Introduction

I have learned
To look on nature, not as in the hour
Of thoughtless youth; but hearing often-times
The still, sad music of humanity,
Nor harsh, nor grating, though of ample power
To chasten or subdue. And I have felt
A presence that disturbs me with the joy
Of elevated thoughts; a sense sublime
Of something far more deeply interfused,
Whose dwelling is the light of setting suns,
And the round ocean and the living air,
And the blue sky, and in the mind of man [1]

Spirituality is a rather fashionable word these days. All kinds of human endeavors are described as having a spirituality. It would be easy to dismiss this as woolly minded sentiment, which perhaps sometimes it is, but I believe that there is merit in looking beyond our instinctive prejudices to examine one fundamental aspect of medical practice that above all lends itself to spirituality. The consultation between the doctor and the patient, that cornerstone of medical activity, has been subject to much analysis but little has been written about the spiritual aspects of it.

I will attempt to define spirituality and then consider how it might be recognised in the consultation. A brief but illuminating definition of spirituality is given in Ewert Cousin’s book on ‘Christian Spirituality: Origins to the Twelfth Century’[2] where it describes as that which ‘focuses on that inner dimension of the person called by certain traditions the spirit. This spiritual core is the deepest centre of the person. It is here that the person is open to the transcendent dimensions; it is here that the person experiences ultimate reality’. Many encounters with patients involve that deepest centre of the person, whether the doctor’s or the patient’s or both. There is that sense of ‘something far more deeply interfused’ that Wordsworth describes above, the sense that we are standing on holy ground.

Few authors attempt to discuss the spirituality of the consultation. One exception is Toon[3] who touches on it in his treatise of the virtuous practitioner. He argues that medical practice can and should be based on the virtues categorised in the western Christian tradition, such as fortitude, faith, temperance, charity and hope. These will encourage the doctor to act with compassion, humility and responsibility. The virtues Toon describes are ultimately spiritual, even though he regards them as the traditional precepts of secular moral thinking. I will attempt to summarise the factors that seem to me necessary for the spirituality of the consultation to emerge.

Being there

Firstly, there is the all - important matter of being there for the patient. This means much more than simple availability, although that is a necessary prerequisite. It involves the deliberate focussing of attention on the patient and their problems to the extent that they perceive that the doctor is truly concerned about them. With time and practice, it is possible to give the impression of focussed concern by means of the appropriate use of communication skills, and no doubt all doctors do this from time to time when under pressure. This is not the ideal, however, and whilst good communication skills are necessary to establish rapport with the patient, to truly be there for them requires an effort of heart (I can think of no better phrase) which goes beyond techniques of communication and that the patient is likely to discern and appreciate. It is hard to define exactly what this is, but probably both the patient and the doctor know, in some intuitive way, when it has occurred. The result is a deepening of the doctor-patient relationship in a way that leads to more rewarding consultations and increases the likelihood of the patient being healed; in other words, becoming whole rather than just recovering from sickness.

Meaning

Secondly, there is the issue of meaning within the consultation. I believe that spirituality tends to emerge in consultations that are highly charged with meaning for the patient or even the doctor. The patient who is concerned about the meaning of their symptoms or trying to come to terms with the meaning of an established illness or who is revealing to the doctor the meaning that they perceive, is demonstrating an openness of heart and soul that may stir the depths of the doctor who is trying to be there with them. Whilst this happens more commonly with serious and long term illness, it can also occur in brief but intensive fashion when a patient is concerned about a symptom that they fear could portend major disease. To understand the meaning of the illness as perceived by the patient is therefore one of the most important tasks in the consultation so to fail here will leave the patient unsatisfied. For example, all GPs are familiar with the healthy person who consults with unremarkable headaches who, when given time and space, reveals that a friend has just had a stroke or died of a brain tumour. Once the meaning is understood by the doctor, and the patient knows that the doctor understands, the spirituality of the consultation can emerge.

Compassion

Thirdly, there is the matter of the heart being moved. This is not the same as the effort of the heart to be there for the patient which I describe above, but is a spontaneous ‘gut reaction’ which cannot be produced at will or manufactured. It occurs in response to the giving of time and understanding to the patient. When the doctor understands the meaning of their illness to the patient, he may find that his heart goes out to them as he experiences a genuine sense of empathy with them. Perhaps the word compassion describes this, and although compassion is more commonly thought of as a virtue, what I am describing here is something that arises without any moral effort on the part of the doctor. It is in being there and seeking to understand that the moral effort occurs; compassion may or may not follow. When it does, it seems to add a further dimension to the healing quality of the consultation, as though the patient senses the doctor’s compassion for them and this helps them to return to wholeness. They are likely also to respond with gratitude and appreciation to the doctor as their own heart perceives the spiritual contact that has occurred between them and their doctor.

Conclusion

Once all these elements are present, the doctor and the patient together may be aware that they are hearing ‘the still, sad music of humanity...of ample power to chaseten and subdue...A presence that disturbs...with the joy of elevated thoughts... Whose dwelling is...in the mind of man’.

To be unaware of this transcendent aspect of the consultation seems to me to be blind to part of the fundamental reality of being human, for surely all of us have experienced that sense of the whole being greater than the sum of the parts which occurs when we truly communicate with the other person. Here we touch, in some mysterious way, the ultimate reality that surrounds us all as we encounter within each other God in whose image we are made. Jesus said: ‘Whatever you did for one of the least of these brothers of mine, you did for me’.[4]

Medical practice is frequently busy, tiring, frustrating and stressful, but whilst it continues to give a central place to the doctor being there for the patient to come to with their problems through the many ups and downs and perhaps long years of life, it will continue also to offer the possibility of that spiritual contact between doctor and patient which transcends the pressures and strains. As such, it will remain essentially an enjoyable privilege to be a doctor and to spend one’s working life encountering the deepest realities of the human condition.