Rachel Naomi Remen, MD, is co-founder and medical director of the Commonweal Cancer Help Program and founder and director of the Institute for the Study of Health and Illness (ISHI) at Commonweal. ISHI is a training institute for health professionals who wish to serve people with life threatening illness and take a more relationship-centered approach to the practice and teaching of medicine. The institute's approach is based upon experience with over 600 people with cancer who have participated in Commonweal's programs and on Dr. Remen's 20-year experience counselling people with cancer and those who love them.
In addition to being a physician for 30 years, Dr Remen has been a patient of the medical system for 40 years. She has Crohn's disease and has had major surgery seven times.
This article is an edited version of Dr. Remen's August 1993 keynote address to the 25th Convocation of the Association for Transpersonal Psychology.
Years ago, I was at a workshop with mythologist Joseph Campbell, and he was showing us pictures of the sacred. He showed us this wonderful bronze statue of the god Shiva, dancing. Inside a ring of flame the god was dancing. He had one foot in the air, and the other foot resting on the back of a little man, who was crouched down in the dust, giving his full, absorbed attention to something he was holding between his hands. I asked Joseph Campbell, "What is that? What is that little guy doing down there?" Campbell said, "That's a little man who is so caught up in the study of the material world that he does not notice that the living god is dancing on his back."
That little man is a health professional. That little man is the whole health care system. Our medical system has become overly focused on the body and the state of the body, but we are not our bodies. We have bodies, but we are not our bodies.
We need to heal the wound inflicted on us and our culture by Descartes - the mind-body split. But this wound goes much deeper; it's also a split between the sacred and the secular. The split between the sacred and the secular is the illusion that continues to permeate our society. It alters our thinking and causes us to ask the wrong questions, and when we ask the wrong questions, our solutions don't serve us.
During the first lecture in the medical school course I'm directing at the University of California-San Francisco, one of the physician graduates of the Institute for the Study of Health and Illness (ISHI) told the class this story from his own life:
His mother had nursed his father for 10 years while his father deteriorated into Alzheimer's disease. His father's brain had died but his body still walked around and ate, and it was fed, clothed, and cared for by his mother. His speech deteriorated and for five years of his life, he was not able to speak.
His mother was eventually persuaded to get some help. One day, when she had gone shopping, her husband had a massive heart attack and fell to the floor in the living room. The caretakers rushed to his side and one said to the other, "Call 911!" But before this could happen a voice said, "Don't call 911. Tell my wife that I am all right. Tell her I love her." And his father died. Looking intently at the medical students, this doctor said to them, "I challenge you to the question: Who spoke? Without wondering about this question, you can be a doctor to disease but not to human beings."
The recovery of the soul may depend not on having the right answers but on asking the right questions and carrying them with us for our whole lives. The medical system may need to relinquish a single-minded quest for mastery and allow for the presence of mystery. "Who spoke?" indeed.
What does it mean to a physician to practice medicine without mystery? When I was a medical student, my school had a large, black-tie retirement dinner for a very famous man on the medical faculty, whose scientific contribution had earned him a Nobel prize. He was 80 years old. The entire school gathered to honor him, and famous medical people came from all over the world.
This doctor gave a wonderful speech describing the progress of scientific knowledge during the 50 years that he had been a physician. We gave him a standing ovation.
After we sat down he remained at the podium. There was a brief silence and then he said, "There's something else important that I want to say. And I especially want to tell the students. I have been a physician for 50 years and I don't know anything more about life now than I did at the beginning. I am no wiser. It slipped through my fingers."
We were stunned into silence. I remember thinking that perhaps he was senile. In retrospect, it was a very remarkable thing he did. He took an opportunity to warn us about the cage of ideas and roles and self-expectations that was closing around us, even as he spoke to us - the cage that would keep us from achieving our good purpose, which is healing. Healing is a matter of wisdom, not of scientific knowledge.
So, what is the task of the medical system? Our modern view of disease is that disease is centered in the body. The older view of disease is that it is soul loss, a loss of connection, of meaning, of purpose, of essence. If this is so, the real task of the medical system is to heal soul loss, to aid in the retrieval of the soul. The entire culture is ill with soul loss.
What is needed is not to bring spirit into our work, to develop more of a spiritual practice or to go to church more. Our task is to recognize that we are always on sacred ground, that there is no split between the sacred and secular. That the living god is dancing on our back. That there is no task that is not sacred in nature and no relationship that is not sacred in nature. Life is a spiritual practice. Health care, which serves life, is a spiritual practice.
Disease is a spiritual path, too. Much illness is caused by the loss of the soul. Many, many people live lives that are empty. This emptiness is caused, in some part, by living without meaning, or with meaning that is much too small, too trivial, or too material for the needs of a human being.
How did we lose the soul? What happened, I think, is that we entered into a culture that devalued the yin, or the feminine principle. We lost a way of seeing. Yeats says this wonderful thing: "The voyage of discovery lies not in seeking new vistas but in having new eyes."
The yin is a way of seeing, a way of understanding the world, a way of formulating solutions, and a very powerful way of acting. Access to sacred experience requires us to reclaim our feminine capacity, to value the subjective, the intuitive, the qualitative, to not limit our focus to the surfaces of things.
We all know the power of the masculine principle, especially in health care. There are many people who would have died long before today without the powerful, life-saving interventions of masculine-principle oriented medicine. I am one of them. So it is not about throwing away the masculine principle; it is about reclaiming wholeness, integrity.
What does it mean to perceive subjectively as well as objectively? When I started the poetry writing workshops with people with cancer, I was amazed that a poem came to me because I don't think of myself as a poet. My poem goes like this:
for 35 years
1,573 experts with
14,372 combined years of training
Reclaiming the sacred requires this kind of a double vision - the cultivation of a double vision that experiences the objective and the subjective worlds simultaneously.
