It’s the humdrum, day-in, day-out, everyday work that is the real satisfaction of the practice of medicine; the million and a half patients a man has seen on his daily visits over a forty-year period of workdays and Sundays that make up his life. I have never had a money practice; it would have been impossible for me. But the actual calling on people, at all times and under all conditions, the coming to grips with the intimate conditions of their lives, when they were being born, when they were dying, watching them die, watching them get well when they were ill, has always absorbed me.
I lost myself in the very properties of their minds: for the moment at least I actually became them, whoever they should be, so that when I detached myself from them at the end of a half-hour of intense concentration over some illness which was affecting them, it was as though I were reawakening from a sleep. For the moment I myself did not exist, nothing of myself affected me. As a consequence I came back to myself, as from any other sleep, rested. Time after time I have gone out into my office in the evening feeling as if I couldn’t keep my eyes open a moment longer. I would start out on my morning calls after only a few hours’ sleep, sit in front of some house waiting to get the courage to climb the steps and push the front-door bell. But once I saw the patient all that would disappear. In a flash the details if the case would begin to formulate themselves into a recognizable outline, the diagnosis would unravel itself, or would refuse to make itself plain, and the hunt was on. Along with that the patient himself would shape up into something that called for attention, his peculiarities, her reticences or candors. And though I might be attracted or repelled, the professional attitude which every physician must call on would steady me, dictate the terms on which I was to proceed. Many a time a man must watch the patient’s mind as it watches him, distrusting him ready to fly off at a tangent at the first opportunity; sees himself distrusted, sees the patient turn to someone else, rejecting him.
More than once we have all seen ourselves rejected, seen some hard-pressed mother or husband go to some other adviser when we know that the advice we have given him has been correct. That too is part of the game. But in general it is the rest, the peace of mind that comes from adopting the patient’s condition as one’s own to be struggled with toward a solution during those few minutes or that hour or those trying days when we are searching for causes, trying to relate this to that to build a reasonable basis for action which really gives us our peace. As I say, often after I have gone into my office harassed by personal perplexities of whatever sort, fatigued physically and mentaIIy, after two hours of intense application to the work, I came out at the finish completely rested (and I mean rested) ready to smile and to laugh as if the day were just starting.
That is why as a writer I have never felt that medicine interfered with me but rather that it was my very food and drink, the very thing which made it possible for me to write. Was I not interested in man? There the thing was, right in front of me. I could touch it, smell it. It was myself, naked, just as it was, without a lie telling itself to me in its own terms. Oh, I knew it wasn’t for the most part giving me anything very profound, but it was giving me terms, basic terms with which I could spell out matters as profound as I cared to think of.
I knew it was an elementary world that I was facing, but I have always been amazed at the authenticity with which the simple-minded often face that world when compared with the tawdriness of the public viewpoint exhibited in reports from the world at large. The public view which affects the behavior of so many is a very shabby thing when compared with what I see every day in my practice of medicine. I can almost say it is the interference of the public view of their lives with what I see which makes the difficulty, in most instances, between sham and a satisfactory basis of thought.
I don’t care much about that, however. I don’t care a rap what people are or believe. They come to me. I care for them and either they become my friends or they don’t. That is their business. My business, aside from the mere physical diagnosis, is to make a different sort of diagnosis concerning them as individuals, quite apart from anything for which they seek my advice. That fascinates me. From the very beginning that fascinated me even more than I myself knew. For no matter where I might find myself, every sort of individual that it is possible to imagine in some phase of his development, from the highest to the lowest, at some time exhibited himself to me. I am sure I have seen them all. And all have contributed to my pie. Let the successful carry off their blue ribbons; I have known the unsuccessful, far better persons than their more lucky brothers. One can laugh at them both, whatever the costumes they adopt. And when one is able to reveal them to themselves, high or low, they are always grateful as they are surprised that one can so have revealed the inner secrets of another’s private motives. To do this is what makes a writer worth heeding: that somehow or other, whatever the source may be, he has gone to the base of the matter to lay it bare before us in terms which, try as we may, we cannot in the end escape. There is no choice then but to accept him and make him a hero.
