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The James A Vohs Award
••Spring 2000 / Vol 4, No 2

Comments from the Journal EditorsAbstracts from articles published in other journals
Clinical articles on the practice of Permanente medicine
Poetry, Art, Musings from Permanente clinicians
Nonclinical articles on external issuesArticles from a Systems perspective
Book ReviewsCommentary, articles from Medical Directors










Editor's Comments

Healing Physicians: Physicians Healing
Tom Janisse, Editor-in-Chief

In Western medicine, as a discipline and profession, physicians practice science, not healing. Attention to the "art" of medicine has waxed and waned over time in an attempt to characterize the other part of what physicians practice with patients--that interpersonal dimension, that feeling state, the caring for a patient who is ill with a disease. This artful practice can be viewed within the realm of a healing practice.

The word "healing" has recently surfaced within the practice of medicine. Though still peripheral, healing is heard in healthcare conversation, and is visible in articles and in books related to medicine. Actual healing practice is more common in alternative medicine, and appears foremost in the ancient practice of shamanism--a spiritual practice. The shaman--better recognized in the Western world as the "medicine man" or the "spirit doctor"--aids the transformation of a person from illness to health, often in a ceremonial setting. Using ritualistic practices, the shaman invokes the spirits (within humans, and from the non-ordinary, spiritual plane) to diagnose the causative factor, then heals the person, restoring balance or "wholeness." Based on the original derivation of the word, to heal is to make whole.

In his book, "The Spirit of Healing," David Cumes, a Stanford-trained surgeon, raised in South Africa, introduces to Western medicine the Kalahari desert shamans' practice of healing medicine. He cites four factors involved in shamanic healing, that are similarly present in today's doctor–patient encounter:

  1. The healer
  2. The patient's inner healer,
  3. The place, and
  4. The universal field.1

Stanley Krippner, psychologist and paranormal expert, author of many books including "Spiritual Dimensions of Healing: From Tribal Shamanism to Contemporary Health Care," offers a confirmatory perspective, based upon his experience with alternative practices. He describes four basic reasons why treatments in any therapeutic setting work:

  1. The practitioner's personal qualities,
  2. The person's expectations,
  3. The treatment, and
  4. A shared world view.2

Viewing these two sets of four components side-by-side broadens our understanding of the interactive nature of these aspects on effective healing.

Physicians may have lost a sense of the importance they play as a person in their interactions with their patients. A purely intellectual exchange with only a physical outcome is often ineffectual in treating a patient's condition, which has both a physical component and a personal component (psychological, emotional, social, spiritual). Knowledge of the shaman's practice can assist redirecting a physician's practice toward a more balanced approach. This does not require physicians to learn completely knew skills, or practice unfamiliar ceremonial rituals in their office. Rather, the physician's personal self (the healer) can connect in "the human moment"3 with the patient's personal self (the inner healer) in an office or hospital environment (the place) when both have a common understanding, or better, a common belief system (the universal field).

Before we further discuss the components of this shaman-native or doctor-patient relationship, it is important to explore the difference between curing and healing.

Curing vs Healing: Disease vs Illness
Different than curing--ridding the patient of disease symptoms and the body of the physical cause--healing not only alleviates physical symptoms, but, more importantly, resolves a person's illness--those psychological, emotional, social and spiritual aspects that cause distress. In addition, healing practices prepare a person to prevent the illness and disease from returning, and attempt, in a larger life context, to heal the family and even the community.

Illness has a very personal description and meaning. Psychologist and Native American storyteller, Terry Tafoya, cites an example: "Tomorrow in your office you see a Shoshonee Native American for worsening diabetes. If you ask, 'Why did you become sick?' He may say, 'I am sick because your people took my sacred mountain, built over our ceremonial burial ground, or clear-cut my forest.' Any of these acts could spiritually wound this Shoshonee native who believes he is part of nature, and his nature has been violated."4 This illness may worsen his diabetic physical condition.

Cultural practice can be the dominant determinant of an ethnic patient's behavior. Overlooking this context, diagnosis is a futile exercise. The following story paints a vivid image. A middle-aged Haitian immigrant woman was brought into one of our Kaiser Permanente mental health offices by a concerned neighbor. Her husband had recently passed away after a long illness. She spoke English, but not very well. Her summary statement was, "I don't want to do anything; I don't want to see anyone." She would not go out of the house; she wouldn't talk to her friends; she wouldn't have anyone into her house; and she wore only black. Based on her behavior, the therapist believed she was suffering from complicated and severe depression. The therapist treated her for several months, finding any breakthrough difficult. He suggested that she go out, see friends, have someone over for dinner. She refused any suggestions. Finally, he resorted to an exploration of her cultural belief system that might be interfering with her recovery. He asked if she would be better going back to Haiti. She said no. The breakthrough came when he asked her how other Haitian women would handle the death of their husband. She replied that a year must pass first. That only after one year of mourning--wearing black and staying inside--could she again participate in community activities. This was a normal Haitian ritual of year-long mourning. At yearend she would put on a red dress and dancing shoes and go out with friends to celebrate. Her depressive-appearing behavior was a self-imposed sociocultural belief and grieving process. She was "ill" without disease. In fact, her emotional state was one of mourning, not illness.

