Pain and suffering are ordinary and inevitable features of the daily lives of doctors and their patients. Sickness hurts - the limiting dyspnea of congestive heart failure, the stepwise losses of multiple sclerosis, the emotional burdens of AIDS, the visceral pain of advanced cancer. Being a doctor can hurt as well - helplessness and sadness in the face of untreatable disease, guilt over real or imagined lapses, anger at excessive demands of manipulative patients, the actual physical distress inflicted by medical training, and fear for one’s own health. Although, as psychiatrist and novelist Stephen Bergmen (writing as Samuel Shem) insists in Law IV of the House of God, "the patient is the one with the disease," attention to the suffering of both patient and doctor can increase the effectiveness of care for sick persons and would-be healers and is therefore essential.

An observation from child psychology can help to explain the double suffering of sickness. Infants are found to engage in so-called parallel play, during which the play of one infant has nothing to do with the play of a neighboring infant. Only as the infant matures is he or she capable of joining another child in true play, an activity that, by being shared, achieves cooperative meaning. Similarly, doctors and patients sometimes engage in parallel suffering. Both patient and doctor suffer, but their suffering is isolated from one another. As a consequence, the suffering of both patient and doctor is needlessly intensified. Not uncommonly, the doctor or the patient is blamed for the suffering of the other. The isolation, wordlessness, and blame of parallel suffering hurt all who are involved: the doctor, the nurse, the patient, the family, and all who must witness the pain of any of the participants.

For sure, the suffering of the patient differs fundamentally from the suffering of the doctor. The lived experience of a sick person is incommensurable with - although not always less bearable than - either the torment of the house officer or the chronic distress of the physician in practice. A 28-year-old woman learns that her unfaithful husband has infected her with HIV. A 55-year-old man’s colon cancer recurs eight months after what he and his doctors had regarded as curative surgery. A 76-year-old woman gradually develops Alzheimer’s Disease, leaving her five daughters unrecognized and devastated. An 82-year-old man with metastatic prostate cancer can tolerate neither his agonizing skeletal pain nor the mental confusion of opiates. In these as in any physical disease, the body turns on itself, leaving the person who ordinarily lives in that body feeling adrift, enraged or betrayed. Because so much of physical and emotional pain is inexpressible, disease also can leave the patient mute and out of reach.

The physician, on the other side, can suffer similarly intense pain. The intern is summoned to the Emergency Room for her fifth admission, a febrile incoherent injection drug user with a PT of 38, a CD4 count of under 100 and copious hematemesis. A junior resident in July is paged about a patient who becomes comatose shortly after a lumbar puncture upon which the junior had insisted. An attending internist is sued because a patient, appropriately anticoagulated, died of a massive cerebral hemorrhage. Another attending is awakened at 3 am by the police reporting that the doctor’s depressed patient was found dead in the bathtub. The doctor who presumes to take command - as must all doctors - can feel hounded by disease, stupid in the face of nature, and responsible for all bad outcomes.

The doctor’s relationship with the body is opposite to that of the patient’s: if the patient’s awareness of his or her body is heightened during illness, the doctor barely admits to having a body at all. The doctor allegedly can work with no sleep, no regular meals, no self-care, as if placed above the dictates followed by patients and other humans. Both doctor and patient, then, can be in peculiar and non-sustaining relationships with their own bodies and may be, for different reasons, separated from the daily and usually unnoticed physical activities and rituals that give ballast to their lives.

Eventually, doctors are able to transcend the limitations of and the meaninglessness of parallel suffering. Once the residency is underway or over, the doctor learns to acknowledge and set aside his or her own pain and, as a result, is freed to focus on the predicament of the patient. As the doctor recognizes his or her power (not just biomedical power of curing but also the human powers of presence and hope) and as the practice of medicine becomes more satisfying (because one is better at it), the doctor can become more fully engaged in the patient’s situation. Called compassion or empathy, the capacity to reach another human and to recognize another’s predicament can be learned, strengthened, and used to improve medical practice. Once considered either innate or passively absorbed from saintly teachers, compassion can be developed by the most concrete, the shyest, the angriest, or the most narcissistic medical trainee. Compassion overcomes parallel suffering: instead of two people suffering in isolation from one another, two people are concentrating on the plight of the patient and are working together to figure out how best to face the cause of distress. The doctor’s suffering does not disappear, but rather is trumped by the experience of being of help. Since the patient feels safe in the doctor’s knowledge, he or she can better participate in curative, chronic or supportive care.

