Deep Medicine

The Work of Healthcare: Back to the Future

William B. Stewart, M.D.

As we engage the topic of work during 2012, it might be interesting to imagine what the work of healthcare providers might look like in the not-too-distant future. In the USA, the cost of healthcare continues to rise. The proportion of GDP devoted to healthcare expenditures has more than doubled in the past 25 years. Nonetheless millions of people remain uninsured and underserved. As this is being written, debate over President Obama’s federal healthcare plan continues and a Supreme Court decision on its constitutionality is pending creating significant uncertainty among all concerned. Compared with many other countries, our health outcomes are not proportional to the amount of money we spend annually per citizen on healthcare. Furthermore, there remains room for improvement with our approach to health and illness related to access, safety, quality and satisfaction.

Looking at an issue of the magnitude of health requires invoking both the reductionist and holistic philosophic approaches. One school, the reductionist, contends that you cannot understand the whole without knowing its parts. The other school, the holistic, teaches that you cannot know the parts without understanding the whole. As is the case with most profound truths, each statement is true and its opposite is also true. Therefore, to imagine the future of healthcare we must be both reductionist and holistic. Because of the complexity and variables involved, we must look to the microscopic and the macroscopic; the cellular and the cosmic; the high tech and the high touch; and the personal and the public.

It is not enough to consider the specific inciting agents of a disease or a focused treatment of that disruptive agent without appreciating the milieu in which the disease found a place to take hold. Wellness and illness exist on a dynamic spectrum. In their earliest stages most diseases are without obvious symptoms or detectable signs to even the most learned practitioners and most sophisticated diagnostic studies. Nor is one’s health the domain of teams of experts or the biotechnical alone. Health creation is an “inside job” and requires the active participation of the individual. We cannot simply farm out our well-being to experts or surrogates.

In fact, there is no issue that does not affect our well-being. Every issue is a health issue. Physical status, emotional states, absence of meaning and purpose, inadequate housing and education, toxic environments, poverty, violence, as well as lack of family or social support are all health risk factors – and only a partial list of what impacts the status of our health and well-being and the outcome of our illnesses.  The specific signs and symptoms of wellness or disease are merely the tip of the iceberg.  What underlies these “visible”, measureable markers of health/illness include our behavioral, lifestyle, physical, mental, emotional, philosophical, spiritual, social, environmental, economic, and geopolitical realities. Furthermore, they are all interconnected like the ecosystems in which we live. From gene pool to organ systems, medication to meditation, family to culture, village to nation, watershed to biosphere, planet to cosmos — the Earth can no more survive separated from the sun than the body from the heart, or the individual from the collective.

The juxtaposition of the reductionist and holistic approaches brings us to where we find ourselves today in the arena of healthcare. Running out of money; probing our ultimate uniqueness via elaboration of the human genome; mining the riches of technology with devices that can define us and connect us in an instant and gather and collate unimaginable quantities of data while doing so. At the same time, people are seeking a less invasive, less expensive, more humanistic and relational format for healthcare. This desire is seen in the growth in popularity of complementary, alternative, integrative and holistic healthcare. Compared to contemporary high tech medicine, these high touch practices tend to emphasize the power of wellness-promotion, illness-prevention and self-care rather than the treatment of end-stage disease. They emphasize health-creating choices regarding nutrition, physical activity, rest and relaxation, creativity and work, relationship and community, and reflective and contemplative practices. These practices are proactive, preventive, personal, and participatory. They require the active engagement of the individual and initiating action even in the absence of signs or symptoms of specific disease states.

As these high touch, high tech approaches are coordinated they hold the capacity to enhance prevention, diagnosis, treatment and most importantly – quality of life. They hold the possibility to better define and measure biological markers, be they genetic, biochemical, electrophysiological or another yet-to-be-developed “vital sign”, or something as simple and commonplace as weight or blood pressure. They have the potential of being predictive for the individual in a very personal way. Have population studies demonstrated the individual’s findings to be indicative of an impending disease at a very early stage? Should s/he continue on the same path or is a change needed based on the gathered personal longitudinal data?  Is there a specific, focused treatment, compatible with the individual, which can be instituted to prevent the progression of the disease beyond this early state?

