The Real Treasure

I have often been wondering what makes me like hospital so much.

Every time I enter the door of a hospital I find myself in a different dimension. It makes almost no difference whether I happen to be a patient or a medical student. I am well aware that I am in for a hard struggle against my own emotions each time. This is the place to face all the problems and joys that I deeply bury in myself in everyday life. I don't give them the chance to work on me . . .

In the hospital the outside world melts away and I am left alone with may thoughts, fears, expectations and hopes. There is no way to get away from them.

The more I try to analyze the change that takes place in my mind the more I realize that most people go through similar experiences.

Just as if I was led by some Supreme Guide who warns us: Stop! Slow down! Examine your impressions over and over again! Find time to deal with your emotions, let them deepen and don't be afraid of expressing them!

The rat race has been going on for years and I find myself at the starting block every day. The race never ends . . . And yet it is up to me to quit. Sometimes it is some inexplicable force that keeps my legs moving against my will, or so it seems at least. And then at times I have to collect all my strength to keep going and move on. Two voices are forever quarrelling in me: one wants me to stop and the other convinces me that I must go on without thinking twice for that's the way of the world.

It is perfectly enough to fall but once to realize that the race goes on . . . Whether with me or without does not matter in the least.

Something similar happens when people fall ill. It is as if Somebody warned us from above that there is much more to this world than stress and a pressing need to comply with expectations.

People are waiting for you to devote your time to them and listen to their problems.

Upon realising this we usually come up with carefully selected arguments to silence our conscience. We escape to the rush of everyday life more often than not because we are afraid of facing our thoughts. And than - perhaps to shake us up - something really bad happens: someone who is dear to us falls ill and has to be taken to hospital.

All of the sudden we realise that he is the one who is important, everything else is just trifle. At last things fall into place.

Feeble, shattered bodies reveal their long buried pains, grievances and delights. Mothers spend days with their children, spouses talk for hours, family members find their way back to the family.

Does it necessarily have to be this way? Why do we need a tragedy to wake us up? All we'd have to do is find more time for one another.

In the hospital man emerges unmasked, without being able to shroud himself in everyday pretence. As if taking off one's cloths was necessary to get rid of layers of false behaviour that have accumulated in us with time. Suddenly, we look at everything from a different point of view. People, who should have been the most important, all the way through now take the place in our life they deserve.

As I recall my experiences, their most memorable part was usually their atmosphere.

I remember seeing a paediatrician once about my earache. The way he took my head between his big hands was firm and comforting at the same time. I can still hear his deep voice as he was talking to me - it was ever so or comforting. His entire personality reflected some inexplicable power: love.

I have been looking for this feeling of comfort in my relationship with doctors ever since. And in my fourth year I am beginning to realize how very important that first encounter with a doctor must have been. It might even have to do something with my intention to become a paediatric otorhinolaryngologist.

I work very hard to be able to recreate this behaviour in my relationship with patients.

However, bad experiences also haunt me even decades after they happened. After my tonsillectomy the nurse shouted at me for having dirtied the sheet with blood from my nose. It was a bit of shock to be scolded for something I was definitely not responsible for.

Every time this comes into my mind it strengthens my determination never to become so entirely void of emotions and compassion. I shall always try to consider things from the patient's point of view. I am trying to preserve this attitude in other relationships as well, for it seems to make accepting and appreciating people much easier.

One should always bear in mind how crucial this attitude is in the dialogue between the doctor and his patient where every sign, however trivial it may be, has unparalleled importance. The patient waits for a response with all his senses sharpened. He is torn between absolute distrust and total vulnerability. This may be an unconscious process at beginning, and it may remain so all the way through. At this point the personality of the doctor is crucial: it depends on him whether the patient will eventually cooperate or not. If the patient trusts him, he has won his first victory because the patient will reveal his entire being to him - which may even involve leaving all the decisions to be made to the doctor.

Sometimes I am taken aback at the prospect of such responsibility: the life of a man or a woman - in its entirety - is in my hands. What an opportunity!

I shall never forget being treated at the surgical unit of the children's hospital. With both of my hands tied to the side of the bed so as not to tear the infusion out of my arm. I was overwhelmed with anxiety, fear and questions. I was rushed to the hospital on a Sunday morning - the night shift hadn't ended yet. I had very intensive abdominal pain after having been very sick the previous night. As I was thoroughly dehydrated the doctor in charge ordered two litres of physiological saline solution in infusion straight away. It being a Sunday nobody seemed to worry about me too much. Next morning, when a white-clad group of doctors came to do their morning round I was convinced that they were trying to keep something from me. I did not hear what they were whispering among themselves, and since most of what they said was in Latin. I had absolutely no chance of understanding them. And yet I was eager to learn something about my state. I didn't dare ask them but otherwise I was desperately metacommunicating my message to them: please, please tell me something! But of course they ignored me. In these cases one cannot help thinking that something is being concealed from him or her. Later it turned out that my instinct had worked well, and there was indeed something I was not supposed to know: my appendix had perforated by the time I underwent surgery - it was probably the doctor's fault, because they waited until the end of the weekend with my examination.

