Thanks very much.
So, here's a doctor from New York,
dressed in black,
talking to you on September 13th.
And you're going to think I'm going to talk about death,
as did all New Yorkers over the past many days and weeks.
Well, I am.
But I'm going to talk with you about that
in terms of joy and in terms of truth.
I need to tell you a little bit about my medicine
in order to get to the joy.
Todd is right that I came to medicine,
not knowing a whole lot about it,
but I came to medicine because I was a life-long reader.
I was the kind of kid who would get 10 books out of the library
and read them all before they were due,
and I hope many of you were like that too.
And as a reader, I understood, once I opened my practice,
once I finished all the business of staying up all night being an intern,
that what I did in the office, what patients paid me to do,
was to pay exquisite attention to the narratives that they gave me -
which were in words, in silences,
in those facial expressions that we saw earlier today,
in their body, in how the body changed,
in the tracings and pictures that we had of their body,
in what other people said about them -
and that it was my task to cohere these stories
so that they, at least provisionally,
made some sense;
to take these multiple contradictory narratives
and let them build something that we could act on.
So that's what we did.
I realized right away
that I didn't know very much about stories even though I was a voracious reader,
and I went kind of timidly to the English department -
I was at Columbia already -
I went to the English department;
I said, "Could you teach a doctor
something about stories and how they work?"
And God bless them,
the English department was very happy to take me in.
You know, I wrote prescriptions for them;
(Laughter)
I gave them referrals.
But I think they really joined me in the idea that the knowledge they had,
very specialized narratological knowledge,
could do something good in the world.
They didn't let me out until I had a master's degree, a PhD.
They let me write a dissertation on Henry James, who is my beloved author.
And I want to tell you how the story training -
awakening and nourishing my own sense of story -
how it transformed my teaching and my practice.
This was not the first time that anyone had put literature with medicine.
By then - this was the '90s already -
by then, there were persons in - I hope you know this -
in philosophy, in history, in literary studies, in ethics
who had come into medicine,
and they were all helping us to improve our practice
based on human learning
in addition to the scientific knowledge we all had.
So, I was by no means the first one
to bring literary studies into the practice of medicine.
But somehow, by starting as a doctor first
and then getting all this training in stories and how to understand them,
I think I had a more -
my sleeves were more rolled up in using this knowledge.
So my colleagues and I at Columbia
kind of invented, or created, a field that we called "narrative medicine,"
which we define very simply as clinical practice
fortified by the knowledge of what to do with stories.
So that with these skills -
in first of all having a sense of story,
and then being able to recognize when someone is telling you a story,
to absorb the story,
to receive it whole,
to receive all of it,
including even those unsaid hints and guesses
about what might be left unsaid,
to absorb them,
to interpret them,
to honor them,
and then to be moved by them
and to be moved by them to action.
So this is what we called narrative medicine.
We found very effective, economical ways
to teach
the skills of reading and writing and storytelling and receiving
to medical students, nursing students,
doctors, social workers, chaplains, patients, families -
all the people who come in and out of hospitals.
I'm assuming that some of you are from healthcare,
either as professionals or as patients or as families.
You know the kinds of silences there are in those elevators in hospitals.
You know what happens when you pass someone in the hallway
who has no legs or who's bleeding.
You know that.
Our challenge was to bring to these people,
perhaps used to illness,
perhaps hardened against it,
ways to open their own springs of imagination,
of creativity,
of receptivity
so that they would not just not lose their sense of story,
but, indeed, build it.
There were amazing transformations in my practice.
I work in a rather shabby clinic in Presbyterian Hospital,
which is in New York - in the way, way upper parts of Manhattan -
and as I improved my own capacity to read closely,
where every word counts,
I was able to learn how to listen closely,
where every word counts,
So, in the office, when I saw a new patient,
I wouldn't ask millions of questions anymore,
like, no doubt, many of you have been asked by doctors.
Typically what we do, faced with a stranger,
is we kind of start at the top and work down.
I'm sure you've had this:
Do you have headaches?
Do you have nosebleeds?
Do you have trouble with your hearing? With your swallowing?
Do you have trouble with your breathing?
And all the way down.
And what operations have you had?
And what allergies do you have?
And what medicines are you on?
So I learned not to do that,
and instead to say,
"I will be your doctor,
and so I need to know a great deal
about your body and your health and your life.
Please tell me what you think I should know about your situation."
And when I did that,
and when I let persons simply answer,
instead of writing things down or typing or computing,
I would simply sit in my chair,
hands in my lap,
and absorb what was being said.
And what I learned, right from the beginning,
is that persons were not only able but deeply thirsty
to give profound, detailed,
eloquent accounts of themselves.
They didn't always know how or how to start.