Compassion in the doctor-patient relationship canonizes neither doctor nor patient. A structural feature of an effective medical partnership, compassion focuses the personal and technical forces of medicine, making the care not sentimental and passive, but accurate and comprehensive. With compassion, the care is aimed properly and intelligently - not scattershot and anonymous but centered squarely on the individual patient’s physical needs and personal predicament. Theologian Simone Weil writes that "the love of our neighbor in all its fullness simply means being able to say to him, ‘What are you going through?’" The doctor with compassion learns to ask that question and listen attentively to the answer.

As a bonus, the doctor practicing such medicine replaces dread or boredom with satisfaction and surprise while the patient replaces anonymity and unspoken fears with a sense of being cared for and known. There are risks to such medical practice. The doctor will have to tolerate more of the patient’s pain and the patient will be less able to hide, through denial, from the reality of disease. On balance, these risks are not grave enough to outweigh the tangible benefits.

Medical education and training may be risk factors for the absence of compassion. Medical school and residency training teach reliance on logico-scientific knowledge, that is, the universal and replicable knowledge of the world attainable through mathematics and scientific processes. What compassion requires is narrative knowledge - a particularized, storied understanding of the meaning of events that befall individuals - that is used to comprehend such narratives as myths, novels, newspaper stories, fairy tales or scripture. If logico-scientific knowledge permits objective and reliable observations that can lead to generalizable findings, narrative knowledge supports an individual’s comprehension of singular events, relying on metaphor, allusion, and associations with personal experiences and feelings to discover meaning despite ambiguity, contradiction and mystery. Through attention to such elements of narrative as plot, time, and intention, suggests literary critic Peter Brooks, one becomes "engaged in a prime, irreducible act of understanding how human life acquires meaning."

Doctors have the rare chance to combine these two kinds of knowledge. Obviously, doctors have to master such logico-scientific operations as diagnostic hypothesis-testing, epidemiologic predictions of risk, and decision-analysis of benefit. At the same time, though, they confront individuals whose stories, if you will, are falling apart. Because illness disrupts the seamless identities people construct for themselves, the suffering that accompanies illness proceeds, in part, from narrative instability. Tell a quadriplegic man that he is the same person he was before his dive. Tell a woman with metastatic breast cancer that she has not been irretrievably altered by her tumor, her treatment, and her prognosis. Tell the parents of a congenitally deformed neonate that their lives will return to so-called normal. In addition, then, to the care accessible through logico-scientific knowledge, these patients need intensive narrative care: they need to be helped to recognize themselves, through and beyond their illnesses, recapturing the threatened personal unity conferred only through narrative coherence. Writes novelist and critic Anatole Broyard, "Illness is a form of incoherence. I could only become coherent if I were to get well or if I were to die." The compassionate doctor can enable patients to regain coherence despite serious or terminal illness. In addition, through the honesty that comes with compassionate recognition of people’s situations, the doctor will remain healthier himself or herself, drawn neither into neurotic heroisms nor nihilistic routs but be able to be practical, resourceful, and present for the patient throughout the ordeal.

What does a doctor do to increase his or her capacity for compassion? Tendered through narrative means, compassion (or the capacity for it) is developed through narrative means - reading stories, writing them, telling them to others. Doctors do their work by listening to stories and deciphering their meanings, however chaotic the teller or overwhelming the crisis. A student becomes a physician on the strength of his or her powers of narration, for in the telling of the case is the knowledge demonstrated and in the grasping of its meaning is medicine fully practiced. And a patient is healed when the body is set right or the story is heard to the end.

Acts of reading - following metaphors, recognizing allusions, identifying narrative voice, adopting alien points of view, reading one story in view of others told by the same teller - train doctors to become competent interpreters of what their patients try to tell them. Like a reader with a novel, doctors have to enter the narrative world of strangers, not importing their own values or culturally inflected ways of seeing the world onto the report of another, but finding coherence within the givens and world-view of the teller. They have to exercise the clinical imagination as they listen or read, asking themselves such readerly questions as "Why is she telling me this now?" or "What is being left unsaid?" or even the much more simple and profound, "And then?"

