Medicine and the Ministry of Presence
Medicine and the Ministry of Presence

Medicine and the Ministry of Presence

Recovering one of medicine's most underrated yet precious resources: time.

And he said, “My presence will go with you, and I will give you rest.”

—Exodus 33:14

Night after night I sat alone in my one-bedroom apartment overlooking a picturesque street in the heart of Beacon Hill, unable to appreciate its beauty, or beauty around me in any form. For months I’d been putting one foot in front of the other, hanging onto my patients’ need for me to be there for them as the only reason to hold on myself. My body ached and was slow; much slower than it’d ever been. Tasks that used to take ten minutes took nearly the entire day. The two-block walk from my apartment to the hospital took almost an hour. I couldn’t recall the last time I’d eaten more than a few bites. My clothes were falling off my frail frame.

As a psychiatry trainee, I’d diagnosed and treated hundreds, if not thousands, of people with depression—I knew the signs, I knew the symptoms, I knew the treatment. And I knew mine was bad.

Each night, alone in my apartment, I carefully weighed the balance of continuing another day. My work with patients as a psychiatry fellow kept me tethered and connected to a world in which I felt completely alone. The work, however, became all-consuming. While it was keeping me alive physically, it was slowly killing me at the same time. I knew that if I had any chance of recovery, I’d have to stop working. I also knew that work was the only thing I had to live for at that moment. Through the grey-tinted glaze of my depression-coated lenses, the black and white was all I could see.

That’s the thing about depression. It thrives on isolation and loneliness.

After months of sitting alone in my depression, existing—but not truly living—I reconnected with a mentor and supervisor from my internship year. We’d stayed connected over the years, but it’d been a while since we’d last spoken, and after running into one another in the halls of the hospital, she suggested we get coffee. As the little energy I had was being used at work, my instinct was to decline. In the midst of a horrible depression, demoralized and overwhelmed, I was embarrassed that I was anything but thriving.

I said yes to coffee anyway.

And out of that afternoon coffee came a relationship that quite literally saved my life.

My former mentor was someone I looked up to and admired. She was accomplished in her field, revered by her residents and adored by colleagues. I was surprised when she shared with me her own story of depression—from the depths of darkness through her journey to recovery and healing.

In her sharing of her story, I was suddenly not so alone anymore.

What started as a mutual understanding of one another’s pain and suffering became a transformative relationship built on presence.

She sat with me during some of the darkest and scariest moments of my life. She held my depression with me, lifting ever so slightly the burden I’d been carrying around for months. And in the sharing of her presence, she held hope for me—hope that I had been too ill to hold on to for myself.

So often, as doctors, we want to do—we want to prescribe meds, cut out tumours, stop the bleeding. And all of that is necessary. But what’s often missed in modern medicine is the healing power of being present with another person.

It’s not medication that saved my life (though it has helped enormously). It’s not therapy that saved my life (again, it has helped tremendously). It was her presence in my life. It was in no longer being alone. Only then was I able to truly start my healing journey from the darkest depths of depression to what is now a much brighter, more hopeful future.

***

John Donne famously wrote that solitude is a torment not threatened in hell itself. Today, tragically, many people are experiencing their own isolation and loneliness, made yet more oppressive by our year-long pandemic. Even before COVID-19, US Surgeon General Vivek Murthy was sounding an alarm about the epidemic of loneliness in our society.

In his 2020 book, Together: Why Social Connection Holds the Key to Better Health, Higher Performance, and Greater Happiness, Murthy highlights human connection’s critical importance to our mental and physical health. He argues that “loneliness is a natural signal that our body gives us, similar to hunger and thirst . . . that’s how important human connection is.”

As the diary entry of the young psychiatrist above reminds us, the path of isolation can lead us down into the deep, dark caverns of depression. Yet the sacrificial ministry of presence by a teacher and mentor provided her the lifeline. Without the older physician’s willingness to abide with her young colleague and help bear her burdens, recovery might not have been possible.

This has not always been the case in the medical profession, as demonstrated in a wonderful but neglected book by the British art critic John Berger titled A Fortunate Man. Consider the following narrative from this 1967 portrait of a country doctor in England and its stark contrast to the common experience of patients today:

A doctor was finishing a call at the home of an elderly woman suffering from congestive heart failure, newly complicated by pneumonia. Her husband, seated in a chair, remarked that just the day before she had seemed quite well. He began to cry, tears welling up in his eyes. The doctor, who had already picked up one of his bags, leaned back in his chair. “Can you make us a cup of tea?” he asked the daughter. Though in general an impatient man, he knew it was not yet time to leave.

This story offers insight into one of medicine’s most under-remarked yet precious resources—time, or more to the point, presence. The doctor had other places to go, other things to do, other patients to see, but he recognized in that moment that he was being called to remain at the side of a human being in distress, to give his time and attention to ease another’s suffering. He did not open up his bag, pulling out a bottle of pills or a syringe. Instead, he sat back down and gave of himself.

What did the doctor and the grieving husband talk about? Not the survival curve of heart failure or patterns of antibiotic resistance in community-acquired pneumonia. To the contrary, their conversation centred on the orchard at the back of the house and the quality of the apples that year. The doctor was not lingering to offer any words of wisdom on mortality but simply to listen to a man who needed someone to talk with. He was, in a sense, listening to the man’s heart, but it was the kind of auscultation that requires no stethoscope.

