Attending

by Ronald Epstein

  I undertook a practice of presence. I began, consciously, taking in each patient’s face, recognizing yet resisting the urge to look away. I became aware of my own gaze and my facial expressions, noting when I drew back. I discovered that observing is not necessarily seeing. I could observe a woman’s labor without seeing the person. Observing is much like what the philosopher Michel Foucault called the “clinical gaze”—a way of viewing a patient as a disease, a diagnosis, a clinical problem, somewhat less than a person.1 In contrast, by not merely observing, and instead seeing, I could explore what it was like for me to be present.

  Gradually I grew more comfortable. Distance—physical distance and emotional distance—seemed to dissolve. I no longer felt that I was going to drown. I could be more helpful, seeing ways in which I could relieve patients’ discomfort. It felt genuine, intimate.

  At first, presence was an interior experience for me; only later did I realize that it was shared. Patients responded differently when I was present. They looked back, they took my hand. The presence I could bring to a woman in labor seemed like the presence I felt as a performing musician. Being present had an impact on the care I delivered. I discovered what good midwives always knew—that you can “tell” when a woman is progressing in labor; this “telling” depends on presence. I was better able to wait before acting.

  THE INEFFABLE

  At its most basic, presence is made visible when the clinician makes good eye contact, responds to patients’ concerns, and doesn’t stand up and leave before the conversation is finished. However, when patients say their doctor is “really there,” most patients are referring to a quality of being. Presence is a sense of coherence and imperturbability. Internist Tony Suchman calls it the “connexional” dimension of care, often unspoken.2 Presence is a quality of listening—without interrupting, interpreting, judging, or minimizing. In case you hadn’t noticed, doctors don’t do this well. When psychologist Kim Marvel and I analyzed audio-recorded primary care office visits, we saw how doctors would get restless and take control after patients had spoken for an average of only twenty-three seconds.3

  The philosopher Ralph Harper, in his book On Presence,4 considers presence to be a “bonded resonance” in which two people are in touch and in tune with each other. Presence, according to Harper, is especially important in “boundary situations,” times when people feel vulnerable, when life is particularly uncertain and when it’s hard to find meaning. In medicine, these are times when patients face serious illness and loss of function, when patients and their loved ones are frightened, when there are unexpected mishaps. Presence is a gift of dignity and respect when patients need it most. Harper also points out that presence is always shared with a real or imagined other; presence requires a witness, even if that witness is another part of oneself—an observing self.5 In that way I can be present with a patient even when a patient is unable to speak for herself.

  I feel a bit daunted in trying to characterize presence, to render the ineffable visible and leave it no less wondrous. Presence has historically been the domain of poets, philosophers, and mystics; however, it is at the core of health care. When clinicians write about presence, they rarely do so using clinical language. They write stories.6 Surgeons, internists, family physicians, and psychiatrists have described how you cannot force presence into existence, nor does presence reliably happen on its own; you have to make space within which presence can emerge. In that sense, presence depends on emptiness, getting yourself out of the way, setting aside inner chatter—what the Buddha called “monkey mind”—to connect more directly with a person, a task, or a part of yourself. Societally, more than ever we crave presence with ourselves and shared presence with others, patients and clinicians included. With our attention increasingly parsed among tasks that compete for the same set of neural pathways, we are divided into too many fragments—too many to maintain a sense of being whole. Every day our sense of presence is constantly being fractured and repaired—an exhausting prospect. Try having a conversation—a meaningful conversation—while entering data on a computer. At the least, your sentence structure becomes disjointed and you lose your train of thought.

  PRESENTNESS OF TIME

  Sometimes a simple gesture and a few well-placed words can signal presence. One day on rounds in the hospital, as we walked into the room, Laura Hogan, a nurse-practitioner on our palliative care team, said three words to the patient: “What beautiful flowers.” The patient looked at the flowers and smiled. The previous day the patient had had a biopsy that would let her know whether her cancer had progressed; she was still awaiting the results. We all feared that the news would not be good. Laura’s comment communicated that even in dire circumstances it is possible to see beauty and to honor those who loved and cared for the patient, that she was not alone. More often, though, presence is communicated nonverbally—a softness of gaze, a quality of touch, a handshake that is felt genuine rather than perfunctory, a gentle examination of a patient’s tender abdomen.

  Presence is also “presentness” of time. When I feel that I’m being present while caring for patients, time seems to expand or stand still. Several years ago, I went to a jazz concert by Chick Corea’s group. During the opening piece, after each of the musicians had had a chance to improvise, the music reached a resting point, a silence that probably only lasted two seconds. Even though the concert was in a three-thousand-seat auditorium, everyone seemed to feel the same sense of intimacy and connection in that silence. That moment had an exquisite spaciousness, as if the outside world had ceased to exist, a spaciousness that resolved only when the musicians simultaneously struck a chord marking a new section of the music. Think of speeches by Martin Luther King Jr. or Mahatma Gandhi. You are captivated, entranced, transported, and time seems to stop or ceases altogether.

