- Email: [email protected]
Where all the ladders start
Perspectives
The art of medicine Where all the ladders start
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Last year on a visit to my family home in Boston, I was sitting in the kitchen on one of those warm, mid-fall afternoons when you almost feel like you’re back in summer until the sun begins to set at six o’clock. While I was sitting there looking at my laptop, my mother received an email from the wife of a man I have known for many years. In the email, she wrote that she didn’t really know what to say except her husband was an alcoholic, and he was in the hospital, and she was getting a divorce, and that neither she nor he could find a way to tell me this directly. Her husband was in his late fifties when we met. He had been a kind of teacher and friend during those years and the ones that followed. In one way I had been for him, I think, a younger version of himself, both similar and different enough to be what he needed at the beginning of the third act of a colourful, but difficult and lonely life. His marriage some years later was part of this new beginning; a symbol of a life he often told me he had never thought was possible for him. For her, it was her second marriage and a new beginning too. Her email was sad but delicate
William Butler Yeats (left) and T S Eliot (right) at a luncheon given by Kenneth Ballard Murdock in c 1925
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and generous towards her husband, and my mother cried a little reading it to me, but I think, for both of us, most affecting was the fact that this email or something like it was not unexpected. I thought about him on the train ride back to Baltimore that night and during the next few days of medical school, which happened to be devoted to substance use diagnosis, counselling, and treatment. As I listened to lectures on screening questions and definitions of substance use and dependency I thought about the beers we had one night at a baseball game, and then the drinks he refused in later years around the time I noticed all the alcohol had been taken from his house. In small groups at school we talked about the differences between pre-contemplation and contemplation phases, but I was mostly remembering the days when my friend had been sick, and the days afterwards when nobody talked about it. He and I never talked about his drinking, and he kept many other aspects of his life, both past and present, close to his chest. Our best conversations were always about literature, and, in a way, it was then that we were closest. He had most of William Shakespeare’s sonnets memorised, but his true love was American fiction and he could talk about Herman Melville, William Faulkner, F Scott Fitzgerald, and Flannery O’Conner for hours. But he shared my enthusiasm for William Butler Yeats and T S Eliot as well. Few people, I think, can fail to be moved by the hard-won final assertion of Eliot’s “Little Gidding” that “We shall not cease from exploration / And the end of all our exploring / Will be to arrive where we started / And know the place for the first time.” My friend was no exception. Still, whatever tranquillity he discovered later in life, there remained an undercurrent of sadness and inner turmoil, and I could often see some similarity to the tortured, ageing Yeats who, taking stock of a life both full and wasted in “The Circus Animals’ Desertion”, still felt the need for reinvention when he wrote “Now that my ladder’s gone / I must lie down where all the ladders start / In the foul rag and bone shop of the heart.” In medical school there is a lot of talk about understanding alcohol and drug addiction. We are even given explicit examples of “empathic statements” and instructed exactly when in a conversation with a patient to use them; hours are spent in small groups practising interview techniques with detailed templates for reference. Talking to friends at other medical schools, this approach seems to be fairly widespread, but despite good intentions it still feels like something is missing. On the one hand, it goes without saying that, once identified, standardised best practices should be learned, practised, and implemented wherever www.thelancet.com Vol 379 March 31, 2012
Perspectives
