Some musings

‘All men seek happiness, this is without exception’. So wrote Blaise Pascal in his Pensées. But despite his assertion, and our best efforts, too many of us, it seems, find only sadness.
The causes are many, but can perhaps be divided into the grief felt for the thing which is lost – the broken relationship, the missed opportunity, the faded dream – and the sorrow resulting from the fear that the future will bring no relief – the loss of hope itself. As C.S. Lewis wrote after the death of his wife, ‘I not only live each endless day in grief, but live each day thinking about living each day in grief’.

Undoubtedly some of our sadness is of our own making. Ovid, somewhat ungraciously, for surely we all make mistakes, once said that ‘What is deservedly suffered must be borne with calmness.’ Perhaps so, but that is, none the less, easier said than done. ‘But when the pain is unmerited’, Ovid continued, ‘the grief is resistless’. Regardless then of the reasons for it, sorrow has the capacity to overwhelm us.

Despite the joys that are undoubtedly present, this is often a sad world, frequently a vale of tears. And regardless of the cause, the sorrow of sadness hurts. Frequently that pain, for want of anywhere else to take it, is brought to the GP. Without doubt, there is a lot of it about, and it cannot easily be dismissed with the psychological equivalent of ‘it’s probably a virus’ and a facile assurance that the feeling will soon pass. What then are we to do?

First we need to make the right diagnosis – we need to distinguish normal sadness from pathological depression. The former, I believe, is by far the more common. And having made our diagnosis we need to resist the temptation to medicalise normality, even if by presenting to the GP, the person in front of us has themselves sought out a medical solution to their distress. It’s then that we need to be truly general practitioners, super generalists even. In fact we need to be so general that we are not medical at all since it is then that the labels of ‘doctor’ and ‘patient’ become barriers to what we really need to be – simply human. Of course we all want to help and we may understandably want to offer what only we as medics can, namely medication, but to do so tells the patient they are wrong to feel the way they do, that their sadness is inappropriate when, in truth, it is nothing of the sort.

There is, perhaps, a better, though less comfortable remedy. We need to understand the sadness even if we can not fully explain it. Having recognised the normality of the sorrow ourselves, the sad patient in front of us needs to be helped to see the normality of their feelings too. To those who are new to sadness this may come as a shock, especially in the entertainment rich and superficially upbeat culture we inhabit. Abraham Lincoln commented that ‘In this sad world of ours, sorrow comes to all; and, to the young, it comes with bitterest agony, because it takes them unawares.’ Rather depressingly, but perhaps accurately for some at least, Lincoln continued with, ‘The older have learned to ever expect it.’ To acknowledge the normality of sadness is not to deny the intensity of the suffering – because it’s normal doesn’t make it any less awful. But only having acknowledged its normality can we truly accept the sadness, and allow the grief to be expressed without trying to explain it away. After all, you can’t rationalise away that which is not irrational.

We like to solve problems – to ease suffering. But sometimes their is no pill to take away the distress, no wise insight that will alleviate the pain of sadness. To pretend otherwise is untruthful, unhelpful and unkind. As physical pain alerts us to something being wrong and indicates action must be taken, so too emotional pain can serve a similar purpose. Denying its normality, denying its usefulness, removes all hope of ever addressing it’s cause.

But sometimes, of course, the cause can’t be addressed – there is no earthly solution, there is no going back, no doing things differently next time. Sometimes not even time will help. Sometimes the pain of sadness may go on and on.

In such circumstances we may well feel useless, but that’s not necessarily so. Knowing our inadequacy allows us to stop being doctors who can’t help and allows us to become people who can – by entering a little into the grief of those with whom we sit. It’s good to share their sorrow, it’s helpful to ‘weep with those who weep’, because being alone in one’s sadness is too great a burden for anyone to bear

In ‘Out of Solitude’, Henri Nouwen wrote, “When we honestly ask ourselves which persons in our lives mean the most to us, we often find that it is those who, instead of giving advice, solutions, or cures, have chosen rather to share our pain and touch our wounds with a warm and tender hand. The friend who can be silent with us in a moment of despair or confusion, who can stay with us in an hour of grief and bereavement, who can tolerate not knowing, not curing, not healing and face with us the reality of our powerlessness, that is a friend who cares.”

And perhaps that is exactly the type of GP who cares too.

AFTERWORD:

I wrote the above some months ago when involved with somebody who was, back then, already experiencing a period of prolonged personal sadness – a sadness that continues still. Some of us may be familiar with the words of the psalmist who wrote, ‘Weeping may tarry for the night but joy comes in the morning’. I don’t doubt the truth of these words but the night for some has already been very long and the day seemingly remains an eternity away. Elsewhere in those ancient writings are chronicled the trials of Job and the ineffectual efforts of his comforters who needed to learn what we too must appreciate – that sometimes it is best to simply ‘weep with those who weep’ rather than to try to argue them out of their sadness or, worse still, point out to the one who is sad the mistakes we think they have made to bring about their misery. Regardless of whether we believe in God, we can I think agree that there is wisdom here.

Regret and sadness have much in common. In my first year as a GP Principal I recall visiting a patient who had had severe diarrhoea and vomiting for a few days. He was sufficiently dehydrated to require admission and I requested an ambulance to attend within the hour. There was, uncharacteristically for those days, some delay in the ambulance attending, and sadly the patient suffered a cardiac arrest and died on route to hospital. The next day I chatted to my partners about the case. All were supportive and quick to point out that I had acted appropriately, that, if anyone, the ambulance service was at fault and that the outcome would not have been any different even if the ambulance had attended earlier. But the response that helped me most was that of my senior partner who simply acknowledged that it was tough when things went wrong and related an incident when he regretted a judgement he’d made some years previously. That such an experienced and respected GP could ‘regret with those who regret” was very comforting for me.

Yesterday I came across the quote ‘Good judgment comes from experience. And experience? Well that comes from bad judgment.’. It’s a humorous saying but not without some inherent truth. If we consider the sense of the two statements with a degree of logic we get the following syllogism: ‘If the avoidance of mistakes comes from experience, and experience comes from making mistakes, then the making of mistakes is necessary to gain the experience to avoid mistakes.’ Now I am aware that there are some flaws in both initial statements, the avoidance of mistakes doesn’t only come from experience, and experience doesn’t only come from making mistakes, but for all that, since we are all flawed individuals, I think it remains the case that we learn much from our inevitable mistakes – mistakes that are maybe even necessary to make us more experienced better doctors. Experience comes over time so older doctors perhaps know this best – and know too what it is to experience the associated regret. Like Lincoln suggested of sadness, so older doctors have perhaps come ever to expect regret.

And if mistakes and regret are an inevitable but necessary part of being a doctor then perhaps too sadness is an equally inevitable and necessary part of being human. If mistakes and regret make us better doctors maybe then sadness has the capacity to make us better people. Perhaps wisdom is acknowledging this to be the case and learning to accept that life is sad rather than trying to constantly avoid it and rationalise it away when it does make an unwelcome appearance.

If so, I wish I were that wise.