  When physicians are being present, patients feel that spaciousness. I remember the first time I felt it as a patient. I was in my late teens and had not been feeling well for over a month; I was weak, tired, and feverish, with a sore throat, headaches, and no energy. I would get better for a while, then it would come back. I had recently graduated from my pediatrician to a new “adult” doctor, whom I did not know well. He was thorough and gentle as he examined my ears, throat, neck, chest, and abdomen. I presume that the physical examination was normal and uninformative; it confirmed a diagnosis that he had already made.

  Time seemed to stand still. I was worried; he was imperturbably calm. He was much older than I, but that didn’t seem to matter; he was warm and his eyes had a softness. I felt that he understood me and my situation, and the distance between us seemed to dissolve. He said that he’d seen this cluster of symptoms, which was probably a lingering virus, and that time would heal. He ordered a blood test just to make sure. That’s all I needed.

  This was the first time I felt understood and cared for—honored and respected—by a physician. I carried his presence with me after I went home and found his virtual presence quietly reassuring; I was not worrying alone. A couple of weeks later, I began to feel more myself. His image came to me years later as I was contemplating going to medical school and later during the dark moments when I wondered whether memorizing names of bacteria and reciting differential diagnoses was all that it could be about.

  Later still, I discovered that I could be present in that way—and share my presence with patients. I had a new patient in my practice—Haqim, sixteen years old, muscular, confident, and robust. He had acne on his back and shoulders. He asked question after question—about hormones and how they affect the skin (and why they make people unattractive), how each medication worked, whether he could try two of them at the same time, and how long it would take for the bumps and cysts to go away.

  He was worried—very worried. I listened, without interpreting or reflecting—I just listened. I explained that time would heal, with the help of a few creams and pills. After a few more questions about how the pills actually worked, he relaxed and even smiled. We spent th
e remaining five minutes of the fifteen-minute visit talking about his family. Since then Haqim has mentioned to me on more than one occasion that he wants to become a doctor.7

  TIME AND INTIMACY

  How can presence happen, though, when office visits are constrained to a mere fifteen to twenty minutes or even shorter? Elapsed time might be out of a doctor’s control to some degree, but perceived time can always be created. I teach physicians to sit down while talking with a patient, rather than standing; in a study of surgeons making quick hospital rounds, patients felt that doctors actually spent more time when they sat down, even though the elapsed time was the same as when they stood.8 A research colleague, Kathy Zoppi, found that parents were more satisfied when they perceived that pediatricians spent more time with them—the true elapsed time didn’t matter as much.9 Sometimes time is created through silence. As in music, where silences can have the same exquisite beauty as notes, silence can deepen a relationship between a doctor and a patient. It doesn’t take much—a few seconds at most—to reassure a patient that the doctor is there, listening, attending, not rushed.10 Using silence effectively is even more relevant now that visits—in the hospital and in office practice—are crammed with more administrative imperatives.

  Musicians know about presence and its absence. When you’re caught up in your thoughts and just going through the motions, your professional colleagues will say you’re “just phoning it in.” And you’ll think, “I played a good concert. Wish I had been there.” It’s the same in medicine. When you’re being present (or when you’re phoning it in), patients know and you know. My mentor George Engel would say that patients want to know and understand and to feel known and understood. There’s a difference between merely knowing about a patient and knowing the patient as a person. Knowing is much more personal and intimate. During training, supervisors and colleagues warned me of the dangers of becoming too involved with patients. Patients die, and they are ravaged by unspeakable tragedy, depredation, and abuse. Getting too close to the edge of this vortex feels dangerous. You fear that you’ll lose perspective and degenerate into a mass of emotional jelly. Clearly, though, boundary situations require a greater sense of presence—not less. Only with a radically tenacious shared presence can a clinician maintain the sense of intimacy necessary to truly be there with a suffering patient.11 In medicine, trainees hear little about how to do this. Staying coldly objective seems safer. It also has its perils. While doctors sometimes have to distance themselves emotionally as a survival strategy, making detachment a habit sterilizes clinical care of its richness and meaning. For me, being present means aiming for the sweet spot in which I am emotionally accessible to myself and others in a way that clarifies my vision of the patient, his clinical situation, and our relationship.

  Dirk is a seventy-year-old man with paranoid schizophrenia whom I have had in my primary care practice for over twenty years. Dirk has spent nearly all of his adult life in mental hospitals and group homes. He’d usually be laconic during our visits: I’d ask questions and he’d answer in a word or two. Over the past year, Dirk has had several episodes of passing out or nearly passing out. His blood pressure was low, likely a side effect of his psychiatric medications. While none of his injuries were serious, I was worried. That day, Dirk was his usual emotionally flat self; I couldn’t tell what he was thinking. He recounted having fallen in a stairwell with the same monotone he’d use if he were reading a list of telephone numbers.

  Then I said, “I’m worried,” and waited. To my surprise, Dirk became more talkative. He said that he was worried too. We talked about the risks and benefits of lowering his medication doses—which might help with the episodes of passing out, but might risk worsening his psychiatric condition. He then talked about how it felt to be different, the stigma of his mental illness. I was speechless; I had completely underestimated his insight.

