Annals of Behavioral Science and Medical Education 2012, Vol. 18, No. 1, 49–51

©2012 by the Association for the Behavioral Sciences and Medical Education 1075–1211/12

Reflections Sandra L. Bertman, Ph.D. Section Editor Section Editor’s Note: The Reflections section introduces resources and techniques not only for use in clinical and academic settings, but for personal renewal. Please continue to submit any of the following: (1) your own cannon (see template*at the end of the Reflections section or from Annals 2010, Vol. 16, No. 2,47,48) (2) an exercise you have found successful, and, of course, (3) original works including submissions such as essays, poems, stories, humor, timely reviews, and visual art (300pi, 4x6) with commentary relating to the humanities, behavioral medicine, or health care. Charles Sasser, MD, FACP FAAHPM, AAHPM received the 2011 Humanities Award from the Academy of Hospice and Palliative Medicine and the 2011 Distinguished Service Award. Sandra L. Bertman, Ph.D. 159 Ward Street Studio Newton MA 02459 http://www.sandrabertman.com Email: [email protected]

Avoiding Burnout: How I Can Still Practice End-of-Life Care after 30 Years Charles G. Sasser, M.D. Someone asked me this recently and I am still mulling over the answers. To be honest, I had a serious encounter with burnout in the early 90’s, not so much with hospice (palliative care as a subspecialty did not yet exist), as with the practice of Internal Medicine. Many of my aging patients (who had helped raise me – I had returned to my home town to practice) were getting older and sicker with chronic, incurable illness and nothing I offered medically seemed to help. Many took my pills without benefit. Many would stop taking them and get better. I had been in practice long enough to watch many standard treatments fall out of favor and then recycle. And the credibility of many giants in medical research unraveled with the revelation of financial conflicts of interest. I became disillusioned with both scientific research and my anecdotal experience of the apparent weakening benefit of pharmacologic intervention to my patients’ overall well-being.

Author’s Note: My father, a beloved country surgeon, died when I was 11, and the “next day,” my mother said, “Go find your father.” This journey took me to distant lands but, not surprisingly, brought me home to practice medicine in their ghostly shadows. Here, I have lived a very ordinary life, married to a lovely, patient woman; raised three gorgeous daughters; searched for life's meaning(s); battled a receding hairline, an advancing waistline, and other travesties of aging; and now am challenged to see the world anew through the eyes of six amazing grandchildren. I have been witness to, cared for, and presided over, the physical decline and death of family, friends, and others in the community who chose me as their physician and thereby took me to raise. After 37 years, the practice of Internal Medicine continues to bring me great personal satisfaction. My special interests are in hospice and palliative medicine, and the healing potential of stories. Attending the suffering of remarkable people at the end of life's journey, when the banalities and facades are swept away and meaning and value are discovered anew, claims my attention in a very powerful way. To come back to the town that raised me to practice medicine on the people who raised me is the discovery that learning from people who know and love me, and are now my patients, even as they grow old and die, never ends.

Then I had a life-changing experience – an introduction to the theory and practice of Narrative Medicine – that provided a critical infusion of enthusiasm and purpose. More about this later. In reflecting back on how I have been able to sustain enthusiasm in an environment of constant loss, tragedy, and suffering, several critical components have come to mind. Perhaps the most important has been what I would call synchrony: the various compartments of my daily activities have generally

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REFLECTIONS complemented each other in the evolution of my life, from home to church to work to physical activity to my reading and scientific study. The sustaining drive has been to have one area not be inconsistent with the others; to be attracted to those that complement each other. Neurocognitive dissonance is a painful state compelling resolution. The pursuit of neuro-physicocognitive synchrony remains central to my sanity:

1. Books about Medicine (about my father’s legacy) with strong idealistic themes

a. Thorwald Jurgen: Century of the Surgeon b. Somerset Maugham: Of Human Bondage c. Sinclair Lewis: Arrowsmith

I. The synchrony of personal clinical experience with the scientific literature. The risk here is balancing a healthy cynicism for much that is touted as “standard of care” with the practical realities of caring for people in the confines of a broken health care system (read The Moral Underground by Lisa Dodson).

d. Eric Cassel: The Healer’s Art 2. Books of Self-Discovery a. Thomas Harris: I’m OK, You’re OK (and many that followed dealing with pop psychology/Transactional Analysis)

II. The search for, and finding, a metaphorical system – Quantum Theory – that better explains contemporary reality than the 17th century, antiquated “Modern Science Project” of single cause and effect, simplicity, entropy, and analytical reductionism with which we have been too long saddled.

b. John Sanford: Most of his works on wholeness, healing, and dreams as, for example, Evil: The Shadow Side of Reality, motivated me to read widely on Shadow Psychology and strongly influenced my ability to make peace with, forgive, affirm, and love myself; this theme strongly resonates with the religious/spiritual theme, as it gave me permission to forgive and find a meaningful place for all the religious recordings of my upbringing while feeling less controlled by them.

III. The synchrony of my religio-spiritual explorations and their verification in home and hospital. The language I use to frame the fundamental questions about life and all its triumphs and tragedies, its positives and pathos, must serve me equally well in all my daily encounters.

3. Religious/Spiritual Pursuits

IV. My reading and study continues to be synchronous with the pursuit of this most fundamental question. This brings me to my “Canon,” those books which have had a strong guiding influence on the peculiar way in which I have framed my personal cosmology, essentially since I first started reading. A recent article in the “Reflections” section of the Annals of Behavioral Science and Medical Education1 reminded me of the importance of their contributions.

a. The 12-volume Interpreter’s Bible: this to emphasize the centrality of religion in my life and ongoing struggle to reconcile Bible-based faith with daily realities of injustice and suffering. I read this as preparation for teaching a nine-year Sunday school survey of the Bible. b. Marcus Borg: The Heart of Christianity, which helped me place most of my inner conflicts with my mother’s (the Church’s) faith into a workable and reconciling framework. Of major importance is his embrace of other faith traditions, while still encouraging me to honor and be observant of my own.

