A Case Study in Life Doctoring

A recently bereaved widow, whose husband Harry died from a heart attack, finds herself suffering disturbing chest pains at night and goes to sees her physician. The physician sees her symptoms only as signs of some possible organic disorder which might be ‘causing’ them. He sends her to a consultant to test for possible heart conditions. The tests proving inconclusive, the consultant ends up diagnosing mild angina, and prescribes beta-blocker. These in turn prove to have little effect on the patient’s symptoms.

On visiting her physician a second time however, the latter recalls her recent bereavement and, as a result, begins to read the bodily ‘text’ of her symptoms in a different way, understanding them in the life context of her loss and the pain it may be causing her. Rather than seeking a purely clinical ‘diagnosis’ of the patient’s symptoms he himself listens to his patient in a genuinely patient way. As a result an insight flashes through his mind which he shares with her. He ‘sees’ that she may be suffering from a doubly broken heart: “the one that killed Harry, and the one you’re left alive with, that hurts when you’re most alone in the middle of the night…the broken heart that gave up and the one that has to carry on painfully.” This heartfelt hearing of the patient and the heart-to-heart talk that ensue are the first time anyone has ever acknowledged the pain of her grief. It gives her the strength of heart to acknowledge and bear it in a new way. Her symptoms disappear. The patient’s heart symptoms disappear as bodily symbols and metaphorical signifiers of her pained heart, not through an intellectual understanding of their significance alone but through an memory arising from the feeling heart of the physician.

This paradigmatic case vignette, cited by Dr David Zigmond in an article on different modes of patient-physician communication, goes to the heart of the contrast between biomedical diagnosis and what could be called ‘life diagnosis’.

The root meaning of the term ‘diagnosis’ actually is ‘through knowledge’ (dia-gnosis). Yet the Greek verb, gignostikein, from which the word gnosis (knowledge) derives did not mean merely knowledge of or about something – (for example biomedical knowledge of the body). Instead it denoted the sort of knowing we refer to when we speak of being ‘familiar’ with people, of ‘knowing’ them well or intimately as human beings – in much the way that family doctors used to know or be familiar with their patients, as if a part of their families.

It was this type of ‘knowing’ that the doctor in Zigmond’s case study brought to bear in relating to the widow – not just his standard body of medical knowledge ‘about’ the heart as a biological organ and the type of ‘diagnosis’ to which it can lead. His method consisted simply of having the patience to listen to his patient in a different way – not seeking a diagnosis of a possible heart ‘condition’ but affirming her heartbreak in a heartfelt way. By ‘bearing with’ his patient in this way, helping to bear the burden of her pained heart with her – she no longer felt herself so painfully alone in bearing it – and was able to find a new bearing towards the bereavement that occasioned it.

The paradox that Zigmond notes however, is that despite the inconclusiveness of the initial medical tests, had the physician himself not embodied this new and different bearing towards his patient – had he not heard her in a heartfelt way as a human being but simply treated her as a potential ‘case’ of angina – then the patient herself might well have found herself in the position of having no way to express the heartbreak of her loss except through actual and perhaps increasingly acute cardiac symptoms – using her biological heart as an instrument of what Freud called ‘organ speech’.

The physician’s capacity for a different type of listening – one that did not merely serve as a prelude to some form of purely biomedical diagnosis was therefore ‘preventative medicine’ in the deepest sense. For it may well have forestalled a process whereby this patient might well have ended up either as a genuine ‘heart case’ requiring serious medical intervention. Alternatively, she might have found herself seen as a so-called ‘heart sink’ patient – someone who repeatedly ‘bothers’ her doctor, but whose medical tests continue to reveal no conclusive, measurable signs of any organic disorder or heart disease – thus suggesting some form of malingering. Yet such ‘heart-sink’ patients are not a marginal group. In their persistence, they are simply unconsciously reacting to the absence of a type of listening that most patients actually seek – the type of listening required for ‘life diagnosis’ and ‘life doctoring’.

This one single case described by Zigmond is therefore ‘paradigmatic’ – for in its simplicity it nevertheless reveals in full clarity the sharply opposing frameworks or ‘paradigms’ of Biological Medicine and Life Medicine, Bio-medical Doctoring and Life Doctoring.  Indeed recent research has shown that indeed many older widows die within three years of their bereavement – not due to arterial disease but principally through an enlargement of the heart’s pumping chamber – in other words a (painfully) ‘throbbing heart’.

Zigmond also offers us a study in the very meaning of ‘diagnosis’ as such – showing how different ways of listening to and coming to ‘know’ a patient can themselves have a direct bearing on the patient’s health and medical condition itself. Our biology has its basis in our biography, and in that larger body of awareness that is our life world as a whole. For it is always within the specific contexts of our life world that we experience ‘dis-ease’, just as it is capacities of awareness that allow us to relate to and respond to our life world in a healthy way – with awareness.

Illness can and has been understood in many ways: in a purely objective and biomedical way, as a mechanical, neurophysiological ‘effect’ of psychical stress or trauma, as a relation to our life world and other people in it, as a form of silent bodily communication or even protest, as blocked action or communication, and/or as a metaphorical language through which we give silent bodily expression to any subjectively felt ‘dis-ease’. Understanding illness as a metaphorical language of awareness embraces all other understandings of it. More importantly it provides us with an understanding of illness that affirms its innate meaningfulness in the life of the individual – as an expression and embodiment of their lived experience of themselves and of their life world as a whole, as an expression and embodiment of the degree of awareness they bring to their experience, and as an expression and embodiment too, of the specific capacities or ‘organs’ of awareness that they do or do not exercise in relating and responding to their experienced self and world – for it is these specific capacities that offer new keys to diagnosing illness as a ‘language of awareness’.

Reference:

Dr David Zigmond, Three Types of Encounter in the Healing Arts: Dialogue, Dialectic and Didacticismialogue, Dialectic and Didacticism

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