In Ayurvedic medicine (the classical practice of medicine in India) and traditional Chinese medicine, the “constitution” of the individual is determined and treatment tailored to the patient based primarily on thorough history-taking, physical examination, and an on-going relationship with the patient, his/her family, and their community. Because of the personalized approach of these systems of medicine, even people of similar age, gender and illness are likely to receive different treatments because of their unique needs. Contemporary Western medicine via its scientific, reductionist pathways is at the frontier of developing the tools to further refine such ancient empirical approaches through the marvels of modern science and technology. Will future versions of our ubiquitous cell phones be the devices to take and record personal biologic measurements? Will comprehensive genetic and blood analyses and advanced data collection and management replace today’s more limited laboratory testing, setting the stage for sequential monitoring over time and early targeted treatment intervention when deviations from the established norms are detected? Will outcomes then improve? Will this individualized biologic and data driven approach free up more time for the highly desired person-to-person interaction that defines “personalized” care in the holistic and interpersonal  way rather than the scientific reductionist way? Will integrated teams in “patient-centered medical homes” dealing with multidimensional personal and social health determinants be the next preferred healthcare delivery model across the lifespan?

There is a revolution going on in healthcare. It is not confined to debates in Congress or to decisions of the Supreme Court.  Nor is it about purely economic considerations.  It is about the true meaning of health and healing and the moral, ethical and compassionate principles and values of the practice of medicine. It is about how we can best utilize the human and other resources available to us to create individual well-being, the public health, and planetary healing. The potential for improving the health of the Earth and of those travelling upon it is monumental. We are each healers with unique medicine to contribute to this worthy work.

Resources:

Hood, L. and Flores, M., “A Personal View on Systems Medicine and the Emergence of Proactive P4 Medicine: predictive, preventive, personalized and participatory”, New Biotechnol, 2012, doi:10.1016/j.nbt.2012.03.004.

Morrison, Ian, “Massively Coordinated Care”, H&HN(Hospitals &Health Networks) Daily, May 1, 2012, www.hhnmag.com.

Dear Friends,

Gratitude for another richly inspiring call this past Saturday! Our guest speaker, the surgeon turned Integrative Health pioneer, Dr. William Stewart (fondly dubbed “Dr. Uncle Bill” by the ServiceSpace community!) riveted listeners from the very start with an eloquent explanation of “Deep Medicine”. The title of his fascinating book, and a phrase that conjures up the mystery of healing, and a conviction that it arises not just from the mind but the innermost recesses of the heart. “There is no issue that is not a health issue,” he boldly declared. Retracing his journey, this born healer delighted us with stories of his preschool days spent ‘tending stuffed animals and stepped on grasshoppers’, awed us with operating room tales from his days as a renowned oculoplastic surgeon, and moved us with stories of the ‘instantaneous experience of humility’ that he walked into while serving with Dr. V and the Aravind Eye Hospital in India. Sprinkled throughout his reflections were profound and practical insights on what it means to commit to a planetary medicine that truly heals both us and others: “We understand ‘care’ but we don’t really understand ‘self’ very well”.

Stay tuned for Bela’s recap of the call. In the meantime, for those interested, here’s the full audio recording. If you’d like to learn more about Dr. Uncle Bill’s work you can visit the Institute for Health and Healing website, browse through his personal blog or look through his wonderful book. And if you’d like a glimpse of his eloquence in action, here is a link to a beautiful speech he recently delivered in India.

Saturday’s call was twice blessed, by a moderator who is yet another shining star in the field of medicine. Dr. Sriram Shamasunder — the beloved doctor-poet whose compassionate work regularly takes him into some of the most impoverished areas of the world. For those unfamiliar with his work, here’s a DailyGood on Sri that we ran a little while ago.

