I enjoy work like Thomas R. Egnew’s article, published in The Annals of Family Medicine. Egnew asks a simple but profound question, and the answers open up new avenues for understanding the role storytelling plays in a medical relationship.
If healing is a part of medicine, why is there no
operational definition of healing, nor … any explanation of its mechanisms?
Egnew briefly mentions two possible reasons for this. It’s likely that
modern medicine considers holistic healing beyond its orthodoxy. As proof of this, there is no MeSH heading on MEDLINE for “healing”, but there are
qualifiers [to “healing”] associated with the spiritual and religious aspects of illness and recovery.
Egnew admits that the paper’s argument relies on the connection of medicine and healing, but the
industrialization of health care in the United States may render the results of this study superfluous1:
That healing remains a core function of medicine is questionable, because modern medicine focuses on the efficient dispersal of biomedical services, not healing. Still, patient care remains a core function.
patient-centered approaches to clinical care are having positive impacts on the patient-physician relationship and health outcomes,2, 3, 4 we should consider how we can help clinicians and professionals expand their view to include healing. If “healing” can’t be part of modern medicine, its advantages can at least be incorporated into patient care.
The Three Components of Healing
Conducting a series of interviews, Egnew identifies 3 main components of healing as relayed to him by “allopathic physicians”:
- Narrative, and
Egnew admits that “wholeness” is itself difficult to define. The discussion, though, centers around two characteristics of wholeness. Wholeness can be best described by noting its absence. Also, wholeness and therefore, healing itself
is independent of illness, impairment, cure of disease, or death. One physician interviewed noted,
I certainly have seen people finding a wholeness as they die.
Isolation, loss, and a personal feeling of inadequacy characterize a lack of wholeness. Reflecting on my own personal experiences with illness, there was always an awareness that this affliction is definitely happening and definitely happening to me. At the same time, though, I oddly didn’t want to think that my condition was me, or that those experiences were somehow a part of me. Egnew reports that illness
denies most conceptions of what it means to be yourself and that drives to the heart of my own experiences.
I reflected on Egnew’s discussion of illness as isolating, too. During my illness, I was physically, literally, and socially in isolation. I was in a hospital room far from my everyday life. I was in literal isolation because of a drug-resistant infection. I was also in self-imposed social exile. Who wants their friends to see them, emaciated and full of holes? The fact remains that physical separation is a simple consequence of illness and convalescence.
Egnew’s discussion of narrative picks up this social theme: narrative is a social phenomenon. One of the overarching themes in the article is that healing is more likely when there is a continuity of care and a relationship between professional and patient. Narratives are richer, more meaningful, and more useful when they are told over time and in the context of someone who knows the previous narrative.
Connected with this is the idea of healing as a reinterpretation. James W. Pennebaker and Janel D. Seagal wrote in the Journal of Clinical Psychology that putting experiences into words changes how the teller thinks and organizes trauma in their head. In the same vein, the physicians Egnew interviewed reported that it’s difficult for patients to change how they think about illness
until they’ve told you the story.
All of these ideas are stitched together in Egnew’s final component of healing: spirituality. Like wholeness, spirituality is difficult to define. Egnew discusses various aspects or results of spirituality, including harmony,
when what you know, and what you say, and what you feel are in balance, and reconciliation. Egnew mentions both interpersonal reconciliation and a personal reconciling and acceptance of illness and suffering.
All of these ideas converge on Egnew’s definition of healing:
In summary, healing was defined in terms of developing a sense of personal wholeness that involves physical, mental, emotional, social and spiritual aspects of human experience. Illness threatens the integrity of personhood, isolating the patient and engendering suffering. Suffering is relieved by removal of the threat and restatement of the previous sense of personhood. Suffering is transcended when invested with meaning congruent with a new sense of personal wholeness. Wholeness of personhood is facilitated through personal relationships that are marked by continuity. … Healing is the personal experience of the transcendence of suffering.
Suffering, Healing, and New Narratives
The key that ties all of the ideas together is suffering. Suffering — in whatever form — is part of the human experience. Suffering creates a
crisis of meaning5, which demands that we form some new narrative in line with our experiences during and after the illness.
Transcending suffering — healing — requires that we find some meaning in suffering.
Egnew has created an
operational definition for healing, and opens up new avenues for exploring how healthcare providers and patients can better communicate. The main question becomes “How do we engage suffering without inducing it?”
Empathy offered inopportunely, however, exacerbates distress, and inordinately emphasizing biomedical data delegitimizes the suffering contained in the patient’s story.6, 7, 8 Some physicians question the legitimacy of being a guide for patients or find the moral authority associated with the role uncomfortable, whereas others fear the intense feelings encountered on the healing journey.9, 10 Not knowing how to engage suffering risks iatrogenically inducing it.
I don’t have easy answers to how physicians can better engage suffering in the interest of healing. I do know that the answers are tied in with the ability to hear and understand the patient’s story.
Even though it is the patient who must find the meaning that transcends his or her suffering, the physician can catalyze this process by sensitively attending to and engaging the patient in dialogue regarding the patient’s suffering.
The article reviewed: Egnew, T. R. “The Meaning of Healing: Transcendental Suffering.” Annals of Family Medicine 3, no. 3 (2005): 255–62. https://doi.org/10.1370/afm.313.
2 Stewart, M., et al. “The Impact of Patient-Centered Care on Outcomes.” The Journal of Family Practice 49, no. 9 (September 2000): 796–804. ↑
3 Little, P., et al. “Observational Study of Effect of Patient Centredness and Positive Approach on Outcomes of General Practice Consultations.” BMJ (Clinical Research Ed.) 323, no. 7318 (October 20, 2001): 908–11. ↑
4 Krupat, E., et al. “When Physicians and Patients Think Alike: Patient-Centered Beliefs and Their Impact on Satisfaction and Trust.” The Journal of Family Practice 50, no. 12 (December 2001): 1057–62. ↑
5 Barrett, D. A. “Suffering and the Process of Transformation.” Journal of Pastoral Care 53, no. 4 (1999): 461–72. ↑
6 Reich, Warren Thomas. “Speaking of Suffering: A Moral Account of Compassion.” Soundings 72, no. 1 (1989): 83–108. ↑
7 Morse, J. M. “Toward a Praxis Theory of Suffering.” ANS. Advances in Nursing Science 24, no. 1 (September 2001): 47–59. ↑
8 Kleinman, A., and J. Kleinman. “Suffering and Its Professional Transformation: Toward an Ethnography of Interpersonal Experience.” Culture, Medicine and Psychiatry 15, no. 3 (September 1991): 275–301. ↑
9 Hooft, S van. “Suffering and the Goals of Medicine.” Medicine, Health Care, and Philosophy 1, no. 2 (1998): 125–31. ↑
10 Verhey, Allen. “Compassion: Beyond the Standard Account.” Second Opinion 18, no. 2 (October 1992): 99–102. ↑