I have been preparing for the upcoming Personalized Lifestyle Medicine Institute webinar, “Creating Successful Patient Healing Journeys: Restoring Connection, Finding Hope and Evolving Wellness” scheduled for 6 November 2024. I will be joining the expert panel which includes Dr. Jeff Bland, Dr. Deanna Minich, and Dr. Brian Thomas Swimme. During this preparation, I have written two blogs on the patient encounter. Today’s is entitled ‘Metaphors and Purpose’ and next month’s is ‘Effective Office Visits’.
In contemplating the nature of the exam room experience, I've been examining how the metaphors I use to describe the practitioner-patient relationship have changed over the years. When I first practiced, I used a coaching metaphor. I very much admired Sleepy Thompson, the football coach and athletic director at St. Stephen’s and St. Agnes School where I attended when it was St. Stephen’s School for Boys. He was a much-admired coach who was deeply concerned about his players, their growth and their performance. While he emphasized practical skills Monday through Friday, his passion was in helping boys be good men – living the role of ‘gentleman scholar and athlete’ to use an old University of Virginia expression. Active on game days, standing on the side lines, observing, and coaching, he was right there; deeply involved in his player’s performance. If the defense was on the field and a pass play was developing, he'd be yelling ‘pass’ to alert his defense from the sidelines. And that's how I saw my role as a physician closely directing the patient’s pursuit of health.
As years passed, I eventually saw my role differently. I recognized that motivation that primarily came from a coach-physician was generated externally and frequently didn’t last. Additionally, external motivation decreases a patient’s autonomy, reducing their independence. The metaphor of first mate would now better describe my evolving role. In the British Royal Navy fictionalized in C.S. Forester’s Hornblower novels, a young midshipman or lieutenant was the officer of the watch with full responsibility for making decisions and issuing orders during their watch. They were in charge, but they were supported by a crusty first mate or coxswain who possessed an intimate knowledge of sailing, of being in those waters, like an experienced pilot taking a ship into a harbor. I was this source of information and experience. Having sailed these waters before, I could provide advice to the patient, but ultimately, it was the patient’s ship, and their decisions were final.
As we all recognize, medicine has been changing and not necessarily for the best. While running the Personalized Lifestyle Medicine Center for Metagenics before it closed in April, I saw many examples of the deteriorating relationship between patients and their primary care providers (PCPs) in the traditional practices. Though my proposed metaphor for that style of practice may sound funny (you may laugh), it is not meant to be insulting. Instead, I think it is a fitting description of the brokenness of our health care system. If you're not actively engaging the patient in relationship in the exam room, the PCP’s role may be fittingly described as the hole marker/ball washer that stands next to a tee box on the golf course. A patient might get some description of what lies ahead (how far, how the hole looks), and might get an intervention, their ball is washed (acute symptoms being addressed), but they play a lonely hole until they get to the next tee box. Though modern practitioners have recognized their patient’s autonomy, the system hasn't necessarily helped the patient step into a responsible role as they endeavor to journey to wellness. Patients are left to wander, picking and choosing among diversions and solutions that all promise the short path to health and wellbeing. If they are lucky or smart enough to make the correct selection, they frequently might not have the drive or support to make the behavioral change that will make for a successful journey to wellness.
I now see myself in the metaphor of both sentinel and prophet - a standing, observing sentinel stone marking the starting point of a journey, but also the prophet being critical of the status quo and issuing an invitation to the patient to remember their uniqueness and their sacredness. You may have read our paper, “Our Healing Journey”[1], that was published in Integrative Medicine – A Clinicians Journal two years ago. It proposed a different relationship with the patient; an encounter in which it is vitally important to discover the patient's purpose. A patient’s inability to see their purpose and the brokenness of their dreams is the greatest obstacle to achieving wellbeing. As we grow, are educated and acculturated, we're told that our imaginations aren't important. We're told that our imaginary friends aren't real. Young children, when asked, express their dreams of being an astronaut, ballerina, quarterback, president, nurse, doctor, teacher, scientist, stockbroker, soldier, or movie star; they dream large. And yet the dreams are discounted; it is unlikely that any child ever wished to be the unknown, fifth row back, fourth cubicle over, in a grey, sullen workplace.
When we dreamed those roles, we dreamed a heroic purpose, we were going to be agents of change. We intended that our lives would be meaningful contributions to society. Instead, we attended the school systems of which Aldo Leopold questions “Is education possibly a process of trading awareness for things of lesser worth?”[2] We studied to get into the right high schools and the right colleges so we could grow up to have the American Dream, the achieving materialistic dream of a great salary, of success, and of having people be envious of us. Fame and achievement were the markers of success and somewhere along the way we had lost that best part of Joseph Campell’s hero's journey. The gift of a hero's solo journey of initiation was received by the hero, but the wisdom, the gift, received was intended to benefit both the individual and their tribe. The hero was empowered, crossing the threshold from adolescence to adulthood, ready to take their place as a contributing purposeful adult. Bill Plotkin[3] proposes that many of us in Western achieving-conformist society are developmentally stuck in early adolescence. Many haven’t crossed that threshold into being a true adult capable of recognizing her soul, his eco-purpose, their specific niche in the more than human world, a world of our ancestors, our descendants, our fellow beings whether they be humans or the plants and animals that share our planet. This niche is a unique role that only we are crafted for; we are the only one who is called to have that purpose. Tiny habits and external motivation often don’t produce or indeed sustain the lifestyle changes necessary to restore wellness; instead, patients need to identify what is important, meaningful and valuable and thus choose behaviors that support the achievement of their goals.
Daniel Boone is remembered for heroically leading people through the Cumberland Gap into modern day Kentucky in the late 1700’s. Thousands would eventually follow his path and travel where they hadn’t envisioned themselves going even though the true geological/topologic challenge was relatively a minor one.[4] The gap has an elevation of 1631 feet while the surrounding mountains only climb to approximately 2500 feet. Ultimately, it took an individual with a prophetic voice to call his fellows to journey.
In our webinar, we will talk about our journeys, about how patients know, and how do we empower patients to heal and pursue wellbeing. It is my hope that you will have exam room experiences that remind you of your unique purpose. As Pat O’Donohue has written in the afterword to his brother John’s book, Anam Cara,[5] “The deepest dream of the human heart is to be held and be called beloved on this earth”.
Next month, look for my blog on ‘Effective Office Visits’. And have a great Halloween.
[1] Lamb J, Stone M, Buell S, Suiter C, Class M, Heller L, Minich D, Jones DS, Bland JS. Our Healing Journey: Restoring Connection, Finding Hope and Evolving Wellness. Integr Med (Encinitas) 2022;21 (2):34-40.
[2] Leopold, Aldo; Kingsolver, Barbara. A Sand County Almanac: And Sketches Here and There. Oxford University Press; Oxford, UK, 2020.
[3] Plotkin, Bill. The Journey of Soul Initiation: A Field Guide for Visionaries, Evolutionaries and Revolutionaries. New World Library; Novato, CA, 2021.
[4] Bellows, Amanda. The Explorers – A New History of America in Ten Expeditions. HarperCollins Publishers; New York, New York, 2024.
[5] O’Donohue, John; Higgins, Michael D; O’Donohue, Pat. Anam Cara: A Book of Celtic Wisdom (25th Anniversary Edition). Harper Perennial; New York, New York, 2022.