And the inspiration train continues to continue! Here’s a sneak peek at next week’s speaker: Nimesh Patel — better known as Nimo — the gifted artist-musician who traded in celebritydom for a one-of-a-kind service journey that all began with a bright-eyed band of children in the slums of Ahmedabad. Next week, he along with sixteen of these children will fly across the globe on a world tour with Ekatva – a remarkable dance performance dedicated to the spirit of Oneness. A performance that was two incredible years in the making and that could not have gotten this far without an unflagging commitment to inner transformation. To RSVP visit http://ijourney.org/forest

With gratitude for the deep medicine of these calls and the community they foster.

In service,

Pavi (on behalf of the magnificent “Forest Farmers” Bela, Bill, Nipun, Kanchan, Rahul, Amit & Audrey)

–
If stories come to you, care for them. And learn to give them away where they are needed. Sometimes a person needs a story more than food to stay alive. – Barry Lopez

“The Proof of the Pudding”

William B. Stewart, M.D.

It is a well known and often heard saying that “…the proof of the pudding is in the eating.” However, in fact, it is in the digestion and assimilation of the pudding, not simply in the ingesting, wherein lies the proof or value of the pudding. Often what looks, smells, and even tastes good to us is not necessarily what is actually “good” for our health and well-being. What we “want” may not actually be what we “need”.  Sometimes we actually bite off more than we can even chew. You can’t tell a book by its cover, good things come in small packages are other common sayings which remind us that things, in the final analysis, are not necessarily what they seem initially. Until we really get into something or it truly gets into us we just don’t know. Time is needed to digest, absorb, assimilate, and integrate experiences. From an exotic meal to an unfamiliar environment to a new group or behavior, we need to process, or to use a more medical word “metabolize”, that to which we are exposed  before we can fully assess its value and impact. Whether the new recipe will ultimately cause us agony or ecstasy – at the time of eating – is uncertain.  Sometimes we bite off more than we can chew, sometimes our eyes are bigger than our stomachs, sometimes even too much of a good thing is not a good thing, and some things no matter how sweet they seem will simply not agree with us.

In the fall of 2011, my wife and I spent two months in India where we worked, consulted and studied. Although we had been to India many times before, this trip was of longer duration than usual, during a hotter time of the year, to places familiar and new, with dear, old friends and many people and destinations  we had never encountered before. We returned to home and family during the long Thanksgiving weekend and I promptly returned to work at the Medical Center the Monday after Thanksgiving. Until someone asked me “How was your vacation?” I hadn’t realized the impact our travels to India had had on me. Yes, I had been away in an exotic part of the world. However, the word “vacation” in no way captured the essence of our experiences.  It was then that I appreciated that a significant part of what I had “ingested” in India remained undigested, incompletely metabolized and unassimilated.

Although my physical body had returned home on the Thanksgiving weekend, it has taken me more than three months, a season really, to begin to digest, assimilate and integrate my thoughts, feelings, and changes with my “real” daily life and “regular” work world. This integrative process is a creative activity and as such it requires work. This personal work of integration takes quiet time and introspection. These are two activities which are conducive to the winter season, however, not conducive to the “busyness” of one’s everyday life. Personal “inner” work also requires focus and discipline to differentiate the wheat from chaff and to know what to keep and what to discard. This particular work, I hope, explains the hiatus from contributing to my usually monthly Deep Medicine blog, to which I am returning with this entry.

During this formative period of “metabolism”, I have suffered and benefitted from “writer’s block” or some related syndrome. Nonetheless, during my season of integration, a small pamphlet, “A Year of Deep Medicine”, has been published containing 12 adaptations of talks presented to clinical and administrative staff at California Pacific Medical Center, San Francisco during 2011 under the year-long theme of “Everybody Makes a Difference”. These talks make up the heart of my Deep Medicine blog. In 2012, a similar series of talks will occur. This year the overarching topic is “Working Together”.  Adaptations of these presentations will also be posted as blog entries.

Work manifests our creativity, productivity and connectivity. It can be dream-come-true and/or drudgery. It takes many forms from job to calling. Our “true” work puts us in touch with ourselves and with others, not just at the level of personal interaction, but in the sense of service to the community. Work is one of the most significant health-related activities there is. Whether working, over-worked, addicted to work, resting or recovering from work, underemployed or unemployed, work can be agony or ecstasy and often is a source of stress. We are all familiar with the multidimensional impact that stress has on our bodies, minds and spirits. At the same time work also provides purpose, meaning, contribution and fills our needs for sustenance, connection and survival.