The imbalance in the medical system, the emphasis on masculine-principle approaches and perceptions that pervades our entire culture, diminishes everybody. It diminishes the people who work within the system, and it diminishes the people who seek out the system for their healing. When you leave the doctor's office you may feel diminished, even though you have been given the right diagnosis and the right pills. Think of the masculine symbol, the circle with the arrow on one side. If someone relates to you in a predominantly masculine-principle style, you experience their strength, their capacity. You get rescued, as it were, and you feel smaller.
What is it like, then, to relate to someone who is relating to you in a predominantly feminine-principle style? Think of the feminine symbol, the circle with the "plus" under it. This symbol is called Venus's mirror. When someone relates to you from the feminine side of themselves, what you see reflected in Venus's mirror is your own strength, your own capacity, your own uniqueness. What would the medical system be like if it could do that for us, as well as providing the right diagnosis, the right pills?
The yin is about comfort in the world of relationship, the world of connection, the interdependence of things. We have had a disease-centered medical care. We have moved to a more patient-centered form of care. What we need is a medicine based on right relationship.
What we have now is a medicine of isolation. The shadow side of the yang, or masculine principle, is isolation. We have actually institutionalized isolation in medicine. We even have a language that nobody can understand. There is no reason why true things cannot be said in little words.
What does it look like when you start healing professional isolation?
At the end of our ISHI curriculum workshop at Commonweal we do a healing circle, a ritual we also do with people with cancer. The first time we did this, the eight doctors, all men, were sitting in a circle with their eyes closed. I have a little Zen gong, and when I strike the gong, the man to my left says his name aloud. The others then meditate on this man, pray for him, dream his dream with him, hope for his well being, believe in him, all in total silence, of course, for about two minutes. When I strike the gong again, the next man says his name aloud and everybody meditates on him for two minutes. And we go around the entire group this way.
Just before the end of this exercise, I opened my eyes and saw that some of the men were crying. At the end I asked about this, and one physician said, "I have never been wished well by another doctor before." The others just nodded. Medicine is a culture of competition, independence, isolation.
What we are building at ISHI is a healing community, physicians who are in relationship to each other in a way that is healing so that they can endure the difficult work of being a health professional without burning out, people who know about healing through personal experience. The yang cures. The yin heals.
At the close of each workshop we ask, "What did you learn? What are you taking home with you?" A cancer specialist said, "I just realized that I was numb. I was so numb that I didn't know that I was numb. Here, for the first time, I have found silence - silence in the woods, silence in the yoga. I didn't know I needed silence, I didn't know how to get silence, so I made myself numb instead." This man might have been talking for the entire culture. All of us are numb because we do not allow silence. Silence is a quality of the yin.
Because the medical system does not yet understand the full range of human needs it wounds people - both doctors and patients. It does not recognize the full range of human strengths, either. What is needed for the healing of the medical system is what is needed for the healing of the culture. Because we are wounded in the same way as our institutions, when you are trained by an institution your wounds increase. In our training we are actually rewarded for our woundedness and punished for our wholeness. Medical training at the moment is like a disease. We have to recover from it, and many people never do. I am a recovering physician.
The medical system does not trust process. The whole concept of "fixing" and "broken" suggests an insensitivity to the process nature of the world. The essential word of process is "yet." "Yet" is seeing with feminine eyes. We are all "works in process." That means that judgment is really inappropriate, or premature, because none of us are finished ... yet.
When I began to be interested in the spiritual, I remember literally praying that I could stop seeing people's faults so that I could release myself from my habit of critical judgment. I still see what I saw then, but I now recognize that what I am seeing is not deficit but the growing edge in every human being. I am seeing the "yet," the place where God is present, the place where the work happens.
Our medical system needs to see human beings as a process. Moreover, it needs to recognize that human process is purposeful. It is a process that involves movement toward greater meaning. People who report near-death experiences also report an ineffable knowing about the purpose of life. According to these reports, the purpose of life is to grow in wisdom and to learn how to love better. It is so simple and general a purpose that we are each free to find our own way to do it. To more fully serve life, medicine needs to help people to grow in wisdom and to learn to love better.
The challenge for us is to shift from being the fixers of the broken to the holders of the "yet" for people who have lost sight of the "yet" and those who do not believe in it. A stanza from a poem written by psychologist Dorian Ross, PhD, after her surgery supports the power of this position.
Mother bathing me each morning
with hospital rough washclothes
but with such tenderness and wish
for warm water
that my skin did not hurt, it moved
out towards her,
recognizing at last its own
a trust that went deeper than peril,
her force becoming mine
but in surprising ways . . .
It was the cream she put under my eyes
believing that there would be a time
again that I would
care about beauty
believing in this body when I could not.
One of the most powerful things we do at the end of the five-workshop ISHI curriculum is ask doctors who have practiced for 20 or 30 years to write a poem that captures for them the meaning of their work. What these physicians are really doing is rewriting the Hippocratic Oath, each one recovering the sacred in his or her own way.
Here is such a poem written by Vivekan Don Flint, coordinator of ISHI, and myself.
ON THE INSTITUTE
In a place of stillness,
the one who thinks
hears the whisper of the heart.
In a place of trust,
the one who cures,
In a place of acceptance,
into a butterfly
Is there a way to practice medicine, such that we are grateful for the opportunity to practice medicine? Is there a way to practice life, such that we are grateful for the opportunity to practice life? So that at the end of many years of such practice, we might feel that we had been privileged and had not let the opportunity slip through our fingers? The healing of a system and the healing of the world happens one heart at a time.