Stanford physician, Alan Barbour, and author of the book, "Caring For Patients," describes in the following diagram "the elements of the doctor's responsibility for the disease (the medical model) and those of the doctor's responsibility for the ill person."5

Curing a disease is a reductionist approach, fragmenting the organ from the whole person. It is an expression of the biomedical model of the body as a machine with a broken part. People are more than the sum of their parts.

1. Healer
The words "healer" and "healing" sound strange and unfamiliar to physicians since they were rarely spoken or referenced in medical school. The only reference I can recall is to "wound healing." We were trained to restore organ function, but not in the context of restoring balance, personal or family, emotional or spiritual.

Internist-author of the book "Healing Words," Larry Dossey also wrote, as editor of the journal "Alternative Therapies," an article called, "Whatever Happened to Healers?" He commented on physician training: "Medical school, instead of nurturing and developing the natural healing talents of gifted young students who have sought to help people, seem adept at extinguishing them.

The first two years seem to desensitize students with the endless lectures and information and data and memorization and the sparse contact with patients." A medical student, in a letter written to him, exclaimed that medical school "crushed the human person into the spiritless formula of science."6 How can we expect compassionate physicians to emerge from such a dispassionate training program?

Addressing a more widespread phenomenon in our modern culture, New Yorker cartoonist, Cheney, draws out an image applicable to medicine. The scene is a hallway in any office building. Several people gather around a man who just dropped a sheaf of papers that lay strewn on the floor at his feet. He presses his left hand against his chest and his right hand braces him against the wall. He says, "Really, I'm fine. It was just a fleeting sense of purposeI'm sure it will pass."7 This fleeting sense of purpose for a doctor is the caring for a person who is ill, rather than our frenetic, headlong rush to cure a patient's disease or just ameliorate their symptoms with a drug.

To accomplish this, physicians must reconnect with their own personal, emotional, and spiritual self. Dr David Cumes comments on this: "It is ego that leads physicians to believe they know best. It is ego that enjoys the patient who shuts up, follows instructions, and falls into the role of passive victim with the disease. Many physicians become disconnected from their spiritual self because of the rigors of their profession, and are thus incapable of 'seeing' the souls of their patients. Some physicians are wounded in the medical training process and so this becomes a deterrent to their ability to heal themselves or their patients. Some of the best Western physicians have shamanic abilities and often put them to good use without realizing it. However, Western medicine has difficulty validating these nonobjective methods that are not easily measured. The portal to this alternative healing is the right brain, and, for this, we need to open the heart. We need more heart in our modern system and a little less intellect."1

If we recall the yearning we had to become doctors; the desire we had to help other people; the chance, through our work, to perform a greater good, to achieve a higher purpose, how does that express itself today? Has medical school and modern medical practice dropped the enormous, dense, complex science of medicine onto the physician's heart, causing shortness of breath and profound fatigue? How can the spirit of the art of medicine energize the practice of medicine to restore the balance necessary for physicians to simultaneously treat the physical disease of diabetes and the personal distress of being an ill diabetic? Curing addresses the former, healing is what addresses both.

Even for the most intellectual scientist among us, if we are considering simple ways to connect with patients that have value for them, then the electronic medical record (accessible at the time of visit), or even the paper chart (if available at the visit), can be used to advantage. Recording several words in a social history about personal aspects of a patient or comments about family members, or important life episodes, can remind you about your patient.8 Recalling a personal moment with your patient can reconnect you at the personal level. This is true even if the patient knows you remember only because you made a note in their record. That you thought enough to note something personal, and then mention it later, demonstrates you care about them as a person, or at least that you are attempting to relate on a personal level. This is one way to act like a physician healer.