During 2012, we will engage issues such how we are influenced by work being at the center of our adult lives; how it benefits and burdens us; and how our personal/”inner” work relates to our work in the world. I hope that you will join me over the coming months of 2012 in this exploration of work.

Adapted from a presentation at the Inaugural Ceremony

Dr. G. Venkataswamy Retreat Center (Nithyatha/Perpetuity)

AuroFarm, Aravind Eye Care System

Tamil Nadu, India

2 October, 2011

“Seeing is not merely a physical act. The heart of vision is shaped by the state of the Soul.”      John O’Donohue

Dr. “V” is a visionary, a pioneer, a teacher, a change agent, a healer, a holy man, and everyman. It is a deeply meaningful and humbling honor to have the opportunity to speak at the Inaugural Ceremony of this Retreat Center named in his memory.

When my wife, Susy, and I first came to India in 1983 with my friend and colleague, Dr. David Vastine, and his wife, Marcia, it was to teach ophthalmic surgery and to serve a recently formed eye hospital and a man with a deep commitment to service and a lofty vision – to eliminate needless blindness.

At that time, more than 25 years ago, the world was a different place. It was a time when a “cell” referred to a basic anatomic and physiologic component of the body or a small room in a jail to confine law-breakers – not a telephone. It was a time when “mail” required an envelope, stamps, and many days or even weeks to be delivered, not access to the “internet” and a few keystrokes for virtually instantaneous delivery to all corners of the planet. It was a time when we, and the first generation of the Aravind Eye Hospital “family” of ophthalmologists, administrators, and innovators, were younger than the second generation is today. That second generation, which is now accepting the reins of leadership, was out of diapers then, but not out of medical school, married, or actively in the process of raising the next generation.

We came to India to teach and contribute. We learned far more than we taught and were given far more than we left behind. The light that Dr. V brought into the eyes of his patients, into the lives of those around him, and into the world struck us like a bolt of lightning and opened, not only our eyes, but our minds and hearts – transforming us and adding us to his battle against needless blindness. Since our initial “inoculation” of the vision, mission, and people of the Aravind Eye Care System, we have become “addicted” to the compassionate service and spiritual aspiration they provide. This combination, which characterizes the “Aravind Family”, has strongly influenced our lives and has brought us back to India many times.

Dr. V’s battle against needless blindness, on the one hand, is fought in hospital clinics, outreach camps, community centers, operating rooms, and laboratories where the challenges of preventable and treatable diseases are daily encountered in endless quantity and the truths and principles of science predominate. On the other hand, seeing meant more to Dr. V than getting light to the retina. It was about illuminating the inner life and recognizing the deep spiritual reality which connects everything in the visible and ever-changing manifest world of our daily external reality. This inner battle against needless blindness acknowledges the direct experiences of the rishis of the Upanishads, the prophets of the Judeo-Christian-Islamic traditions, the masters of the ancient orient, the rationalists of the Mediterranean basin, and the shamans and medicine men and women of indigenous cultures across the globe. It is a battle against ignorance, anger, differences, intolerance, greed, unkindness, injustice and hatred – all forms of blindness.

Dr. V embodied the accumulated wisdom about the spiritual quest shared by seers and sages of all traditions from thousands of years ago up to present times as summarized and synthesized by Aldous Huxley in the “perennial philosophy”. This philosophy involves 3 main points. (1) There is an infinite, changeless, eternal reality underlying the constantly changing visible world. (2) This same reality lies at the core of every creature. We call it Soul or Self. (3) The purpose of life is to discover this reality experientially and to act on it. Our spirituality is a progressive awakening to this inner reality and a sign that this reality is seeking to emerge.

Dr. V’s battle against needless blindness is no less heroic than the battle immortalized in Arjuna’s conversation with Krishna on the battlefield of the Bhagavad Gita. Like Arjuna’s battle, Dr. V was engaging external and internal foes. Dr. V’s battle is a battle in the external world against eye disease and visual loss. A battle, no less fierce, is waged within for self-mastery and self-realization of our true self. Both battles are fought through our daily choices and actions.

