WEEKLY NEWSLETTER 7TH FEBRUARY 2020

Healing as a Servant Instead of a Prophet

Michael Lee, Jr., M.D., J.D.

We had just completed a dramatic 3 hours in the emergency department: one patient in shock, another in status epilepticus, and a third with multiple traumas after having been hit by a car. I took one self-congratulatory moment before checking the board. Fortunately, there was only one new patient, and he was waiting to be seen for a less urgent problem. I shook off the stress of the past several patients and walked over.

The lights in J.’s room were off, and the room was quiet — eerie, almost. We could hear the soft beep of a pulse oximeter next door. Trying to muster some energy and put the patient at ease at the same time, I sat gently on the countertop to introduce myself and to hear his story. J.’s symptoms had started 6 months earlier with persistent nausea; he didn’t vomit, but his appetite had steadily declined. He’d lost 15 pounds in the past 2 months, his schoolwork had deteriorated dramatically, and he’d withdrawn from his friends and hobbies. He’d made five previous medical visits — including visits to his primary care physician and two different emergency departments — and his mother fretted that everyone he’d seen had reported that his laboratory studies were normal and sent him on his way without a “real” diagnosis.

The first half of my response, shared while I examined his abdomen and pupils, was easy and automatic: we would check a few labs, evaluating J. for celiac disease or inflammatory bowel disease while screening quickly for a cancer. But then, having reached the heart of the issue, I paused. I spent a moment simply looking at J. His unshaven, teenage face looked haggard, and his thin, gangly frame was curled up on the corner of the bed. He was too withdrawn to make eye contact. I realized belatedly that he hadn’t yet said a word; his mother had been speaking for him.

J. needed me to be honest with him — to tell him that I suspected his symptoms were manifestations of depression rather than a primarily gastrointestinal issue and that help was available — but I hesitated, knowing how often such conversations went poorly. Typically, I would recommend a behavioral health evaluation and outpatient follow-up for somatoform symptoms, and the patient and his family would resist. Usually, they saw my recommendations for low-intensity interventions as a sign that I didn’t take their suffering seriously; in the face of that perception, my training and our institution’s reputation meant very little to them. The seemingly ceaseless arguments about antibiotics for fatigue, magnetic resonance imaging for chronic abdominal pain, and subspecialty consultations for just about anything I could imagine usually left me exhausted and my patients dissatisfied.

Recently, weighed down by these ever-present conflicts, I had been contemplating the story of Naaman, from the Old Testament’s Second Book of Kings. The Bible describes Naaman as a “great man” — a prominent, valiant general from the nation of Aram. But Naaman had leprosy. Seeing him suffering from this disfiguring, debilitating, and highly stigmatized illness,1 one of his household servants — a young Israelite girl, kidnapped by raiders and held captive in Aram — spoke up. “If only my master would see the prophet who is in Samaria!” she said, referring to the famed Israelite prophet Elisha. “He would cure him of his leprosy.” Eager for a cure, Naaman loaded 10 talents of silver, 6000 shekels of gold, and 10 sets of clothing onto his horses and chariots and traveled to the door of Elisha’s house in Israel. There, a messenger greeted him with an easy prescription: “Go, wash yourself seven times in the Jordan, and your flesh will be restored.”

Far from being overjoyed at the simple, low-intensity treatment plan, Naaman became enraged. “I thought that he would surely come out to me and stand and call on the name of the LORD his God, wave his hand over the spot, and cure me of my leprosy. Are not Abana and Pharpar, the rivers of Damascus, better than all the waters of Israel? Couldn’t I wash in them and be cleansed?”

In the famed prophet’s absence, and with their master on the verge of abandoning his chance at healing, Naaman’s servants spoke up. “If the prophet had told you to do some great thing, would you not have done it?” they asked the general. “How much more, then, when he tells you, ‘Wash and be cleansed!’” Naaman, conceding the point, “dipped himself in the Jordan seven times” and was healed. He then returned to Elisha to express his thanks. Elisha — in person this time — accepted Naaman’s gratitude but refused payment, sending the great general off in peace.

I had applied to medical school imagining the satisfactions of Elisha’s role: drawing patients from far and wide, dispensing healing recommendations, and being offered gratitude in exchange. But lately, as my supposedly expert pronouncements continued to collide with patients’ unmet expectations, I’d noticed something else about the story. Elisha, the famed prophet, had done no better with Naaman than I was doing with my patients; it was the encouragement of his servants that truly benefited Naaman. One young girl, setting aside the fact of her own kidnapping, pointed Naaman toward the healing that was available in her homeland. And a cohort of other servants, unnamed and mentioned only as a group, accompanied Naaman hundreds of kilometers south to a foreign and frequently hostile country. They brought his burdens to the door of the prophet’s house, hoping that the gifts they had carried would be adequate payment, only to be met instead by a messenger. They lived in a society where lepers were stigmatized and exiled,1 and they had spent years hopelessly watching their master’s disease progress. Finally, after watching and listening over the course of a long journey, they spoke up at the critical moment — offering not prophecy or expertise on leprosy, but the still, small truth that Naaman needed to hear.

Remembering the example of Naaman’s servants, I refrained from imposing third-party expertise on J. Instead, I asked to speak to him alone and had simply one question: “Tell me what you’ve been feeling.” He didn’t answer at first, and so for a few moments we simply sat quietly in that dark room. Slowly, he described his symptoms: palpitations, nausea, and headaches, along with fear, worry, and perseveration. Things had gotten worse, not better, when he had stopped going to school. The isolation seemed to exacerbate his symptoms; attending events with friends ameliorated them. He talked about his plans to apply to college as a biology major and his hope of attending medical school someday. As he spoke more freely, he began making eye contact.

Together, we looked up the clinical definition of depression. J. turned on the lights in order to read better and walked through the criteria, checking them off one at a time. Later, with his mother back in the room, we reviewed the laboratory testing that indeed came back normal; he asked what each test meant, and together we reviewed the diseases, from celiac to Crohn’s, that he didn’t have. When it came time for our behavioral health specialists to evaluate him, he engaged with them eagerly and shared his story with them, too. “J. states,” they wrote, “that he’s been thinking a lot about what Dr. Lee shared with him about physical symptoms of depression and anxiety. ‘That’s exactly what it feels like,’ he says.” As his anxieties and fears emerged into the open, where J. could receive help for them, I felt my own faith returning, too.

Some of my patients arrive in extremis, needing immediate rescue; some present with intellectually stimulating diagnostic puzzles. But I’ve found that the encounters that stay in my heart are those with patients like J.: people who tread wearily into my care, having already seen other expert physicians to no avail. For these patients, it is often not my knowledge or training that matters, but my willingness to accompany them, however briefly, on their journey before speaking the quiet, simple truths that can point them toward the help they require — to attend to them not as a distant prophet, but as a trusted servant.

The patient’s initial and some identifying characteristics have been changed to protect his privacy. Disclosure forms provided by the author are available at NEJM.org.

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