Doctors ought to read whatever suits them, for it is close reading itself that confers narrative competence, rather than the content of a particular book, and one can argue that the benefits of literature in medicine are achieved by simply reading the best books ever written. Nonetheless, pathographies - books written by patients or patients’ family members about their sicknesses - may be particularly helpful to doctors trying to fathom what their patients go through. Pathographies provide full, rich, nuanced reports of illness that bring the reader directly into the patient’s life. Some books such as Simone de Beauvoir’s A Very Easy Death, Gilda Radner’s It’s Always Something, Anatole Broyard’s Intoxicated by My Illness and Other Writings of Life and Death,⁸ Paul Monette’s Borrowed Time: An AIDS Memoir and Reynold Price’s A Whole New Life provide immediate and compelling entries into the world of patients.

Although reading certainly exercises the organ systems required for compassionate medical care, writing or telling narratives are equally effective paths to that goal. Medicine is one of the few learned professions whose work is done in longhand. Doctors write about their patients at great length - in so-called progress notes in medical charts, in referral letters, in office visit notes. Because it is governed by strict rules of structure and voice, the medical chart attains the status of a literary genre. Its generic rules severely constrict the doctor’s presence. The passive voice, the use of the omniscient narrator, the detached objective observer required by the medical chart conspire to leave the writing person out of the story altogether.

Such personal erasure is essential to effective and objective medical care, no doubt, and yet much of what occurs in the care of sick people is emotionally charged and evocative of painful personal memories for the doctor. One thing that helps doctors to achieve a balance between the detachment required for effective medicine and the engagement required for compassionate care is to write in narrative genre about patients in their care. Although such material does not belong in a hospital chart or other such medicolegal document, it needs to be written in some form.

Many medical journals, including the Annals of Internal Medicine, The American Journal of Medicine, and the Journal of the American Medical Association regularly publish doctors’ reflections about their practices. Students in many medical schools, including P&S, are encouraged by their faculty to write about the personal experiences they undergo during their clinical clerkships, not to dramatize what occurs on the hospital wards but to find coherence in what otherwise may feel chaotic, surreal, or crazy. Many practicing doctors routinely write - in journals, diaries, or letters about the patients who move them, who drive them crazy, who mystify them, or whom they will mourn, because acts of writing tap into personal sources of knowledge not otherwise consciously available to the writer.

Those doctors with no time or inclination to write can still do something else. They can tell their stories to their peers. A psychiatrist in the British National Health Service, Michael Balint, introduced doctors to the practice of telling, in small confidential groups of colleagues that meet regularly over time, about their problem patients. So-called Balint groups allow general practitioners to reflect about their patients in terms wider than the strictly biomedical. Members of these groups discuss patients who bedevil them, and talking about them with supportive colleagues often leads to otherwise obscure solutions to clinical or interpersonal problems. Routinely talking among trusted peers about the patients one worries about or feels guilty about or loves inordinately (as happens commonly in medicine) can have striking results. Doctors find that they are not the only ones to have hateful responses or loving feelings toward their patients. They discover new methods of being with such patients that enable movement, or even movements, of fundamental change to occur. As described by general practitioner Oliver Samuel, "Learning about the patient’s condition was replaced by experiencing what the patient was feeling. The doctor was suddenly engaged in the situation, rather than studying it from outside."

Ordinarily, doctors narrate clinical events either in the service of biomedical care (attending rounds, consults, discharge summaries) or in highly private confessional situations, as when a doctor divulges a fear about a patient to a spouse. On the whole, non-doctors are not very good listeners to such stories. A husband or wife will learn not to ask "How’s your guy?" when the answer concerns blood, pain and death. However, when doctors talk to one another about the technical and human dimensions of their experiences with patients, they gain clarity, a sense of proportion, and, when needed, absolution. Such conversations lend a narrative coherence not only to the patient’s experience of sickness, but also to the doctor’s experience of caring for patients and, over time, can deepen the doctor’s skill and worth to patients. For students and housestaff in the ambulatory setting, the Physicians-In-Charge (PICs) and the Firm Chiefs are available to listen and help with difficult or troubling patients.

Doctors do not come effortlessly to be able to recognize their patients’ full predicaments or to provide selfless, compassionate care. The pressures of sickness can force doctors and patients into positions of parallel suffering, in which their helplessness and blame overcome their generosity and capacity to be of help. However, when narrative skills are exercised and when the salient cognitive and imaginative faculties are strengthened, any doctor can learn to join with his or her patients, to grasp the full meaning of suffering endured, and to lessen the burden of illness on all involved through his or her attentive presence.