From the economic perspective of contemporary US health care, it was a bizarre encounter. The man wasn’t even his patient. In consideration of the doctor’s time, no diagnostic or billing codes would be assigned, no revenue generated. And lingering at the man’s side carried a high opportunity cost—the doctor was not seeing other patients. Yet there he sat, waiting for the tea to be prepared, to cool sufficiently to drink, and sipping it at leisure, as if he had nothing else to do but shoot the breeze. A casual observer might have concluded that the doctor was idle. But he wasn’t.

The doctor was practicing the medicine—the ministry, really—of presence. Largely neglected in medical education and all but completely ignored by contemporary health-care metrics, some might question whether presence is really a thing. After all, it seems such physicians are merely taking up space, passing the time, and getting nothing accomplished. Do they have time they need to kill before their next visit? Was an appointment cancelled? Are they simply resting?

No, they are not wasting time. They are in fact putting it to good use. They are exercising this most priceless yet equitably distributed resource to its fullest extent, tending to a person less as a body in need of repair than a spirit in need of comfort, and recognizing that every person reaches points in life when the only thing anyone can offer is the balm of companionship. Sometimes merely being there requires everything doctors have. It isn’t so much that Berger’s doctor is talking or listening. He is abiding. Though a visitor, he is practicing hospitality.

Something similar happens in the book of Job. The greatest man in the east has lost all his property, his family, and his health. He is sitting in ashes, having fallen as far as a human being can possibly descend. But when his three friends Eliphaz, Bildad, and Zophar show up, they do not attempt to make things right or talk him out of his despair. Instead, they take their places at his side and simply sit with him for seven days and seven nights. They practice a ministry of presence. Only later do they make the mistake of trying to explain what has happened to him.

Centuries ago, hospitals were conceived along similar lines of hospitality. They served the sick and injured, but they also provided shelter to travellers, food and clothing to the poor, homes for the lame and infirm, and spiritual sustenance to those in need. Those who founded hospitals intended them to minister to whole human beings, whose care often required patience. Discharge planning was not the top priority, and some patients remained for months, years, and even lifetimes. The hospital and the people in it would be there for them as long as was necessary.

Suffering can be likened to a journey. Physicians cannot know the entire path, but they have travelled along similar roads. They cannot remain at their patient’s side throughout an illness’s full course, but they can accompany them through especially difficult passages. They cannot carry their patients, but when the load grows heaviest, they can share their burdens. Along such journeys, knowledge and experience are important, but so too is wisdom. And sometimes the wisest thing to do is simply to be there.

Embodiment can be viewed as a curse. It is only because we have bodies that we are subject to disease and injury. Blood vessels can become blocked, cells can turn cancerous, organs such as the brain can begin to degenerate, and every tissue in the body can be parched, torn, burned, or crushed. If only we could transcend our frail frames, we might suppose, life would be happy and carefree. No wonder human beings throughout history have dreamed of invincibility and immortality—witness how superheroes dominate contemporary cinema.

Yet embodiment is also a great blessing. It is because we are embodied that we can be there for one another. Although we could opt to be somewhere else, we choose to be present with the one we are caring for. And as we commit our bodies, the mind and the heart can learn to follow. As we are present physically, we can learn, through mindfulness, meditation, and prayer, to be fully present in mind and spirit. We can learn presence’s true meaning.

There is a difference between those who merely sit by the bedsides of patients and those who practice presence. Sitters, typically hired at minimum wage, often fall asleep. Those who practice presence, however, are intentionally present, not merely putting in their time but intending to serve those they are attending to. Presence in this sense is a continuously renewed commitment, dedicating our awareness to another person in need. In discovering presence, we learn to live and to be. In learning to be present, we discover what a gift it is to be alive.

Of course, presence need not be silent. It is equally possible to be present in conversation, genuinely immersed in what is being said. In good circumstances, words can enhance presence, helping us to achieve an even greater degree of connection with another person’s thoughts, feelings, and experiences. We can listen to another’s story and share our own. It is largely through words that we get to know and care for one another, deepening even further our being together.

Viewing it in this way, there is more purpose to presence than we might otherwise suppose. When Berger’s doctor requests a cup of tea and the young psychiatrist’s mentor remains at her side, they are dedicating part of their lives to another human being. More important than the amount of time spent, they are undistracted, intent, and fully present. In so doing, they are dispensing one of medicine’s—and humanity’s—priceless gifts, one not dissipated but deepened in the act of sharing.

Jennifer Leah Goetz
 
Jennifer Leah Goetz

Jennifer Leah Goetz, MD, is an assistant professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine. She is double board-certified in general adult psychiatry and child and adolescent psychiatry. She serves as an attending physician in both the inpatient child and adolescent services and in the eating disorders program at Johns Hopkins Hospital and is the medical director of the child and adolescent inpatient unit.

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James W. Lynch Jr.
 
James W. Lynch Jr.

James W. Lynch Jr., MD, is professor of hematology/oncology and serves as the assistant dean for admission at the University of Florida College of Medicine. He is a nationally recognized expert in the diagnosis and treatment of lymphoma and a lifelong medical educator. He has been recognized as a distinguished teaching scholar at the University of Florida and in 2019 received the Lifetime Achievement Award from the Society of Teaching Scholars. He serves as the board president for the Christian Study Center of Gainesville.

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Richard Gunderman
 
Richard Gunderman

Richard Gunderman, MD, PhD, is Chancellor’s Professor of Radiology, Pediatrics, Medical Education, Philosophy, Liberal Arts, Philanthropy, and Medical Humanities and Health Studies at Indiana University, where he also serves as John A. Campbell Professor of Radiology. He is the author of over eight hundred articles and fifteen books, including a 2020 biography of Marie Curie and the 2021 history of infectious disease, Contagion.

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