Ever since, I always spot it when doctors try to conceal something from patients. Sometimes it is only a sign of their ignorance but more often it is the diagnosis of a fatal disease. I study patients' response to this attitude. I can't see any difference in their reactions: it doesn't matter how educated the patient is or where he or she comes from - they all know by instinct that the doctor is not telling them the truth. The patient who is assessing the doctor's reactions with all his might, cannot be deceived.

The basis of a satisfying doctor-patient relationship is mutual trust. To achieve this both partners have to lay their cards on the table - which is impossible without absolute sincerity. This requires openness on both sides. Most problems, however, occur at this point. People are afraid to be open with each other - perhaps because this inevitably makes them vulnerable. Doctors in their turn are likely to believe that their authority will be questioned if it turns out that they, too, are fallible human beings. They should that without accepting their own shortcomings with their patients.

The appropriate attitude has to be intuitive; there's no recipe for that. It would be far too easy that way. The most essential part: personal contact would be lost and could never be recovered.

There is only one way to learn this attitude: one has to be open towards others, pay attention to them and trust them - in one word, appreciate them as they are. I am trying to understand people. For that reason it is essential that I learn more of other cultures' customs, beliefs and attitudes to medicine.

On second thought, sincerity towards others is also my duty. Obviously, this is the only way I can establish meaningful relationships. In fact this should be natural for everyone. It is quite distressing that nowadays it has to be taught. Yet if I manage to use this skill I have the chance to make my patients and people in general forget about their fear of sincerity and openness.

What is the reason why people are so tremendously afraid of sincerity, of revealing their true self?

I believe this is because they think that if their shortcomings become obvious they will lose the respect and appreciation of others. The smallest exposure of oneself to others makes one vulnerable. As if we invited others to demean us. But why do we think that people are so sly? Apparently because the same instincts are at work in us, too. What we are likely to forget is that by becoming reclusive we merley put off unpleasant experiences for a while, but there is no way to get away from offences inflicted upon as by malevolent people.

Yet is there any way I can establish a sincere relationship with my patients in the face of all the inhibitions that have accumulated in our society?

One doesn't have to contemplate extraordinary solutions. It is usually enough to behave naturally. I could elaborate on the importance of metacommunication but for the time being I content myself with taking up the most essential rules.

First, I have to meet the patient in private and preferably in a quiet place - it is well known that first impressions are especially important. We should be face to face without placing various objects between us because they can all too easily turn into ”walls” and separate us. Establishing eye-contact is also very important. The doctor should not interrupt the patient, but at the same time he should be ready to help him or her if he or she needs this. One has to be especially careful: anything said at the wrong place or time can easily be misunderstood. If the situation permits, I may even touch the patients arm or hold his or her hand. This might have to be postponed till a later occasion, or it can also take place at the bedside. This is very delicate question and one has to take special care so as not to let the patient misinterpret my gestures. There are no rules of thumb here, the doctor has to know how much physical distance his patient needs and tolerates. Apart from that I most be perceptive and notice every sign the patient communicates to me, no matter how small or tentative they may be. There is only one way to succeed in this: I must regard the patient as a person and deal with him accordingly without identifying him with his illness.

I have to devote time to him. There are many things that cannot be done in a hurry. If we give someone our time we give him the most valuable gift in the rush of everyday life. The doctor might very well be the only person who listens to the patient's problems. This is sad, but it happens all too often.

But we should always bear in mind that the patient was the one who had taken the first step towards us. We must not take advantage of this. It is not our merit that he has turned to us. We will only take the chance to gain distinction in his eyes later. How can we possibly know what an effort he had to make to overcome all his pride and anxiety, and come to us with his most personable problems. On the patient's part this is the first step towards the confidence that I have already talked about. What a privilege this is for me! Are we worthy of such confidence, offered regardless of what kind of people we are? It is up to us to meet the patient's expectations. He puts his trust in us in order to give us a chance to prove that we really deserve it. Under no circumstances should we gamble with his confidence. We should never forget that not only is our personal trustworthiness at stake but also that of the entire medical profession! The patient's evaluation of other doctors may very well depend on us.

For who can cure anyone who has lost confidence in doctors? I might be a good professional but if the patient does not trust me, all my efforts are in vain.