  This brief exchange opened up a new chapter in our long relationship. In the past, I didn’t feel that we had achieved any kind of connection. It took twenty years for that moment to emerge, and I now see him as more of a whole person. It’s reciprocal—I get the sense that now he sees me as a person, not just “the doctor.” Periodically I wonder if I had never given him a chance, that by doing the habitual doctorly things—asking questions, poking, prodding, giving advice—I had inadvertently silenced him. Now we, together, had the opportunity to make a better decision—to lower his medications. I am better able to advocate for him and to address his housing and medication needs and the social activities that give his otherwise impoverished life meaning. Dirk has slowly become more disclosing, sharing more of himself. I have a better understanding of what he fears, what he needs, what he enjoys—and who he is.

  STORMY SEAS

  Laura Kerner was seventy years old and enjoying her retirement until she had a heart attack followed by pneumonia, septicemia (infection in her bloodstream), and a blood clot to her lungs. During her four weeks in the hospital, despite intensive treatment, she was declining; her heart did not have sufficient reserve; she was suffocating for lack of oxygen; her liver and kidneys were failing; she was dying. She had previously said that she would not want life support if she was not expected to survive.

  As the days passed, Laura had fewer and fewer lucid moments and was increasingly agitated and delirious. Suctioning her oral secretions would provoke coughing spells. Drawing blood required multiple attempts. Even moving her in bed made her short of breath and she had to be restrained to keep her from pulling out her IVs. Distressingly, the ICU team had to withhold painkillers and sedatives because they tended to lower her blood pressure. As her chances of a meaningful recovery diminished, her physicians and nurses grew increasingly distressed.

  As a palliative care consultant, my job was to help Laura, her family, and the ICU team make important decisions about her care, but no one could agree on anything. Some family members thought Laura would want hospice care, whereas others demanded that “everything” be done, “no matter what.” Each day the family divisions grew more acrimonious. Her son would say, “You doctors are trying to kill my mother,” “You’re just giving up,” “She’s always been a fighter and you’re taking that away from her.”

  Doing things—explaining, offering opinions, directing—had already backfired; I certainly was not going to tell them what to do. All I could do was be attentive and present. I found it easy enough to be aware of my feelings of irritation and anger and my judgments about her family’s motives (Are they uncaring?), capacity (Are they paranoid? Do they really understand?), and morals (Are they irresponsible?). It was another thing to set those feelings aside and welcome their questions and take in each of their views. I’d have to consider the possibility that I misperceived their motives and see my own contributions to this mess—perhaps by having taken sides when I shouldn’t have. I had to cultivate a sense of hospitality.

  THE GUEST HOUSE

  This being human is a guest house.

  Every morning a new arrival.

  A joy, a depression, a meanness,

  some momentary awareness comes

  as an unexpected visitor.

  Welcome and entertain them all!

  Even if they are a crowd of sorrows,

  who violently sweep your house

  empty of its furniture,

  still, treat each guest honorably.

  He may be clearing you out

  for some new delight.

  The dark thought, the shame, the malice,

  meet them at the door laughing and invite them in.

  Be grateful for whatever comes,

  because each has been sent

  as a guide from beyond.

  —Jellaludin Rumi

   translated by Coleman Barks

  The presence I was seeking had been described in a poem, “The Guest House,”12 in which the poet Rumi commands you to welcome into awareness the dark thoughts and feelings of chaos, disruption, and powerlessness, and to respond deliberately—by be
ing available, open, receptive, and—yes—cheerful. Easier said than done, I thought. I tried slowing down. I would take a breath and wait before responding—to make sure that I was not reacting out of anger or impatience and was not severing the tenuous connection I had with them. I invited them to slow down too. Even with the pressures to rush to a decision, I encouraged them to take a few more minutes to make sure they were comfortable. Eventually, they seemed more present too. They could finally respond thoughtfully to the question “Right now, what are the two or three things you’d most wish for—for Laura and your family?” With the passing days, they allowed us to provide pain medications and attend to Laura’s comfort under their close watch, and they could not but notice that she was more peaceful, more comfortable. To my amazement, after she had died a few days later, her family expressed gratitude for our team’s care.

  MAKING SPACE

  Cognitive neuroscientists are now beginning to consider how the interior and personal experience of presence manifests in the brain. As you can imagine, studying presence is one of the hard problems of neuroscience—much harder than studying attention, memory, or perception—because it is so subjective. In exploring the meager research on presence, I was surprised with what I found. My sleuthing led me to research on video games and virtual reality, environments in which people become so fully immersed that they feel that the situations are real, sometimes even more real than real life. Players enter into relationships with humanoid avatars, experiencing a sense of shared presence as if their “companion” were alive. The electronic medium and all of its artificiality seemingly vanish, and people achieve what the Italian neuroscientist Giuseppe Riva calls “embodied immersion”;13 your sense of self dissolves, perhaps like the feeling of presence that musicians, teachers, and doctors feel when they’re at the top of their game.