“The value of experience is not in seeing much, but in seeing wisely.”
– Osler, “Aequanimitas”
Recently, my family and I were leaving a restaurant, and in so doing, we crossed a large parking lot filled with a seemingly endless number of pebbles. My youngest daughter, whose hand I was holding, suddenly pulled away from me. I stopped short, about to reinforce with her the importance of holding hands in the parking lot, when I looked down and noticed that out of this legion of seemingly identical small stones she had urgently bent down to pick one up. She smiled and handed it to me.
“I wanted this rock, papa. It’s for you.”
“For me?” I was taken aback by the sudden gift. “Why did you pick this particular one?”
“Because it’s for you, papa.”
She then gently reoffered her hand, and we ambled back to the car where my family was waiting for us. When I returned home, I took the little pebble and placed it with the other small tokens of affection my children have been providing me with over the years. Tiny rocks and occasional sticks form the bulk of the odd collection with the more organic flowers, leaves, and specks of grass of yesteryear long having returned to the earth from which they first arose.
What was it about that particular rock that grabbed my daughter’s otherwise somewhat wandering attention? Perhaps it was the way a small crack had begun to cleave through the center of it. Or maybe it was the way the angle of the sun at that particular moment illuminated it amongst its, to my eyes, millions of surrounding tiny and identical stony reproductions that caught her eye. It is unlikely that I will ever know what fleeting beauty graced her presence at that moment, and it is unlikely that she will ever be able to express it. I do know it was an act of love and an opportunity to share something beautiful in a way that she could understand.
Wabi-sabi is the Japanese art of finding the beauty in what is common. To my understanding, wabi means the discovery of small imperfections in everyday objects that somehow give them an almost ironic perfection, and the word sabi represents the calm and tranquility that can be found in the ancient object that has passed its brief moment of utility. Together wabi-sabi is the lichen on a fallen oak branch, the lustrous emerald green of a dead beetle with its leg angled just so or the chipped marble that has broken away off a gravestone. It is perfection in imperfection — or rather, it is the imperfection that makes a thing perfect. It may be found anywhere and at any time if one just knows how to look.
The trick, of course, is to recognize this beauty when it is present before us. Usually, during the chaotic attempt at order that represents my typical day in the emergency department, it is very easy to become lost in a swirling maelstrom of data; vital signs, lab values, time to needle, HEART, PORT, pain and Press-Ganey scores, metrics and medication reconciliation. To practice modern medicine successfully these are necessary things but, I must insist, they are not sufficient.
In a standard medical education today we are so dialed in on the science that the art escapes us-and much to our great loss! Surely, one might not unreasonably argue that there is beauty in science. And indeed there is but the science we are taught is hollowed out in fact and mechanism; in the minutiae of chemical processes and physical laws without the farther perspective of recognizing the miracle of such a marvelous entity as a human being not collapsing under the weight of its own almost insane complexity.
We diligently examine each brick of the edifice and fail to realize that we are standing in the cathedral at Chartres. This appreciation of the beauty of each individual human being that presents to us — this acknowledgment of the true and the beautiful — is the secret art that underlies what we do as physicians. It’s really true that the beautiful is good, that the good is true and that the truth is beautiful. Science without art is mere mechanism-like winding up a robot. This type of medical practice frustrates patients and physicians alike, for we are not robots to be programmed and troubleshot, and we don’t appreciate being treated as one. Knowledge comes, but wisdom lingers. We forget our Tennyson at our peril.
Do we really practice without art in the modern era? I do not think we are bereft of its joy, but we are as watercolors left out in a rainstorm. The colors are blending together and bleeding away. We speak of the “chest pain in room three,” the “miscarriage in room seven,” and the “cardiac arrest in the trauma bay” without thought to the terrible anxiety in room three, the devastating sense of loss in room seven or the sudden interruption of a life and all of its wondrous connections (and the ramifications caused by its sudden absence) in the trauma bay. We blindly enforce guidelines upon patients based upon a 30-second chief complaint and a set of vital signs rather than engaging with and examining patients to see if they might benefit from a protocol. We allow ourselves to be called, and tragically sometimes refer to ourselves, as providers rather than physicians. This is akin to confusing a great work of art in a museum with the cheap reproductions in the gift shop.
No, thank you! I would prefer to have a physician care for me. Is that elitist? Yes, but only in a way that is, almost ironically, uniform to all of us as patients. I demand that my physician can discern and appreciate that which marks me as not an automaton — who can find the spark of my humanity. The physician that patients long for, and that we long to be, can seek out that spark in all comers; the neglected nonagenarian, the crack dealer in handcuffs, the howling newborn, the apneic opiate addict, the grief-stricken and the jubilant, the lost and the found, the broken and the whole … and on and on and on.
A physician can find heart disease in one’s ear lobes, liver disease in one’s eyes, substance abuse in one’s fingertips, dementia in one’s handwriting, despair in one’s feet and venereal disease in one’s gait. A provider can bill and code. A physician can practice the art of wabi-sabi in the human being and in so doing catch a glimpse of the soul. A physician can find amongst the seemingly ordinary that which makes one magnificent. A provider takes what is magnificent and turns it into a bland and nearly meaningless statistic.
Sometimes, as I see patients on a busy shift and start to pigeonhole them into a chief complaint or worse, a billable chart or a collection of data points to plug into a decision rule, I am reminded by my daughter that there is beauty in the world and that it is all around us. Vita brevis, ars longa. In medicine, this is the art of wabi-sabi practiced on the human spirit but, of course, to see it, we must know how to look. This takes time. It takes a hell of a lot of effort, but it is this skill that imbues honor on the title of physician and to preserve this honor. We must preserve this dear art of ours. If we fail, we will indeed be mere providers, fit for automatons and robots, for corporate guidelines and government statistics, but not worthy of men and as such, not deserving of the honorific physician.
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