Mystery and the unknown have been on my mind recently after facilitating one of the final sessions of The Healer’s Art course for first year medical students who have elected to explore the relational, humanistic, emotional, and compassionate aspects of becoming and being a physician. The Healer’s Art course, conceived and developed by Rachel Naomi Remen, M.D., at the Institute for the Study of Health and Illness (www.ishiprograms.org ) is taught at over 70 medical schools in the country and internationally. The course is based on the discovery method and allows students in small groups to explore humanistic and professional values in a safe environment where experiences, feelings, and beliefs are shared. Talking about awe and mystery in medicine and in life are very much a part of this course.
It is difficult sometimes for physicians to accept how much mystery there is in medicine, not only regarding diseases and their diagnosis and treatment, but also in what transpires in the course of an illness and in all the unspoken aspects of the doctor-patient relationship. One of Dr. Remen’s most cogent observations is that we have let science define life, but “..life is larger than science….and science cannot explain everything.” (CD The Will to Live and Other Mysteries by Rachel Remen and Mystery and Death Teleconference on www.rachelremen.com) Despite the astounding advances that have occurred in medical diagnosis and treatment today, much still remains unknown. And in this age of unprecedented technology, the public expects the answers will always be there, even when those answers cannot always be forthcoming. This situation can certainly be frustrating for physicians who prefer to be in command of a medical challenge and control outcomes as much as possible.
I was aware early on of the occasional pitfalls of diagnosing the correct disease in my rheumatology patients. Sometimes, when seeing a new patient with arthritis or collagen disease type of symptoms, I could tell by the third sentence of a patient’s history what the diagnosis was. I still made sure that I ruled out other possibilities, but the diagnosis choice emerging from the patient’s symptoms was very clear. There were other times I could listen to the patient for 30-45 minutes and still not know what disease the patient had; the clinical picture just wasn’t clear. In addition, sometimes in rheumatology there could be overlapping symptoms from different diseases in the same patient, and one couldn’t be sure just what diagnosis the patient had. Thus, it was a clear experience of the mystery of diagnosis and not knowing.
In my early years of practice, this situation seemed like a threat, where my expertise was called into question, but as I went along and gathered more experience, I became more comfortable with not knowing when it came to a diagnosis. In time, I could more easily say to the patient, “I don’t know at this time, but here are some possibilities to consider.” I gradually became more comfortable with the mystery and uncertainty. I dealt with the insecurity of not knowing by reassuring the patient that tests would be done, some generalized treatment could be started in the meantime, and that the actual diagnosis would most likely be clearer with time and the evolution of the disease and its symptoms. And that is what usually happened.
But if anyone had told me that I must “embrace the mystery” of this predicament, I would have looked askance at the person making such a suggestion. It can remain difficult for a physician to say, “I don’t know” to a patient. Of course, reassurance should be given that all efforts will be made to find an answer. But if a patient has put you on the pedestal of “all knowingness,” it may be challenging to admit you’ll have to look for answers. Most of the time the answers do eventually become evident, but accepting the mystery in the meantime can be difficult.
Yet, admitting that you don’t know is the first step to take before you can solve the problem. It would be unprofessional to tell patients they had a certain diagnosis, when you weren’t sure they absolutely did. That’s not a good way to navigate the sea of uncertainty. It can mislead the patient and also keep the physician from asking further questions that might lead to an answer. I have always been amazed at how difficult it is sometimes for students, residents, or practicing physicians to ask questions about things they don’t understand during a conference or lecture. I realized relatively early that if I failed to admit that I didn’t know something by asking a question, even if the answer was painfully obvious, I would never learn. But I also found it very amusing when people would come up to me after a conference or lecture and thank me for asking the question, because they were too embarrassed to ask the same question themselves.
The discomfort physicians may feel whenever confronted with uncertainty is astutely assessed by Rachel Remen when she says, “As physicians, we are trained to treat uncertainty aggressively, as if an emergency. The unknown is the enemy.” (Mystery and Death Teleconference on www.rachelremen.com ) I think Dr. Remen may be referring to the times when events happen in medicine that cannot be fully or easily explained. Examples are patients with life-threatening cancer who have spontaneous remissions; patients with other serious terminal illnesses who surprisingly survive; patients who seem to be doing well and then deteriorate without any specific cause that can be found despite intense medical investigation; patients who have been uncommunicative in a coma for weeks who suddenly talk right before they die; dying patients who are waiting days to see a relative and then die soon after the relative gets to the bedside; patients who die the minute an attentive relative or friend temporarily leaves the room after a previous long bedside vigil. The examples are many. And answers are not always forthcoming. But that’s the time when the not knowing and the mystery can be embraced. Dr. Remen feels that moments of mystery can open up the chance for possibilities and hope. Part of our humanity is not always being sure of the answers.
I once participated in a summer workshop with Animas Valley Institute (www.animas.org) where I had to spend some time deep in the forest at the foot of the Berkshire Mountains during the night. The intent was to explore what your soul’s purpose really was while immersing yourself in the mystery of the darkness. At dusk I went out to the spot I had chosen off the trail in the woods. Once it got dark, the moon, which was almost full, came out intermittently, but I still couldn’t see much around me. I understood more than ever before how “deafening” the silence could be. There were moments of choruses from the night birds, but I had a real sense of stillness. We had had a previous discussion with our group leaders about giving oneself over to mystery, both deep inside us and around us, so that subject was very much in my thoughts. While lying on a tarp on the forest floor, I suddenly realized I had no idea of what was around me – deer, squirrels, foxes? I first was frightened, mainly because I didn’t know. But then remembering our group’s earlier discussion, I decided to give myself over to the mystery and see how it felt. “How does it feel not to know?” I asked myself. And lying there for a while pondering that question, I suddenly felt exhilarated. Not knowing was not so bad; in fact, it was exciting. I had never before experienced such a reaction, actually such a rush, to being uncertain. The experience was actually transforming. I had never previously experienced the pure joy of not knowing.
I got my things together and decided to go back to the lodge where the group was staying. It was then I realized I couldn’t find the trail and was completely lost. Mystery again! There was a moment of sheer panic being deep in the extensive woods in the middle of the night and having no idea where I was. The fear was soon assuaged by the realization I could always sleep out in the woods for the night and find my way back in the early morning light. But I decided to try to do that in the darkness. After a period of exploring through the uncleared terrain with a flashlight, I found one of the trails, but still wasn’t sure where I was. With the aid of a trail map and a bit of pondering as to what trail I had stumbled on and what trails I needed to get to, I made it back to the lodge. But while I was walking through those dark woods, for a while not really sure where I was going, I gave myself over to the mystery of the experience again. The joy of the uncertainty and the unexpected thrill of being lost filled me up again. It had taken ten minutes to get out at dusk to my chosen spot in the woods and forty-five minutes to get back with only the flashlight guiding me through the darkness. But the four hours I spent in the dark, deep woods, allowing myself to get comfortable with the unknown made an indelible impression on me. I had been very far removed from the exacting world of medicine and science, but the experience of mystery had opened me up to myself, my surroundings, and the real beauty of being human and not always knowing.
Donald M. Friedman, M.D.
Spirituality and Healthcare