imagined the heart attack had a psychological origin, once the cardiac muscle was damaged it needed to be treated as a physical injury. Thus the medical care we were giving was appropriate.
I wasn’t so sure about this. Because, if you imagined that the mental process had injured the heart, then couldn’t the mental process also heal the heart? Shouldn’t we be encouraging people to invoke their inner resources to deal with the injury? We certainly weren’t doing that. We were doing the opposite: we were constantly telling people to lie down, to take it easy, to give over their treatment to us. We were reinforcing the idea that they were helpless and weak, that there was nothing they could do, and they’d better be careful even going to the bathroom because the least strain and—poof!—you were dead. That was how weak you were.
This didn’t seem like a good instruction from an authority figure to a patient’s unconscious mental process. It seemed as if we might actually be delaying the cure by our behavior. But, on the other hand, some patients who refused to listen to their doctors, who jumped out of bed, would die suddenly while having a bowel movement. And who wanted to take responsibility for that?
Many years passed, and I had long since left medicine, before I arrived at a view of disease that seemed
to make sense to me. The view is this:
We cause our diseases. We are directly responsible for any illness that happens to us.
In some cases, we understand this perfectly well. We knew we should have not gotten run-down and caught a cold. In the case of more catastrophic illnesses, the mechanism is not so clear to us. But whether we can see a mechanism or not—whether there is a mechanism or not—it is healthier to assume responsibility for our lives, and for everything that happens to us.
Of course it isn’t helpful to blame ourselves for an illness. That much is clear. (It’s rarely helpful to blame anybody for anything.) But that doesn’t mean we should abdicate all responsibility as well. To give up responsibility for our lives is not healthy.
In other words, given the choice of saying to ourselves, “I am sick but it has nothing to do with me,” or saying, “I am sick because I caused the sickness,” we are better off thinking and behaving as if we did it to ourselves. I believe we are more likely to recover if we take that responsibility.
For one thing, when we take responsibility for a situation, we also take control of it. We are less frightened and more practical. We are better able to focus on what we can do now to ameliorate the illness, and to assist healing.
We also keep the true role of the doctor in better perspective. The doctor is not a miracle worker who can magically save us but, rather, an expert adviser who can assist us in our own recovery. We are better off when we keep that distinction clear.
When I get sick, I go to my doctor like everyone else. A doctor has powerful tools that may help me. Or those tools may hurt me, make me worse. I have to decide. It’s my life. It’s my responsibility.