Themes driving my literary/narrative search for meaning: • Reconciling my father’s death with my own mortality. He was a country surgeon in the first part of the 20th century whose death at an early age (for him and me) left me inflicted with a clear mandate to return home and “pick up the mantle,” with consequences not always healthy.

c. Elizabeth Lesser: The New American Spirituality. Again, a way of allowing resonance and synchrony among the various faith traditions, journeys, and experiences, without blending or melting or losing distinctiveness; engaging the paradox of our insignificance in the Universe and our specialness in community.

• Discovering the resonance between End-of-Life (EOL) care and the gradual development and application of Narrative Medicine as a practical skill set (more later). • Finding religious/spiritual and spiritual/scientific resonance.

4. Shifting from the Cartesian-Newtonian to the Quantum Model, which does so much more, metaphorically, to resonate with post-modern realities.

• Reframing the metaphorical basis of my personal cosmology from a Cartesian-Newtonian to a Quantum frame of reference.

a. Diarmuid O’Murchu: Quantum Theology, which greatly enhanced and facilitated my cosmological shift to a Quantum model of the inter-connectedness of Creation. It incorporates the best of ecumenical, eco-feminist

Many of the books chosen are simply representative of the literary genres I pursued in my personal search for meaning. Readings and their relevance 50

SASSER theology and the metaphors are so much more applicable to today’s issues of complexity, multiple cause and effect, uncertainty, complementarity, interdependence (cooperation vs. competition) and paradox.

attention was brought back to the patient’s story – long devalued by the plethora of methods now available to measure the body’s various organic interactions – as an area rich in diagnostic potential. As any wise clinician will tell you, “If you listen to your patients long enough, they will tell you what’s wrong with them.” Third, learning how to listen, to draw out, and to reframe their stories might have major therapeutic potential, apart from – and in addition to – any scientifically proven interventions. I was certainly aware of how certain things said to me could be either deeply wounding or powerfully healing. Now in the doctor-patient dialogue, words themselves became powerful healing agents. When all biomedical interventions had been exhausted, there were still powerful interventions available that I especially, as healing authority, could employ. Fourth, to really understand the relationship between this person and his illness, the piece of the story I had been trained to investigate – the signs and symptoms piece – now had to be placed in the context of a much larger story, the story of who this person was, how he had arrived at this place and time in the Universe, who and what had influenced him to become as he was, what tragedies he had endured and triumphs achieved, and how these had molded him to confront his current state of fractured wholeness in just this unique way. In order to do this, I now had to expand my role as clinician to that of mini-anthropologist.

b. Margaret Wheatley: Leadership and the New Science complements Quantum Theory from the educational /business perspective. Discovering synchrony in different disciplines helps “flesh out” concepts into real-life meaning. V. My daily and annual encounters with fellow travelers in the field of EOL care. This is a unique calling, fraught with emotional stress and intensity, and the people called to it have a pathological need to cling to each other for support. This is the psychological basis for a truly dynamic interdisciplinary team. Doctors have an almost innate inability to ask each other for help – real help, I mean – the kind you ask of “friends who will come when you call in the middle of the night” (Judith Viorst: Necessary Losses). I realized this again at a recent annual meeting of the American Academy of Hospice and Palliative Medicine. A colleague introduced himself and immediately began to tell me the story of an “interesting case” which, within a few minutes of the telling, brought us both to tears. The vicarious suffering of palliative care is great but incredibly binding.

As I began to explore the nature and potential of the patient’s story, I became increasingly aware of how impoverished were the descriptions of the illness narrative in the medical record. In my mind as I wrote or dictated, I changed the implied reader from a faceless third party or lawyer to that of the patient herself. I began to quote her so that all who read it might gain a little insight into the actual experience of her illness. Just the simple changing of that image to the patient herself, whose past triumphs and inner strengths, as revealed in her narration I only had to point out, made a dramatic difference, not only in the empathy I could now offer, but in the empathy I could experience for myself. In the process of restorying another, I restoried myself.

VI. The synchrony of Narrative Medicine and my personal experience with medical practice. The concept was introduced to me in 1991 by Margaret Mohrmann (Medicine as Ministry; Attending Children). I was dangerously close to burnout when, at a meeting in the North Carolina mountains, she posed a question that changed the direction of my life: Consider your patient, she said, as the author of a story he is writing with his life and he is the hero, flawed though he may be, of his own story. You are not the author of his story. Your influence is peripheral at best, though you may be called on, in situations of major illness, to edit a chapter or two. This is not your story, great healer though you may be. This is his and you are largely a bystander, a witness. Your role as editor is to help him tell a coherent story and ultimately find meaning in it. You, too, have a story to tell, with an equally flawed hero, but that’s another story.

References 1. Elpern DJ. Why read? Ann Behav Sci Med Educ 2010;16:47-8.

Charles G. Sasser, M.D., FACP FAAHPM, AAHPM

As the implications of such a perceptual shift in how I might view the practice of medicine and my patients swept over me, I felt a liberating surge of hope and renewed enthusiasm. First, I was no longer ultimately responsible for the outcomes of all their illnesses. Their deaths were no longer my personal failures. My role in the healing dynamic was now much clearer: it was very important, but not central, to the patient’s story. Second, my

Medical Director, Mercy Care Hospice and Palliative Care, since 1981 Medical Director, Conway Medical Center Palliative Care Consultative Service, since 2002 Conway, SC Email: [email protected]

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