When we act on this greater, underlying reality, which pervades the Universe, dwells within us, and connects us to each other and to a Unity or Divine consciousness, we act from love and do no harm. We live a caring, compassionate life, seeing ourselves in every person during every encounter. Unattached to selfish desires, egoistic pursuits, or greedy expectations, we act from a place of equanimity. When our seeing allows us to envision the deep connectedness in which we exist, we practice a deep medicine. This medicine has roots in the facts and truths of contemporary science and an appreciation of the truths of spiritual consciousness that give meaning, purpose, faith and power to our lives.

This union, this “yoga”, of the scientific and the sacred, which Dr. V embodied, brings us the tools to win the battle against needless blindness – in all its forms. Inspired and elevated by Dr. V’s transformative vision and work, may this Retreat Center always remind us in “perpetuity” of his living legacy so that we can bring light to wherever darkness exists.

“When we grow in spiritual consciousness,

We identify with all there is in the world.

Then there can be no exploitation.

It is ourselves we are helping.

It is ourselves we are healing.”

Dr. G. Venkataswamy (Dr. “V”)

1918 – 2006

The season of summer is the time of long warm days, summer vacation from school, holidays from work, and a time for dreaming.  Angeles Arrien in her classic book, The Four Fold Way (HarperSanFrancisco, 1993), defines summer by the direction of the East – where the sun rises; by the element of fire – which can warm us, cook our food, and burn or destroy.  Summer carries the resource of vision and the way of the visionary . This draws us to our dreams for the future, creativity, authenticity and truth. The way of living of the visionary asks us to be in right placement and to connect with our life’s dream, purpose and meaning. This requires slowing down, being quiet and going inward. All activities consistent with a lazy summer day.

During summer we are called to learn and know who we really are so that we can bring our authentic self and personal gifts, talents and contributions forward. Sometimes during our lives we are “forced” to hide our real selves (e.g. to conform to peer pressure, or join the corporate trance) to survive. This hiding may become a pattern of living and lead to self-abandonement and/or denial.

Read more…

From auto repair to healthcare, there is an emphasis on customer satisfaction. We are thus surveyed and tallied for any and every service we use and product we buy. The push for quantification and objective scoring is accompanied by the desire for a “wow” experience by client and provider alike.  In a culture where attention spans are short, quick fixes desired and multi-tasking the rule, this quest for excellence, if not perfection, seems somehow contradictory.

Where will these peak experiences and masterpiece-like products come from if we are unable or unwilling to invest the time and energy to nurture the creativity that ignites a flash of genius or embrace the years of training and practice that ultimately result in the master and the masterpiece?

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I have always been befuddled by the term “work-life balance”. Is our work not an integral part of our life? Is our work not part of the expression of our creativity? With or without a formal job, aren’t we involved in constructive pursuits? Is our work not an essential part of our service to our families, communities, and the “greater good” or “big picture”?

What is meant by work-life balance? What amount of work is too much or too little? Isn’t work truly part of a balanced life? Is the old adage that the only thing worse than having a job is not having a job true? Are we perhaps actually seeking work-rest or work-play balance?

In her book, The Four Fold Way (HarperSanFrancisco, 1993), Angeles Arrien describes 4 domains of life: work/creativity; health; relationship; and resources/blessings. Our work is not external to our life, it is integral. It is a part of our life, but not all there is to our lives.

Peter Block in The Answer to How is Yes: Acting on What Matters (Berrett-Koehler Publishers, San Francisco, 2003), provides insight to our relationship with work. When we are working or at work, it is still our life. Our working and non-working hours are not meant to be in opposition to or in conflict with each other. Rather what we are seeking is balance in our lives. We need balance among those aspects of our lives which are necessary, practical and useful and those that bring meaning, purpose, passion, joy and contentment. Our balance must support our individual needs and desires and the demands placed upon us by our “collectives”, i.e. our workplace, family, community and culture. This equilibrium is a moving target – a delicate “dance” between our personal objectives and the impact from the responsibilities which come our way from the various collectives in which we participate.