All day long the doctor carries on this work, observing, weighing, comparing values of which neither he nor his patients may know the significance. He may be insensitive. But if in addition to actually being an accurate craftsman and a man of insight he has the added quality of some distress of mind a restless concern with the . . . If he IS not satisfied with mere cures, if he lacks ambition, if he is content to . . . If there is no content in him and likely to be none; if in other words, without wishing to force it, since that would interfere with his lifelong observation, he allows himself to be called a name! What can one think of him?
He is half-ashamed to have people suspect him of carrying on a clandestine, a sort of underhand piece of spying on the public at large. They naively ask him, “How do you do it? How can you carry on an active business like that and at the same time find time to write? You must be superhuman. You must have at the very least the energy of two men.” But they do not grasp that one occupation complements the other, that they are two parts of a whole, that it is not two jobs at all, that one rests the man when the other fatigues him. The only person to feel sorry for is his wife, she practically becomes a recluse. His only fear is that the source of his interest, his daily going about among human beings of all sorts, all ages, all conditions will be terminated. That he will be found out.
As far as the writing itself is concerned it takes next to no time at all. Much too much is written every day of our lives. We are overwhelmed by it. But when at times we see through the welter of evasive or interested patter, when by chance we penetrate to some moving detail of life, there is always time to bang out a few pages. The thing isn’t to find the time for it – we waste hours every day doing absolutely nothing at all – the difficulty is to catch the evasive life of the thing, to phrase the words in such a way that stereotype will yield a moment of insight. That is where the difficulty lies. We are lucky when that underground current can be tapped and the secret spring of all our lives will send up its pure water. It seldom happens. A thousand trivialities push themselves to the front, our lying habits of everyday speech and though are foremost, telling us that that is what “they” want to hear. Tell them something else. You know you want to be a successful writer. This sort of chitchat the daily practice of medicine tends drastically to cure.
Forget writing, it’s a trivial matter. But day in day out, when the inarticulate patient struggles to lay himself bare for you, or with nothing more than a boil on his back is so caught off balance that he reveals some secret twist of a whole community’s pathetic way of thought, a man is suddenly seized again with a desire to speak of the underground stream which for a moment has come up just under the surface. It is just a glimpse, an intimation of all that which the daily print misses or deliberately hides, but the excitement is intense and the rush to write is on again. It is then we see, by this constant feeling for a meaning, from the unselected nature of the material, just as it comes in over the phone or at the office door, that there is no better way to get an intimation of what is going on in the world.
We catch a glimpse of something, from time to time, which shows us that a presence has just brushed past us, some rare thing – just when the smiling little Italian woman has left us. For a moment we are dazzled. What was that? We can’t name it; we know it never gets into any recognizable avenue of expression; men will be long dead before they can have so much as ever approached it. Whole lives spent in the tremendous affairs of daily events without even approaching the great sights that I see every day. My patients do not know what is about them among their very husbands and children, their wives and acquaintances. But there is no need for us to be such strangers to each other saving alone laziness, indifference and age-old besotted ignorance.
So for me the practice of medicine has become the pursuit of a rare element which may appear at any time, at any place, at a glance. It can be most embarrassing. Mutual recognition is likely to flare up at a moment’s notice. The relationship between physician and patient, if it were literally followed, would give us a world of extraordinary fertility of the imagination which we can hardly afford. There’s no use trying to multiply cases, it is there, it is magnificent, it fills my thoughts, it reaches to the farthest limits of our lives.
