Sunday, October 28, 2018

LOVE IN CLINICAL PRACTICE (part 1)




In my first years as an attending physician, I would sit in a workroom and listen to residents tell me about the patients they saw. And sometimes it was clear that the resident found a patient especially emotionally challenging. And as we got up to go back and see the patient together, I would tell the resident: “OK, let’s go bring the love.”

The way I said it back then had the wry, tossed-off feel of the language of doctors-in-training and doctors-just-done-with-training. In that time of our lives, many of us say things that we mean deeply, in a tone that suggests nothing is all that important. When you’re just starting out, you’ve either got to act like the weight is less than it is, or sink under it.

Later we get used to the idea that everything is important. We accommodate ourselves to the weight of the work. We just say it. And the learners tagging along with me these days can do with that phrase what they will: we’re going to bring the love. Without irony or apology.

Since then, some increasingly serious and earnest version of “bringing the love” has become ever more central to how I think about my practice. And yet I struggle with how to talk about love, and how to express and use it in my work.

For many clinicians, technical prowess is nearly sufficient, and the simple consistency of good customer service makes up the rest of the balance. In fields of medicine that allow for this, clinicians may be more efficient, less exhausted, and at least as useful for their patients, if they lack spiritual aspirations or leave them mainly for family and community. One need not speak of love if you can just show up to work and do the job.

And yet in at least some areas of practice, sufficiency of technique and service seem somehow still not sufficient. People drawn to these areas of practice are often clinicians who seem to feel some kind of calling, some aspiration emerging from a sense of purpose not focused on competencies but on connection.

Such clinicians have the potential to be terrible for their patients. Connection without competency, in the clinical setting, is a pernicious scam.

But let us presume, for the moment, technical competence. What is the rest?

Some portion of the remainder resides in the territory of spiritual love. It has something to do with what bibles of the 16th and 17th century translated as “lovingkindness”, a translation also used for overlapping Hindu and Buddhist concepts. All of them add up to some broad feeling of unconditional compassion.

And yet it is also more specific than that: I search for it deliberately and intensely for my patients in a way that I do not for other people; and in a way that other people do not for my patients. If there is a broad spiritual element of this feeling of love, it is also true that there is some special type of effort required to create this particular love, specific to a professional relationship with a particular person. I seek this kind of love with my patients, and my patients only.

Let us assume I can remove any hint of sexual desire or agenda from the relationship; failing to do so is a betrayal. And not incidentally, since I take care of a patient population with a horrifyingly high prevalence of past and current sexual coercion and violence in their histories, to express a professional love is both dangerous-feeling and also deeply important.

So, it should go without saying, but is nonetheless worth restating: there can be no mixing of types of love. Love, if it is part of why and how I do my work, must be completely compatible with my professional role. Meaning, it is what I should bring to the work regardless of who you are; it is ideally what you get by hiring me for the job of being your doctor. And if the best waiters and bartenders and school bus drivers can bring the love in their daily work, so should I be able to follow their examples.

Still, how do I dare speak of love? Even without sex mixed in, love can feel dangerous and unpredictable. This is because love is mostly perceived as an individual relationship; and indeed, if love claims to be unconditional, it almost never is. There are rules of engagement. You have to follow the rules, or the most important ones anyway, to get the love. 

Even when love is steady, it is difficult for either the giver or receiver of love to distinguish between some hard-to-reach, hard-to-define ideal of enlightened spiritual love on the one hand, and an easily-perceived warm individual relationship. If it’s about two people—and not about a doctor trying to bring love to all of her or his work—then it also has some degree of conditionality, and thus a greater possibility of pain, sewn into it.

Even when love is not painful, it is a drug that some people grab at for longer than is good for them. In this way, a gift of love can expose a bottomless need in its receiver.

And love can be a trick: unkept promises of love, and convincing illusions of love, are insidious tools of manipulation and power. Love appears in advertising slogans for everything from all-wheel-drive station wagons to Latin American despots. It is easily grabbed at and waved about by those whose true motives are not love. 

Even leaving aside pain and need and deception, the very idea of love is inevitably vague and imprecise. At best, to speak of love in any of its forms is to risk sentimentality and treacly irrelevance.

In the clinical setting, to talk seriously of love, to organize oneself around love as an idea, is probably an act of hubris. If as a clinician, I say that I want to bring love to my work, how do I explain the accumulated hours of my day in which I was distracted, overwhelmed, barely present, irritated, frustrated? If I fail at love more than I succeed, how much can I pat myself on the back for "bringing the love" when I manage it?

And let me set aside one other form of love. Some of my patients are so deeply soaked in shame, in a feeling of worthlessness. that I feel the need to somehow convince them that they are worthy. If I were a more religious person, I could simply tell them that they are God's children, or that Jesus loves them. I know that even though I was not raised in the church, and am not a church person now, some of how I think about love in my clinical work comes from Christian tradition. But this gesture, even if I were qualified to make it, would risk making the medical visit the tool of evangelism, instead of at the service of the patient. It is not love if I give away buprenorphine to sell Bibles.

But for all this, I find that when I can find my compassion and loving kindness, my sense of love for my fellow human, it does actually influence the relationship and makes me a more powerful and trustworthy clinician. I remember one conversation recently where the person I was talking to was becoming more and more frustrated, focused on achieving a goal he'd come to get me to help him with that I wasn't going to help him with, and I found myself getting into that defensive mode, starting to get ready to push back.

And then I consciously remembered: bring the love.

And I quietly, not so he would notice, took some slow breaths and I looked at him and tried to summon up love for him. And over the next few minutes, the conversation turned. I brought something else to it, something more believable; he visibly calmed and began trusting me just that little bit more; and we ended up talking in a collaborative and more honest way. A close replica of love can certainly serve as a successful clinical tactic. But it is not love if it is just a tactic. For a clinician who can operate this way, one might hope it could become a way of life, a force of spirit and power of intention that moves past the electronic medical record, peels away the billing codes, gets to what's important.

Many clinicians find and work with love in clinical practice from time to time, golden times, complicated times, It is important to many of us. And it is especially important with those who society has pushed aside, the people who stand alone, who have beaten and exploited and abused, who doubt their worth. The people who need the love.

Yet, as I think about all of its problems and caveats, love as a part of clinical practice remains difficult to achieve, and it is undoubtedly full of treachery and problems.

In other words, when love becomes a professional aspiration, I think it should inspire suspicion and skepticism. 

And yet, I still can’t shake the feeling that, on a good day, it’s what I come to work to do.




(...probably to be continued.)


* * *

In a different context, Robin S asserted, 
"Words are so easy to say; you've got to show me love."
Massive early 90s gay club hit. Still a groove to be reckoned with, in my medical opinion.






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