possible. On the other hand, the more standardised and choreographed these interactions become, the more it feels like I am inadvertently emphasising the distance between myself and the patient. It is a tricky matter, though, and what is intellectually or even emotionally satisfying may or may not be what is, in a practical way, best for the greatest number of people. Nonetheless, I think it safe to say that true empathy on the part of health-care providers is categorically a good thing for those being treated, the cultivation of which requires introspection and selfknowledge as well as appreciation for the complexities and subtleties of other people. One of the most compelling moments during our 3-day unit on substance use was when, towards the end, a couple of recovering heroin addicts talked to the class for an hour or so. I remember the younger of the two men speaking about the many different places he had lived while trying, all at the same time, to find heroin to get him through the day, evade drug dealers who were after him, and kick the addiction that was destroying his life. It didn’t matter though, he said, because “no matter where I went, I was still myself”. The power of this observation springs from the universality of the feeling it describes. For who doesn’t know what it’s like to expect an external change to be transformative only to find afterwards that some things inside you stay the same? I remember once, when I was about 10 years old, the only thing I wanted for Christmas was a fishing rod. I got my wish, and the very first thing I did after unwrapping my present was to take the tip of the rod and snap it in half, which I justified after a period of tearful guilt and anger as testing the strength of which the packaging boasted. Another patient told us about looking at a glass of bourbon and telling himself “this is bad for my health, this is bad for my job, and this is bad for the people I love”, right before he would knock it back. I didn’t really know what alcohol was when I was 10, but even then I already knew a thing or two about self-sabotage. Luckily, most of us will never know what it is like to drink away the life we always told ourselves we wanted. But everyone knows what it is like to get what you want and still not feel completely satisfied. This is not to suggest that only medical students or doctors who feel identical inner torment can have a meaningful understanding of addiction. There are, of course, differences in physiology and environment that preclude any exact alignment of experience, but you don’t have to shoot heroin twice a day or drink a half-pint of vodka at breakfast to understand in a personal way some of the feelings that drive that behaviour. As far as we know, Samuel Johnson was not an alcoholic, but because he saw the problem as a manifestation of an essentially human predicament, he took almost personal offence at the disparagement of those who drank too much. In one of his Idler essays he wrote: www.thelancet.com Vol 379 March 31, 2012
Such is our desire of abstraction from ourselves, that very few are satisfied with the quantity of stupefaction which the needs of the body force upon the mind. Alexander himself added intemperance to sleep, and solaced with the fumes of wine the sovereignty of the world. And almost every man has some art, by which he steals his thoughts away from his present state.
You don’t have to be an addict to understand some basic elements of addiction that seem to grow from our common lot as human beings. This is far from an original thought, but I think it bears repeating since, sometimes, things that go without saying have a tendency to be forgotten. In a way, I found the neurobiological elements of the addiction unit some of the most humane. I was most struck by how much the hard science illuminates similarities and the implications those structural and biochemical similarities have for shared experience. Dopamine is not all there is to happiness, but it certainly has something to do with it. Everyone knows first hand the desirable effects of dopamine, and if you smoke crack cocaine your brain gets a lot of it. And who has not, at some point, sacrificed the demands of foresight for immediate but momentary happiness? So while most of us will not personally experience the constellation of external factors and internal attributes necessary for crack addiction, perhaps we know a little more about it than we think, or act like we do. The same goes for any psychiatric disorder, which Robert Sapolsky puts so eloquently, writing, “When science teaches us repeatedly that there but for the grace of God go I, when we learn to recognize kinship in neurochemistry, we will have to become compassionate and tolerant, whether looking at an illness, a quirk, or a mere difference.” It has been a while now since the sunny October afternoon when my mother read me that email in the kitchen, and I haven’t talked to my friend since I heard the news. I think the next move in this situation is mine, but, for now, I’m going to let the dust settle a bit, or at least that’s what I’ll tell myself. He’s still in Boston, I assume, and I’m down here in Baltimore, and life, as always, is like the ocean that touches both, unchanged in many ways, and, in many ways, constantly changing. I don’t know what we’ll say when the time does come for us to talk, but whatever it is, somewhere inside us both Yeats will be asking “why is life a perpetual preparation for something that never happens?” and, at the same time, somewhere else, Eliot will say “[we] are only undefeated / Because we have gone on trying”.