If I humiliate the patient in his defenceless situation I risk forever closing him into his fears and worries. This clearly makes his situation worse. The feeling of being unneeded, which is fairly common among people, is nourished by this behaviour. Elderly people and patients suffering from severe diseases often complain that they are only a burden for their relatives, they are not good for anything anymore and they would rather die than be a nuisance for others. It is very disheartening to hear this. Yet how wonderfully valuable a broken, wearied person can be!

Death.

We like to avoid thinking about it, simply because we are afraid to face it. Doubts about life after death keep disturbing our peace of mind. One has to prepare for death. Everyone is infinitely alone in this last fight. All we can do is stand by and make the patient feel that he is important to us, but we cannot spare him this final effort.

Yet our presence is important, so that he can leave this world enveloped in love and care. In reality, people on the verge of death are usually left alone in wards. Other patients escape to the corridors.

What are they afraid of? Why are they frightened? Because they are unable to cope with the essentially limited nature of life?

We cannot live together with death, and still less with suffering. We do our best to basish it from our life and our homes. The smallest feeling of discomfort is enough for us to go and see a doctor about it. Once we are there our problem becomes their responsibility, and we might breathe a flase sigh of relief. At the other extreme of the scale, however, there are those who only consult a doctor when their pains are no longer tolerable. In this case they are trying to convince themselves that problems that we don't deal with do not exist. Infact in both cases people attempt to deceive themselves. There is no way to avoid facing our anxieties, fears and problems. They might be pushed aside for a while but sooner or later they are bound to reappear. The only possible solution is to confront them. This may not be a pleasant experience but it will eventually give us of mind.

Doctors very often witness similar conflicts. They watch family members as they rediscover their common roots and make up with each other.

By relegating our problems to hospitals we merely want to get rid of the responsibility they entail, yet it turns out that they are too persistent to disappear so easily. This is why one often hears relatives of terminally ill patients quarrel with doctors when the patient is finally taken to hospital. Their aggressivity reflects their true personality. They try to disguise their own responsibility by reproaching the doctor. Suddenly they would give everything for the treatment that is likely to yield the best results in the shortest possible time. Their ”thorns” are but a means of defence. People like these only care about themselves - they expect the treatments and machines to solve their problems. They don't let the patient die with dignity. But force the doctor to resuscitate him instead. Do they have the right to do this?

I have often been wondering whether it is a good idea to establish institutions where one can suffer and then die, and call these places ”hospitals”, a word cognate with hospitable and hospitability. By saying this I am not questioning the role of hospitals in medical care only their all-powerful nature. Doctors should bear in mind that they cannot do anything against the patient's will. Events that are inherent in human life have been expelled from our homes. Consequently, the two most important episodes of life: birth - the beginning of life - and death - the ending of life - must take place in a completely unfamiliar setting.

In the countryside especially in Transylvania I had the opportunity to meet people who preserved their natural attitude to life. The reason for this is perhaps that they live close to nature and its laws are still familiar to them. Transitoriness and rebirth are equally parts of their life - they still live in the rhythm set by the alternation of these two notions. And yet many ”intellectuals” choose to look down on these allegedly ”simple” people, instead of learning from them.

I am always deeply moved by the bathing of elderly patients at the section of chronic medicine in a hospital. Together with a few university and sixth form college students I usually visit these elderly men and women to give them a bath. First I was worried because I had no idea how I would be able to cope with other people's suffering.

Serious patients are lying here. Almost all of them are bedridden and incontinent. The bodies of most of them are covered with pressure sores. Many of them are hardly able to talk. Yet, suffering is not the central theme any more.

There are some that wait for the inevitable with quiet resignation. There are some that have not got over the revolt of ”the whole world is against me.” Each of them is an enigma: all you have to do is to find the key to them. Here are some that expect gentleness and tenderness of us and some that require a firm, determined attitude.

But they are all alike when it comes to expressing their gratitude for even the tiniest little things. With eyes wide open, they are scanning our movements to know how they can help a bit. Many have got rid of their distrust and fear of our accidentally dropping them after the first occasion. They have incredible strength in those of their limbs that they can still use - some of them can grasp really hard the armrest of the bathing trolley or the bedside. I feel it is a special honour for me that it is me who can wash these frail and feeble bodies.

It is good to know that we are expected.

At times like this, it is always the same image that hovers in my mind: the body is the temple of the soul. How true is this saying. As if the naked body undressed the soul as well . . . There is someone lying before me in her naked truth, in her absolute reality. One who no longer wants to look any better - a person reveals herself to me truly and truthfully, pure and unmasked. What confidence is placed in me with this full and complete exposure. I am always moved when I am granted the treasure of trust.

Can I give as much to provide something in return . . .?