One woman says, "You want me to talk?"
(Laughter)
Another man, one of the first to whom I made this invitation,
started to tell me about the death of his father
and then the death of his brother
and then the trouble he was having with his teenage son.
And then he starts to cry.
I broke my silence: I said, "Why do you weep?"
He says, "No one ever let me do this before."
So a woman I saw - I just saw her a few days ago when I made a house call.
Well, she's been my patient for a long time.
She -
as anyone I speak about or [write] about,
knows what I'm to say,
has read what I've written
and has given, as we say, informed consent for me to do so.
So I'm not breaking any secrets.
I certainly won't use the name, but she has - we have her blessings.
She had breast cancer 20 years ago.
She had a mastectomy -
sorry, she had a lumpectomy, small operation.
She was on medicine for five years; she was told she was cured.
About a year ago, she developed a lump in that same breast.
On biopsy, it was a new cancer.
She was stoic about the recurrence.
She underwent a mastectomy this time.
It's a big operation; it was a disfiguring operation.
She declined breast reconstruction.
She said she was too old for that.
And she recovered uneventfully from the surgery.
But then she began to worry that the cancer would come back.
She was in my office every other week.
On the off-week, she was in the office of the breast surgeon.
She felt a new lump;
she felt something funny under her arm;
there was something not right about the scar.
She was terrified that it would come back.
We kept reassuring her:
"No, that's just how the tissues heal";
"No, that's your cancer markers."
We did blood tests to make sure there was no cancer.
I did an ultrasound of the scar.
She could not be reassured,
and so she thought that we were deceiving her.
Finally, after another one of these exams,
breast examinations in the office,
I thought I could imagine what was deep to the scar.
I leaned back against the sink in my office.
I told her I thought I understood what the fear was.
I told her I thought what she feared was that she would die,
that she had the courage and the vision from these two illnesses
to know what many of us know but refuse to really face up to:
that is simply we will die.
I told her that I thought she was in the glare of this knowledge.
I said, "We don't know what will end your life.
Your body may well harbor now the disease that will do so.
It might be the breast cancer.
It might be something else.
But we know something will take your life."
I said I couldn't do more than we had to assure her of her health,
but here is something I could do:
I could stand with her in the glare of that fear.
And right after that conversation, I checked back with her by phone.
She said she felt much better.
She felt much more relaxed.
She wasn't worried the way she had been,
and she was sure that I was right.
Now, the way I knew that,
the way I came to understand it is that I'd been writing about her,
and I'd been showing her what I wrote about her.
And in that way, we made contact through her illness,
through her fear,
through the glare of death
that was there now, in the room with us -
as it always is -
but there it was in the room with us,
and we could ...
accept it.
And more than that, we made contact through it.
It helped me and this woman to understand what medicine is for,
and even bigger than that,
in excess of the medicine, what ordinary living is for.
It's for the making of contact.
It's through the contact.
And of course, illness exposes,
so that I'm privileged as a doctor
to be in situations where there is very little separating me from a patient.
Do you see what I mean by "exposes"?
You're down to the floor of who you are in the presence of illness.
So, not only did we kind of help the immediate problem
with her own fear,
but we made enduring, life-long contact -
the two of us.
This is possible all the time.
I told her -
I think I told her about a novel by John Banville called "The Infinities,"
in which he overhears Zeus
up on Mount Olympus
looking down at these mortals that he's created,
and Zeus envies the human beings their mortality.
He says, "It's your death that gives your lives meaning."
And so my patient and I understand that,
that it's in the dying, in the limits of the life,
that we have our meaning,
and that we pour ourselves into those things that endure -
the family, progeny, work, art, dance,
life,
play.
Those things that will endure
in time and with others
are those things that give us meaning.
And they're only available to us
through the presence and the truth of death.
When I say, "What is medicine for?"
my patients have been able to teach me, as have my students, what it's for.
When we teach narrative medicine in groups,
it doesn't matter who - doctors, nurses, chaplains, patients, families -
we all join together in a clearing.
These narrative storytellings help us to form clearings -
you know, in the forest
when the trees kind of thin out, and it's moss and it's ferns? -
and we're able,
many different ones of us
from often rather divided camps,
can come together in the clearing of storytelling,
and within the clearing of this human gift of mortality,
and that's where the truth is exposed,
and that's where the freedoms emit.
What medicine is for
is to donate the expertise to an act of fidelity,
to give someone company
and to form staunch, sturdy affiliation
within our clearings,
within our dyads,
within our shabby clinics
so that no one has to be in the glare of sickness,
or even the glare of death,
alone.
I'm fortunate to be a doctor to be able to do this.
Anyone in any enterprise
has the chance for making contact,
as in this room - a clearing.
Thank you.
(Applause)