A Letter to Elizabeth

By Steve Paulus, DO

Dear Elizabeth,

Nine years ago you were carried through the doors of the urgent care clinic where I worked in Santa Cruz. Do you remember? I can recall that day as if it were only moments ago—May 15, 1992. Even now, I still keep you alive within the periodically lit caverns at the frontier between my consciousness and the depths of the unconscious. Isn’t it interesting or odd or paradoxical how we can have certain events indelibly imprinted into our memories? An imprint that is always available, waiting for the proper trigger. Today the inciting stimulus was Mozart’s Concerto for Clarinet in A Major. I am sitting in my favorite coffee house absent mindedly listening to Bach when unexpectedly, my favorite Mozart concerto, shifts my attention from absent to present. This piece always moves me to the interface that connects awareness to inner realms inhabited by shadows.

You appear and I know it is finally time to bring this shadow, which means our story, into the healing presence of light. Not the invading light of scrutiny, but the soft glow of diffuse light only associated with healing. Eventually, you achieved your healing—I still need to find the final link to complete my circle of healing.

I feel compelled to tell our story just one more time; perhaps this is the last time I will need to reveal this intimacy. I hope, this telling will end my struggle and allow for the last elements of healing to enter the shadow that still tugs at my heart and in some distant way holds me back.

At 8:55 PM on a Friday night, your sister carried you into the clinic. How do I remember the day and time so well? This was supposed to be the last five minutes of a 13-hour shift where I saw a total of 89 patients. This was my third 13-hour shift in the same number of days. Tomorrow was my day off. I was free to be ordinary—to not assume the responsibility of being a physician. When you entered, I was already gone. My physical body was in the clinic, keys in hand ready to lock the front door; but my overly taxed mind, my fragile and exhausted emotions, and my compassion were already home, in bed desperately needing to recharge.

Your sister spoke for you, because the walk from the car to the exam room was exhausting—you were collecting the small reserves of energy, trying to bring them together in order to have enough potency to talk. Even talking was depleting. What a great gift your sister was to you. She was your conservation manager; allowing those reserves of energy to only be used for the necessities of healing rather than the superficial non-essential endeavors that proved physically and emotionally exhausting. If anyone doubts the existence of Guardian Angels, they only needed to see and experience your sister to know the existence of beings of Divine intervention.

After you reconnected a fuel line to a deep reservoir of strength, you finally spoke and finished your story. You had Breast Cancer and had two more chemotherapy treatments remaining. Your radiation therapy had ended two weeks earlier. The toxicity of the chemo and radiation was ravaging your body. At 5 feet 2 inches you were never large by anyone’s standards, but now your body was shrunken by everyone’s verdict. You were thin (at 85 pounds), nearly hairless, colorless, drained, and depleted. There was a thinness to your tissues—I could almost see through you!

I impatiently waited for you to end your introduction. Then, I rudely interrupted and blurted out, “What do you want from me. I am not an Oncologist, go see the doctor who orders your chemotherapy treatments.” Obviously sensing my irritation your sister carefully and softly said. “ We heard you were an Osteopath and our friends told us you were different, that you had a special way of helping people.”

It was in that instant that fatigue mixed with cynicism and ignorance blended to produce the opposite of my finest moment. I was discourteous, impatient, and insensitive—I just wanted to go home. You did not want me to function as an orthodox physician. You did not want additional medical interventions. You wanted me to use the training I received as an Osteopath to help you ease the suffering. Please don’t interpret my explanations as an excuse. I take full responsibility for my actions and inactions. Somewhere, somehow in the process of my training to become a physician I periodically misplaced my compassion. I too often became a mechanic repairing machines rather than caring a physician helping patients (human beings who have become ill or injured). I became logical, scientific, linear, and closed-minded.

In the training process to become a physician (the same is true for MD’s and DO’s) patients are often seen as the enemy. War, sport, and disaster metaphors dominate the language of medical school and residency; rather than the hale images of care, recovery, or healing.

We were positively reinforced for being efficient rather than kindhearted. We received pats on the back for remembering all the lab values on the patient with congestive heart failure in room 201 rather than knowing how many grandchildren he had. If patients emotionally reacted or cried we were told to call in a Psychiatry consult. God forbid if we were ever seen as being a “hand-holder.” That was not scientific. Sometimes I felt as though I took a deep breath at the start of medical school—and when you saw me I had only just started to finally exhale; which means I also failed to inspire.

Please know that not all doctors translate the training process in this way. A very small number of doctors in training (with constant attention, vigilance, and courage) maintain the humanistic qualities of care and compassion.

You came to me open and receptive. I came at you full of ignorance. I say ignorance because at that time I chose to ignore who I truly was. I chose to deny my innate sense of compassion. I chose to superficially present a linear, technical, and mechanistic approach to the care of patients. That is mostly how I was trained and how I chose to interpret the allopathic (the western medical) portion of my education. I was trained in Osteopathic medical school to distinctly separate medicine and surgery from the beauty of Osteopathy. Please know that when you saw me I was still emerging from the trauma of medical school and I intermittently slipped back into bad habits.

I am asking for your understanding as well as your forgiveness. I am not making or offering excuses. My experience with you was a pivotal and sentinel event in shaping the kind of Osteopathic physician I am today. I went home after offering you nothing and felt terrible. I knew I had been insensitive and uncaring. I cried off an on for the entire night. I cried the kind of tears that can cleanse and heal the depths of one’s soul. The next day, even though I was off work, I went to the clinic with the intention of calling you. I wanted to apologize, to offer some way to help. When I got to the clinic, there was a letter from your sister.

Your sister expressed your deep disappointment and profound sadness at not being received by me. Emphatically, she also told me not to call; your next chemo treatment was the following day. The weight of this letter slammed my neat and well-ordered misinterpretation of medical practice and shattered my life. You gave me an essential lesson in humility. You helped to dispel a particular brand of ignorance that was insidiously destroying the original reason I became a doctor. Your lesson continues to speak to my conscience and my awareness of the sacred duty each physician enjoys.

I am sorry . . . and, I am thankful that you taught me how to remember who I am and what my duty is, even when I am tired, distracted, mentally busy, or in pain. I can now hold the container of compassion even on the difficult days. I never know when my last patient, on a Friday, at the end of a frenetic week may have great needs demanding my complete attention and full awareness. I now realize that the same Great Teacher who sent you to me, may be sending me another lesson—when I least expect it.

With deep reverence and Love,

Elizabeth died November 2, 1992