Caleb Gardner Johns Hopkins University School of Medicine, Baltimore, MD 21205–2196, USA [email protected]
Further reading Eliot TS. Four quartets. New York: Harcourt, 1943 Johnson S. Rasselas, poems, and selected prose. New York: Holt, Rinehart, and Winston, 1961 Sapolsky R. The trouble with testosterone. New York: Simon and Schuster, 1997 Yeats WB. The collected poems of W. B. Yeats. New York: Simon and Schuster, 1996
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The art of medicine Where all the ladders start
Getty Images
Last year on a visit to my family home in Boston, I was sitting in the kitchen on one of those warm, mid-fall afternoons when you almost feel like you’re back in summer until the sun begins to set at six o’clock. While I was sitting there looking at my laptop, my mother received an email from the wife of a man I have known for many years. In the email, she wrote that she didn’t really know what to say except her husband was an alcoholic, and he was in the hospital, and she was getting a divorce, and that neither she nor he could find a way to tell me this directly. Her husband was in his late fifties when we met. He had been a kind of teacher and friend during those years and the ones that followed. In one way I had been for him, I think, a younger version of himself, both similar and different enough to be what he needed at the beginning of the third act of a colourful, but difficult and lonely life. His marriage some years later was part of this new beginning; a symbol of a life he often told me he had never thought was possible for him. For her, it was her second marriage and a new beginning too. Her email was sad but delicate
William Butler Yeats (left) and T S Eliot (right) at a luncheon given by Kenneth Ballard Murdock in c 1925
1190
and generous towards her husband, and my mother cried a little reading it to me, but I think, for both of us, most affecting was the fact that this email or something like it was not unexpected. I thought about him on the train ride back to Baltimore that night and during the next few days of medical school, which happened to be devoted to substance use diagnosis, counselling, and treatment. As I listened to lectures on screening questions and definitions of substance use and dependency I thought about the beers we had one night at a baseball game, and then the drinks he refused in later years around the time I noticed all the alcohol had been taken from his house. In small groups at school we talked about the differences between pre-contemplation and contemplation phases, but I was mostly remembering the days when my friend had been sick, and the days afterwards when nobody talked about it. He and I never talked about his drinking, and he kept many other aspects of his life, both past and present, close to his chest. Our best conversations were always about literature, and, in a way, it was then that we were closest. He had most of William Shakespeare’s sonnets memorised, but his true love was American fiction and he could talk about Herman Melville, William Faulkner, F Scott Fitzgerald, and Flannery O’Conner for hours. But he shared my enthusiasm for William Butler Yeats and T S Eliot as well. Few people, I think, can fail to be moved by the hard-won final assertion of Eliot’s “Little Gidding” that “We shall not cease from exploration / And the end of all our exploring / Will be to arrive where we started / And know the place for the first time.” My friend was no exception. Still, whatever tranquillity he discovered later in life, there remained an undercurrent of sadness and inner turmoil, and I could often see some similarity to the tortured, ageing Yeats who, taking stock of a life both full and wasted in “The Circus Animals’ Desertion”, still felt the need for reinvention when he wrote “Now that my ladder’s gone / I must lie down where all the ladders start / In the foul rag and bone shop of the heart.” In medical school there is a lot of talk about understanding alcohol and drug addiction. We are even given explicit examples of “empathic statements” and instructed exactly when in a conversation with a patient to use them; hours are spent in small groups practising interview techniques with detailed templates for reference. Talking to friends at other medical schools, this approach seems to be fairly widespread, but despite good intentions it still feels like something is missing. On the one hand, it goes without saying that, once identified, standardised best practices should be learned, practised, and implemented wherever www.thelancet.com Vol 379 March 31, 2012
Perspectives