We exist in a constantly changing reality that repeatedly requires us to make choices and changes to achieve, maintain, or regain our equilibrium. In fact, a favorite definition of mine for health is balance. Finding, losing, and rediscovering balance educates us about impermanence, uncertainty, and the transient nature of life. Seeking balance along our own unique path we develop knowledge and skills that support our well-being, in the context of the natural and created environments in which we live.

When you are confronted with questions about your work-life balance, try to engage the question from the perspective of what really matters to you, supports your heart’s desire, your preferred vision of the future, and is a step in the direction of your life’s dream. Then the issue will be seen in its broadest context – is my life in balance?

 “Far and away the best prize that life has to offer is the chance to work hard at work worth doing.” – T. Roosevelt

Recently I awoke early with a good bit of unfinished business on my mind. My first scheduled appointment for the morning was at 9AM, and there I was awake and alert considerably earlier than I needed to be. I decided to take advantage of this early morning awakening and energy surge. I got up stimulated by the possibility of arriving at the office early and getting the jump on the day by tying up those loose ends that needed attention before the formally scheduled work day began.

As part of the preparation for this flurry of activity, I prepared my preferred morning eye-opener drink. This high powered beverage is a blend of a vital green powder, which began as algae and seaweed, augmented with macro- and micronutrients in the form of various fruits, vegetables and juices — with one’s complete well-being in mind. The final muddy green-blue color and hearty soup-like consistency (depending on the ingredients selected for the day) remind me of the rich and fertile broth characteristic of a swamp. Thus, I fondly call this breakfast beverage my “swamp shake.”

On this particular morning, rather than lingering over breakfast, I prepared a double batch, drank a small portion and chose to bring the rest with me to work. As I poured the remainder into my travel mug, I was very mindful that the mug I selected was one I usually only used for water or herbal tea, since its top was large and the lid somewhat unreliable. I made a mental note to treat this travel container and its contents with special regard.

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The individual always faces a dilemma in becoming part of a group or collective. Questions arise regarding the equation of what is given up by the individual in order to be part of the collective. Can I be free and in relationship? Can I be unique and compliant? Can I take risks, be innovative and be secure at the same time? Will my individuality be subverted to conformity within the group?

In fact, the reason each individual in a group is capable of making a difference is because we each are different. Our differences brought together with a common vision and mission give the collective, family, tribe, institution, corporation, community, city, state, country all the component parts to create a vehicle/container that moves the entire group forward with the creativity, generativity and resilency necessary to benefit the individual and the whole. To best serve the collective, rather than deny our differences and diversity, we must fully express ourselves. That is how we make a difference.

Ralph Waldo Emerson was a Unitarian minister, philosopher, and naturalist of the early 19th century who championed self-reliance and self-expression, and had a strong influence on Henry David Thoreau. Thoreau’s work on behalf of individualism, the natural world and civil disobedience inspired Gandhi, Martin Luther King and Nelson Mandala. In spite of his emphasis on individuality, Emerson saw our individuality in a collective context.  Read more…

“Every person born into this world represents something new, something that never existed before” -Martin Buber

Many indigenous cultures believe that each individual is “original medicine”.  A creation that nowhere else, never before has been created. Nor will it be again in the future. Though we share much of our genetic map, anatomy, biology and physiology with other humans and animals, no two people are the same. We may have the same number of chromosomes and bones, similar blood types and skin, eye or hair color. However, our particular genetic expression, voice, fingerprint, gait, and personality are all ours alone. No one else now, ever before or ever again, carries the same combination of gifts, talents, resources, opportunities and challenges. The unique formulation that we represent is our “original medicine”.

The term “medicine” in this usage connotes not simply a healing balm or potion, but our power. Our medicine feeds our “personal power”. It is our capacity to explore, discover, create, express, grow and heal. Our original medicine is also our “authenticity”. Our authenticity is who we are absent our roles, facades, opinions, and judgments. Authenticity represents our “true self” without self-deception or self-criticism, but with a fair and an honest assessment of what actually is, free of self-deprecation or inflation. Read more…