What is the use of reading the common news of the day, the tragic deaths and abuses of daily living, when for over half a lifetime we have known that they must have occurred just as they have occurred given the conditions that cause them? There is no light in it. It is trivial fill-gap. We know the plane will crash, the train be derailed. And we know why. No one cares, no one can care. We get the news and discount it, we are quite right in doing so. It is trivial. But the hinted news I get from some obscure patients’ eyes is not trivial. It is profound: whole academies of learning, whole ecclesiastical hierarchies are founded upon it and have developed what they call their dialectic upon nothing else, their lying dialectics. A dialectic is any arbitrary system, which, since all systems are mere inventions, is necessarily in each case a false premise, upon which a closed system is built shutting those who confine themselves to it from the rest of the world. All men one way or another use a dialectic of some sort into which they are shut, whether it be an Argentina or a Japan. So each group is maimed. Each is enclosed in a dialectic cloud, incommunicado, and for that reason we rush into wars and prides of the most superficial natures.
Do we not see that we are inarticulate? That is what defeats us. It is our inability to communicate to another how we are locked within ourselves, unable to say the simplest thing of importance to one another, any of us, even the most valuable, that makes our lives like those of a litter of kittens in a wood-pile. That gives the physician, and I don’t mean the high-priced psychoanalyst, his opportunity; psychoanalysis amounts to no more than another dialectic into which to be locked.
The physician enjoys a wonderful opportunity actually to witness the words being born. Their actual colors and shapes are laid before him carrying their tiny burdens which he is privileged to take into his care with their unspoiled newness. He may see the difficulty with which they have been born and what they are destined to do. No one else is present but the speaker and ourselves, we have been the words’ very parents. Nothing is more moving.
But after we have run the gamut of the simple meanings that come to one over the years, a change gradually occurs. We have grown used to the range of communication which is likely to reach us. The girl who comes to me breathless, staggering into my office, in her underwear a still breathing infant, asking me to lock her mother out of the room; the man whose mind is gone – all of them finally say the same thing. And then a new meaning begins to intervene. For under that language to which we have been listening all our lives a new, a more profound language, underlying all the dialectics offers itself. It is what they call poetry. That is the final phase.
It is that, we realize, which beyond all they have been saying is what they have been trying to say. They laugh (For are they not laughable?); they can think of nothing more useless (What else are they but the same?); something made of words (Have they not been trying to use words all their lives?). We begin to see that the underlying meaning of all they want to tell us and have always failed to communicate is the poem, the poem which their lives are being lived to realize. No one will believe it. And it is the actual words, as we hear them spoken under all circumstances, which contain it. It is actually there, in the life before us, every minute that we are listening, a rarest element-not in our imaginations but there, there in fact. It is that essence which is hidden in the very words which are going in at our ears and from which we must recover underlying meaning as realistically as we recover metal out of ore.
The poem that each is trying actually to communicate to us lies in the words. It is at least the words that make it articulate. It has always been so. Occasionally that named person is born who catches a rumor of it, a Homer, a Villon, and his race and the world perpetuates his memory. Is it not plain why? The physician, listening from day to day, catches a hint of it in his preoccupation. By listening to the minutest variations of the speech we begin to detect that today, as always, the essence is also to be found, hidden under the verbiage, seeking to be realized.
But one of the characteristics of this rare presence is that it is jealous of exposure and that it is shy and revengeful. It is not a name that is bandied about in the market place, no more than it is something that can be captured and exploited by the academy. Its face is a particular face, it is likely to appear under the most unlikely disguises. You cannot recognize it from past appearances – in fact it is always a new face. It knows all that we are in the habit of describing. It will not use the same appearance for any new materialization. And it is our very life. It is we ourselves, at our rarest moments, but inarticulate for the most part except when in the poem one man, every five or six hundred years, escapes to formulate a few gifted sentences.
The poem springs from the half-spoken words of such patients as the physician sees from day to day. He observes it in the peculiar, actual conformations in which its life is hid. Humbly he presents himself before it and by long practice he strives as best he can to interpret the manner of its speech. In that the secret lies. This, in the end, comes perhaps to be the occupation of the physician after a lifetime of careful listening.
1. Writing and medicine were synergistic entities that enlightened and motivated this author in his practice. Is there something in your life that will promote and contribute to your journey in medicine?
2. What is it about a clinical encounter that reveals so much truth about humanity?