David Zigmond, Physician in psychological medicine; retired GP

Published in JHH15.2 – Healing Journeys

My initial medical training was in the 1960s. My subsequent decades of work have been as a frontline practitioner: as a small practice GP and a large hospital psychiatrist and psychotherapist. From the beginning of my work I have been intrigued by how we may best understand, balance and weave together art and science; humanism and technology; imagination and data. I believe that much of our current malaise in healthcare services is due to losing sight of these questions, and then our better sense and sensibility.

Man’s loneliness is but his fear of life

Eugene O’Neill (1927), Lazarus laughed

Recently I was meeting and talking with a friend when I became suddenly and unprecedentedly disabled: abdominal pains, intense nausea and retching, and a frightening general weakness and hyperaesthesia – I felt dangerously vulnerable and without a protective skin. Yet I had, somehow, to get home; to thread my way through jostling and heedless crowds and the convergent push of the London underground. I craved my defensible space, to collapse.

Home and exhausted, I managed, with plummeting life-force, to leadenly climb the stairs to the support of my bed and soft containment of the duvet. I needed oblivion and primitive containment. My senses and primevally imagining hind-brain told me I may be dying. Yet my now[1]flickering forebrain was able to feebly interject: ‘No! You’ve probably got something like a Norovirus, that’s all. You’ll be fine, later’. But I wasn’t interested in later. I felt so vulnerable and ill that death now would be a liberation…

The mattress and duvet were essential, but not sufficient: I needed also human connection – a resonance of consciousness in this empty house. With great difficulty I managed to send a minimally phrased, but urgent, request to my partner. She arrives quickly in a flurry of calm but kind helpfulness. She looks at my grey face, unsighted gaze and huddled, trembling body. She is not a medic and is now unusually worried.

‘Shall I get a doctor?’, she says. ‘No … no point’, I grunt feebly, with closed eyes. She waivers with uncharacteristic inaction. ‘Isn’t there something I can do, something I can get you…?’, she sounds almost plaintive in her need to be helpful. ‘No. Just water, in that baby’s cup.’

Her fingers touch me gently on my upper chest, probably to comfort us both. I am aware of instinctively jerking away, backwards: my skinless state renders touch painful.

What then?’ She feels saddened and emptied by this unexpected redundancy.

‘Nothing else. Just be here, in the house somewhere … I need to lie here in the dark and quiet…’ I know this request is important, deep and complex, but my depleted strength denies me explanation or expression.

In several hours of semi-delirium I am aware of her careful household noises: the benign sounds of kindred consciousness. There may be nothing else she can do, but my knowing that she knows my distress, knowing that she is thinking about me with good heart, is powerfully comforting.

Late the next day – the calm after the storm – I am recovered enough for conversation. Q is relieved by the return of life in me. ‘Thank goodness! You look so much better: you looked awful … I wish I’d been able to do more, though’, she pouts, and I think I hear both blame and contrition in her voice.

‘No’, I want to reassure her. ‘Your just being here – having me in mind – made a crucial difference. More than you realise. It’s a strange but powerful truth…’

‘What is?’ ‘

Well, I wanted your presence, your witness, your compassionate thoughts – even though I knew you couldn’t do anything else. I think that is almost universal in our most painful or pivotal life events … even, or especially, our departures – our death…’ I fade into reflective melancholy.

‘Thankfully you now seem far from your deathbed, but not your complicated and morbid thoughts. Anyway, what do you mean?’ Q’s curiosity is hued with teasing, laughter and relief.

I cleave to my seriousness. ‘Well the deathbed scenario is an excellent example of much of this. We cannot there change the course of events, but by our personal accompaniment, and by bearing witness, we certainly change the nature of the experience: we imbue the ineluctable with human value and meaning … but we can only do this by creating human connection.’

Do you think most people think that?’ asks Q. ‘In a way, yes, but they probably express it differently. How else do we account for this recurring and central theme – of the fraternally embraced and witnessed death – in so much art, literature, drama and opera … and (probably) in our private dreams and reveries?’

A week later I am talking with some trainees. We are discussing the nature of pastoral healthcare – what healthcarers ‘do’ when they cannot decisively eliminate, or even contain, a problem? I discuss with them how, despite our many impressive advances in scientific medicine, we are still left with a vast residuum of the incurable and the largely unmodifiable: eventually our lives all end in this territory, either quickly or – more commonly now – very slowly.

So, I am saying, personal witness and accompaniment is certainly important in death and at times of earlier adversity. Yet even throughout life’s more resilient times we are sustained, still, by more remote forms of these: even when we are well it is important for us to know that others are thinking of us, that they have us in mind. How else do we explain the ritualistic significance of birthday or Christmas cards or, increasingly, our compulsive appetites for ‘personal’ electronic signalling?

This is an eternal and almost universal human need. Much of our lives are spent searching out buttresses against, or consolation for, our four basic existential anxieties: the knowledge of our mortality, our aloneness, our ultimate insignificance, all which must be endured in a world which may have no sense or purpose. So no wonder that we need such stroking and containment – more or less directly throughout our lives. This is even more so during our times of vulnerability when personal familiarity, too, becomes especially important. And here fate is particularly unkind, because both ageing and illness are both likely to remove us from our ‘communities’, the most reliable source of the familiar and our stroking…

An attentive trainee jumps ahead, adding his own metaphor: ‘so the malnourished can’t get to the food…’

Another has more severe pragmatism: ‘But a modern GP can’t pay attention to all this. There’s too many, more real, problems that need fixing and managing. GPs now don’t have time … Surely, these kind of problems should be dealt with by someone else.

Who?’

I ask. ‘Well, nurses, counsellors, social workers … that sort of thing. There are charities, too…’ she says, as if she could thus quickly despatch all such problems.

‘Yes, I partially agree’ I say, extending myself toward her more neatly viewed and boundaried world ‘but they will all be strangers – unfamiliar – to the patient. Often the patient will want contact with the doctor they know already, at least to begin with. That doctor can remain as their safe haven, their reliable anchor-point – even their primary attachment – in a care system that’s ever more fragmented and kaleidoscopic. Of course, some patients will necessarily see all sorts of other people, but the GP can still offer that growing familiarity and accessible stability. Personal continuity of care makes our best pastoral healthcare possible: those are the terms I like to use. These things used to comprise the heart and spine – I would say the spirit – of the better general practice, and psychiatry too…’

But we can’t do much of that now. It’s not just the time. It’s also the fact that most of us are working very part-time in large practices with complex rotas: more and more noone really knows anyone. So we rarely get to know our patients.’ She flips away her right hand. She seems, to me, wearily impatient though not discourteous.

Hm. I fear that’s the future: I’m so pleased I lived my life in the past’ I muse with reminiscence and irony.

Well that’s one thing that can’t trouble us with requirements for further planning or choice!’ she rejoins quickly. She is playful now.

Our shared laughter is genuine: sometimes humour provides the most refreshing respite.

The secret source of humour is not joy but sorrow. There is no humour in heaven.

Mark Twain (1897) Following the Equator