What are the qualities that a shaman (or physician healer) possesses? Rolling Thunder, a nationally known Native American shaman, describes a difference in our peoples: "Primitive people have natural human capacity, ability and powers which exceed modern humans. Moderns experience less of our human potential--in sight, sound, touch and smell--than ever before. We do so many unnatural things now, we don't know what is natural anymore."9 Our emphasis on the external and material world results in a reduced sensitivity to the internal and spiritual. Dr Cumes says: "The shaman embraces mystique rather than methodology, the compassionate and the empathic rather than the objective and impersonal, the intuitive rather than the rational. The marriage of science and shamanism creates equilibrium and fulfills the requirement of balancing the opposites for more complete healing."1

In a more mundane sense, shamanic healing attributes would fall generally into the areas of awareness, beliefs, personal qualities, practice--what we say and do. Dr Dossey notes: "Because there may be no such thing as a perfect fit between the beliefs of a physician and a patient, two of the most valuable qualities a physician can cultivate are those of flexibility and tolerance. These capacities make it possible for a physician to honor a patient's point of view, even though it may not be his or her own; and they permit the physician to consider a variety of approaches to a particular problem."10

Peter Silberfarb, psychiatrist and director of the American Board of Family Practice, says, "You'll never find out what worries patients unless you listen, and listening doesn't take a lot of time, for a good doctor. You don't have to spend a lot of time, but you have to spend time being totally focused on the person. Many patients are not looking for anything but reassurance that they'll be okay in our hands."11

These and other personal qualities of composure and confidence, appropriate emotion and body language, all build toward an endpoint of developing a sense of trust. Ultimately, it is to get beyond the purely intellectual and cognitive. It is to be a person with another person.

2. Patient
The patient is the focus of healing. Both the physician and the patient are focused on improving the patient's medical condition and on enhancing the patient's well being. Even as physicians must move past the scientist and search their inner personal self, so patients need to be in touch with their emotions, psyche, social context, and spirituality because ultimately people heal themselves. A patient who only admits his physical symptoms and seeks relief with a pill or procedure will not effectively treat his illness. Components of the patient's inner self include: their expectations, beliefs about the doctor, the treatment, the potential for improvement, the ability to interact with the doctor in a human moment, and their intention to get better. "The belief that therapy can do something to cure a problem is so powerful that this faith has to be taken into account when evaluating the 'actual effect' of different treatments."1

In addition, the support and intentions of family and friends assist the patient's efforts to heal. One of the strengths a person has is a family they are connected to and that supports them. In some families it is the grandparents who are the decision-makers and who must be consulted. When their opinion is consistent with the patient's wishes, synergy occurs.

Belief and Hope
Much has been said about the placebo response, usually to malign it, discount it, or fancifully invoke its effects out of frustration for lack of medical alternatives. Researchers are annoyed with placebo effects which, if present, must be accounted for or compensated for in the experimental group. Despite various opinions most people associate the placebo response with belief. If belief is powerful then the response can be dramatic. Shaman know the power of belief and use it to great advantage for the person they are healing.

"If healers disturb the belief system of the patient by the imposition of their own belief, they will compromise the magical ability of the system to work. Faith or belief in the healer is critical, and there must be a consistency between the patient's notion of healing and the doctor's approach. A Westerner may be satisfied with a written prescription and explanation as to how the medication is going to work; a San (Kalahari desert) native would trust a hands-on approach combined with some sweat from a San dancer in a post-trance state. Similarly, if physicians dispense treatments they do not believe in, this weakens the placebo effect by contracting the field of possibilities, and works against a desired outcome by both doctor and patient."1

How can this approach be applied in a Western medical office? "Some doctors exude a sense of unruffled calm, certainty, trust, composure, and confidence, that augments the placebo effect."1

To offer a perspective on this from paranormal research, psychologists Braud and Schlitz demonstrated in a study that one person (an influencer) could create a reproducible physiologic change (calming or activation) in another distant person (the subject) through intention and visualizing images. "Certain psychological conditions in the influencer appear to play a role in the success of the intentions and imagery: confidence, belief, positive expectation, motivation, level of spontaneity, mood, and rapport."12

3. Place
"Bedside manner," the metaphor for a physician's comforting personal presence, if not compassion, lacks visual potency in the now more common outpatient setting in the doctor's office in a large medical office. If we examine for a moment the "exam room," what pleasing aesthetics are present there to comfort, or to lend a sense of "place," important as context for a meaningful interaction between doctor and patient? Are we expecting too much from the physician in conversation or in empathy to overcome the sterility of the setting? Barren, white rooms with cold surfaces and jarring metal sounds served well to communicate that no germs lived here. But it's also difficult to find heart here. How can we expect a doctor to have an artful encounter?

Of course, healing occurs in many other places. Shaman perform their ceremonies in the wilds of nature, in communal gathering places, or in a native's residence. Place is as much about a comfortable environment of any kind. What is a strain to imagine, however, is how an exam room can achieve a sense of place. Nonetheless, many wonderful encounters occur here between patient and doctor. It is actually a tribute to the ability of two people to overcome physical structure in reaching a state of mutual benefit.

What physicians could at least attend to is the environment of their offices and exam rooms. Look at them with a new awareness and with an eye for comforting and engaging pictures and mementos, with diversity that appeals to many, and with some attention to the furniture. What is the patient's chair like? What is the room setup that allows you and the patient to interact most comfortably?