Auntie Rozi lies by the window in bed number four of ward eight. Every Tuesday evening she waits for her turn lying on her back all the way covered up to her chin. Her skinny, frail body is lost beneath the big blanket; her head is sunk deeply in the pillow. She never speaks a word. She waits with endless patience. She opens her mouth to speak only when asked, but her voice is barely audible. Her eyes tell, however, everything. She radiates confidence. She never shows any signs of dissatisfaction. She is one that relies on us without the slightest reservation. I can never feel any tension, nervousness or fear with her. She takes everything peacefully from us. This earthly misery makes her body entirely exposed. One would believe that no one could take it with a sound mind. Yet auntie Rozi is beyond that. One would think initially that her body had completely slipped from under her control since her members can hardly move; she has got catheters and a guest opening. But as soon as I look at her face, I feel immense internal power emanating from her.

I know nothing of auntie Rozi's life, and we cannot engage in a conversation - in the traditional meaning of the word. This may not be needed, after all. I feel our relation to be very intimate - as if we were old friends who understand each other without words. Her face speaks to me more sincerely than a word can. Her features do not hide anything - pure emotions from deep inside can only give her such a fine lineament.

We have now come to auntie Rozi's bed. I remove the blanket off her and undo her diaper. The boys hold her with firm hands and put her over to the bathing chair. I cover her front side with a clean sheet. We put a washing sponge, the soap and her clean nightdress in her lap. While doing it, all of us speak to her in a kind, cheerful tone. We do this for all of our patients. The ward slowly fills with life - everybody has found her tongue. There are some who reach out for their ”bridgegroom” (local name of the gauze twine tied to the bed) to help them pull upward and be positioned to see us better.

What follows then is the ”ride” through the hallway to the bathroom, where ”splashing” commences. Usually two of the woman nurses give the bath. First we remove the things packed in auntie Rozi's lap, then the sheet and finally we help her to take off her nightdress. The wheelchair is rolled next to the shower stall. We'll ask her if she likes the temperature of the water.

And now comes the fun of splashing!

First quick shower with water; then we thoroughly soap her all over her body carefully watching her catheters and the guest opening. The big hole in the seat of the chair makes it possible to wash her from below. But we have to be careful with the sponge because a big pressure sore had developed there.

When washing her back, I stand in front of the chair and stop it with my foot to prevent it from rolling away. It is as if I embraced auntie Rozi, reaching under her armpit and pull her a bit towards me - in the meantime my companion can shower her backside. We will quickly get over the hair washing too.

Meanwhile we keep talking to her. We incessantly keep asking whether she likes the way we are doing it. She whispers barely audibly: that's right, all confirmed by the gratitude and warmth radiating from her eyes.

Auntie Rozi cannot wash even her face alone. We are helping her with that. My fellow nurse lifts the shower rose quite close to her face. Auntie Rozi looks at me with her eyes wide open.

From this moment on, it is like only the two of us existed in the world. It is rare that I feel so close to another human being . . . How beautiful such a face is . . . how much love it shows . . .

I stroke her carefully - I feel a delicate, soft, wrinkled face in my hand. She slowly raises her head a little higher, closes her eyes not to let the water get in them. Her eyes are full of gum! They probably must not have been washed for over a week. I have got to wipe them a number of times to completely clear it away. By caressing, I try to pass the water to all the little niches of her wrinkles.

Well, we are done!

We have not realized that we had been drenched with water up to our waist. This makes us laugh . . . It does not matter - when we have given a bath to everyone, we will change our clothes anyway.

We dry auntie Rozi gently - making sure not to scrub her skin anywhere. We'll put her clean nightdress on her and off we roll her back to bed. In the meantime the boys and nurses have changed the bed sheets and prepared the new diaper. The strong hands are already lifting her back to her bed. When the nurses have finished dressing her wound, I tie back the diaper.

I ask her if she is lying comfortably. She just looks at me peacefully. She likes everything the way it is. But I keep asking her if we should not pull her a bit further up. She indicates with her eyes that that would be nice. Finally I straighten out the blanket. I caress her face one more time.

And then a little smile appears on auntie Rozi's wrinkled face. It is the greatest thank you I can get from her - it is addressed only to me right there, right then . . .

At times like this I am deeply moved. What a big thanks and gratitude to get for such a trivial thing. It gives me strength - for the entire week. It helps me to overcome those difficult moments.

I do not really know for whom this brief encounter means more. Auntie Rozi does not ask anything about me; she accepts me the way I am - completely exposing herself to me, entirely unbeknownst to her. I get the unconditional trust from her that all of us wish for so much.

Anschrift der Autorin liegt dem Verlag nicht vor.

Auskünfte über die Arbeit kann über die Balint-Geschäftsstelle, Wienhausen erfragt werden.