possible. On the other hand, the more standardised and choreographed these interactions become, the more it feels like I am inadvertently emphasising the distance between myself and the patient. It is a tricky matter, though, and what is intellectually or even emotionally satisfying may or may not be what is, in a practical way, best for the greatest number of people. Nonetheless, I think it safe to say that true empathy on the part of health-care providers is categorically a good thing for those being treated, the cultivation of which requires introspection and selfknowledge as well as appreciation for the complexities and subtleties of other people. One of the most compelling moments during our 3-day unit on substance use was when, towards the end, a couple of recovering heroin addicts talked to the class for an hour or so. I remember the younger of the two men speaking about the many different places he had lived while trying, all at the same time, to find heroin to get him through the day, evade drug dealers who were after him, and kick the addiction that was destroying his life. It didn’t matter though, he said, because “no matter where I went, I was still myself”. The power of this observation springs from the universality of the feeling it describes. For who doesn’t know what it’s like to expect an external change to be transformative only to find afterwards that some things inside you stay the same? I remember once, when I was about 10 years old, the only thing I wanted for Christmas was a fishing rod. I got my wish, and the very first thing I did after unwrapping my present was to take the tip of the rod and snap it in half, which I justified after a period of tearful guilt and anger as testing the strength of which the packaging boasted. Another patient told us about looking at a glass of bourbon and telling himself “this is bad for my health, this is bad for my job, and this is bad for the people I love”, right before he would knock it back. I didn’t really know what alcohol was when I was 10, but even then I already knew a thing or two about self-sabotage. Luckily, most of us will never know what it is like to drink away the life we always told ourselves we wanted. But everyone knows what it is like to get what you want and still not feel completely satisfied. This is not to suggest that only medical students or doctors who feel identical inner torment can have a meaningful understanding of addiction. There are, of course, differences in physiology and environment that preclude any exact alignment of experience, but you don’t have to shoot heroin twice a day or drink a half-pint of vodka at breakfast to understand in a personal way some of the feelings that drive that behaviour. As far as we know, Samuel Johnson was not an alcoholic, but because he saw the problem as a manifestation of an essentially human predicament, he took almost personal offence at the disparagement of those who drank too much. In one of his Idler essays he wrote: www.thelancet.com Vol 379 March 31, 2012
Such is our desire of abstraction from ourselves, that very few are satisfied with the quantity of stupefaction which the needs of the body force upon the mind. Alexander himself added intemperance to sleep, and solaced with the fumes of wine the sovereignty of the world. And almost every man has some art, by which he steals his thoughts away from his present state.
You don’t have to be an addict to understand some basic elements of addiction that seem to grow from our common lot as human beings. This is far from an original thought, but I think it bears repeating since, sometimes, things that go without saying have a tendency to be forgotten. In a way, I found the neurobiological elements of the addiction unit some of the most humane. I was most struck by how much the hard science illuminates similarities and the implications those structural and biochemical similarities have for shared experience. Dopamine is not all there is to happiness, but it certainly has something to do with it. Everyone knows first hand the desirable effects of dopamine, and if you smoke crack cocaine your brain gets a lot of it. And who has not, at some point, sacrificed the demands of foresight for immediate but momentary happiness? So while most of us will not personally experience the constellation of external factors and internal attributes necessary for crack addiction, perhaps we know a little more about it than we think, or act like we do. The same goes for any psychiatric disorder, which Robert Sapolsky puts so eloquently, writing, “When science teaches us repeatedly that there but for the grace of God go I, when we learn to recognize kinship in neurochemistry, we will have to become compassionate and tolerant, whether looking at an illness, a quirk, or a mere difference.” It has been a while now since the sunny October afternoon when my mother read me that email in the kitchen, and I haven’t talked to my friend since I heard the news. I think the next move in this situation is mine, but, for now, I’m going to let the dust settle a bit, or at least that’s what I’ll tell myself. He’s still in Boston, I assume, and I’m down here in Baltimore, and life, as always, is like the ocean that touches both, unchanged in many ways, and, in many ways, constantly changing. I don’t know what we’ll say when the time does come for us to talk, but whatever it is, somewhere inside us both Yeats will be asking “why is life a perpetual preparation for something that never happens?” and, at the same time, somewhere else, Eliot will say “[we] are only undefeated / Because we have gone on trying”.
Caleb Gardner Johns Hopkins University School of Medicine, Baltimore, MD 21205–2196, USA [email protected]
Further reading Eliot TS. Four quartets. New York: Harcourt, 1943 Johnson S. Rasselas, poems, and selected prose. New York: Holt, Rinehart, and Winston, 1961 Sapolsky R. The trouble with testosterone. New York: Simon and Schuster, 1997 Yeats WB. The collected poems of W. B. Yeats. New York: Simon and Schuster, 1996
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