4. The Field
The fourth component of healing is the field, which can be described variously as a spiritual plane, collective unconscious, a common consciousness, or more easily understandable as: a common culture, common experiences, similar belief systems, a shared feeling state, or a shaman-native or physician-patient relationship. Ultimately, the desired state (field) is an interpersonal relationship of trust and understanding.

What complicates this, however, is the unidimensional perspective people possess in Western culture. Tafoya notes, "When we are trained to see something in a certain way we are also trained to ignore the alternate. For example, look at the image in Figure 1.
Figure 1.

We are trained to see the black space--the wave--but we don't see the white space--the spiral--or the black wave and white spiral together as a whole image."4 For many physicians to reach the field of a common consciousness with their patients requires both an alternate and a holistic perspective.

Interdependent Factors
All four of the healing factors are interdependent, with one or more of greater importance depending on the physical condition or illness, or personal relationship. The shaman or physician has great power to heal, or even to make things worse. Tafoya says, "If you try to have someone sing a song that doesn't belong to them or that doesn't fit them then we may do them a disservice, and they may not respond."4 Finding the right song has benefits for both. Joan Halifax, psychologist author of "Shamanism Voices: A Survey of Visionary Narratives," notes that, "The power of song to heal the singer as well as the listener is a persistent and remarkable feature of shamanistic songs."13

Chanting produces a field effect and can facilitate development of a calming state of mind by triggering alpha brain rhythm, and even a trance state. Some form of chanting is ubiquitous among Shamanic healing ceremonies14 to support the four healing factors by adding to the field effect and enhancing interconnectedness.

Physicians can improve the doctor-patient encounter by attending to personal qualities that enhance relationship and trust, and by recognizing their value as a healer in patients' eyes. If physicians can clearly understand their patients' expectations, and align with those, they can then import the power of the belief response to magnify the effect of their shared treatment plan. Within this dialogue, behaviors with caring intention may influence patients' healing response more than had ever been thought possible. By whatever method, creating a sense of place for this interaction adds another potent component; and finally, the field of common understanding of belief systems can create further positive benefit for patients in this patient-physician encounter.

A Moment in Time and Place
From the modern perspective of the corporate business of medicine the bottom line dictates how the doctor-patient relationship plays out. This disturbs many physicians. Edward Hallowell, psychiatrist and author of "Connect," comments on this: "The public still wants to have a doctor. It doesn't want to have a brand. It wants to have something more than a corporate image. It wants to turn to a person in the human moment."3 Achieving this human moment can be enhanced through a highly personal interaction between two people. If that personal interaction can be further enhanced as an ancient healing interaction, then we can hopefully "arrive where we started, and know the place for the first time."15

1. Cumes D. The Spirit of Healing, Llewellyn Publications, Minnesota, 1999.
2. Krippner S. Medicine and the Inner Realities. Alternative Therapies, 3:6, 1997.
3. Hallowell E. The Value of the Human Moment in Medicine. Group Practice Journal, October, 1999.
4. Tafoya T. Mental Health in the New Millennium. Multicultural Health Conference, Portland, Oregon, April, 2000.
5. Barbour A, Caring For Patients. Stanford University Press, 1995.
6. Dossey L, Whatever Happened to Healers? Alternative Therapies, 1:5, 1995.
7. Cheney, The New Yorker, January, 2000.
8. Chin H, Asst. Regional Medical Director, Clinical Information Systems, Northwest Permanente. Personal communication, March, 2000.
9. Rolling Thunder, Interview, New Dimensions Radio, 1999.
10. Dossey L. Healing Words. HarperSanFrancisco Publishers, 1993.
11. Silberfarb P. A Partisan for Psychiatry. Dartmouth Medicine, Winter, 1999.
12. Braud WG, Schlitz M. A Method for the Objective Study of Transpersonal Imagery. Journal of Scientific Exploration 3, no. 1, 1989, 43-63.
13. Halifax J. Shamanic Voices: A Survey of Visionary Narratives. Arkana:Penguin Group, New York, 1991.
14. Moffit Cook P. Shaman, Jhankiri & Nele: Music Healers of Indigenous Cultures. Ellipsis Arts, New York, 1997.
15. Elliott TS. The Four Quartets.

1. Alvord LA, "The Scalpel and the Silver Bear," Bantam Books, 1999.
2. Hallowell E, "Connect." Pantheon Books, 1999.
3. Montour L, "The Medicine Wheel: Understanding 'Problem' Patients in Primary Care," The Permanente Journal, 4:1, 2000.
4. Remen R, "Kitchen Table Wisdom," Riverhead Books, New York, 1996.



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