Abstract
Suffering is a natural part of life, and without moments or periods of pain, we tend not to appreciate the joys and the beauty of life as deeply as we might otherwise. Our wounds, I believe (suffering is one of those), offer us personal power, but not until we are open to understanding their message. We may not know the exact answer or message right away or ever, but we can be open, live the questions and the journey.
Compassion and awareness go hand in hand with any suffering journey, for once we have been stung, hurt and full of despair, we are better able to understand others' pain with an open heart. I believe that it is only when our hearts are pierced to the core that we can begin to understand that there is always a possibility of grace in that process. The following essays explore the challenges of suffering and the deeper meaning that it may possess for both personal and professional revelation. These essays offer wisdom to help us find that deeper grace and provide examples of innovative programming and complementary therapies that help clinicians address and ease patients' suffering.
Dr. Kiran C. Patel College of Osteopathic Medicine
Nova Southeastern University
Fort Lauderdale, FL
Can Frida Kahlo Serve as a Model for Understanding Compassion and Suffering in an Osteopathic Medical School Curriculum?
Janet Lynn Roseman-Halsband, PhD, MS, R-DMT
My paintings are well-painted, not nimbly but patiently. My painting contains in it the message of pain. Painting completed my life. I lost three children and a series of other things that would have fulfilled my horrible life. My painting took the place of all of this. I think work is the best. (From the diary of Frida Kahlo)
Introduction
Frida Kahlo was one of the world's greatest painters whose self-portraits represent her life experiences with burning clarity. Her dreams of studying medicine were cut short after a near-fatal accident as a teenager when she was impaled by a pole in a tragic streetcar accident that nearly cost her life. After spending months in hospital recuperating from surgeries, bedridden and depressed, her father inspired her to paint during her lengthy recovery. She would continue to paint throughout her short life, creating more than 140 works of art, 55 of which are self-portraits depicting and incorporating symbolic portrayals of her physical and psychological wounds. Her courage to depict her suffering of more than 45 surgeries throughout her life is a testament to her profound resilience and captured the raw emotions of her life. Because of her study of medicine as a young girl, Kahlo possessed acute anatomical understanding—a wisdom that appears in her paintings. Kahlo's turbulent and inspiring life was described by one medical student as “a beautiful mess,” an apt description for what Kahlo's life was indeed like, most notably because she showed through her life's journey what the human spirit is capable of in the face of extreme adversity. She was chosen as the topic for first-year medical students in a course entitled “Humanism in Medicine” taught at the Dr. Kiran C. Patel College of Osteopathic Medicine in Ft. Lauderdale, Florida. The osteopathic medical school has long recognized the importance of the medical humanities, with strong support from Dean Elaine Wallace, DO, MS, an expert in the area of spirituality and the humanities. The school not only has a course in humanism and medicine, but will also be including all aspects of the medical humanities in the curriculum in the near future. In addition, for the past two years, it has published a medical humanities journal aptly named, be Still.
Background and Methods
All first-year medical students at the osteopathic medical school are required to complete the “Humanism in Medicine” course, with lectures that include topics on death and dying, arts-based medicine, compassionate care, and patient-centered medicine. We included small group sessions of 50 students in this course to discuss and view the artwork of Frida Kahlo in the fall of 2017. Students were shown excerpts from the PBS documentary “The Life and Times of Frida Kahlo,” which served as an introduction for Kahlo's life. After looking at her artwork shown in a PowerPoint presentation, they were asked to discuss “What do you see?” Anyone who has seen a Frida Kahlo painting knows that it is virtually impossible not to have some type of visceral reaction to her potent work. The presentation also included medical reports from some of her numerous surgeries so that the students could understand her physical challenges. A commentary paper was assigned with the instructions: “Please write a one-page summary on what touched you the most about this documentary and presentation and what was meaningful for you personally. Make sure to include commentary about her art as well.”
The directors for the course (David Boesler, DO, MS, Chair, Osteopathic Principles and Practice, and the author) intended to use the compelling story of Frida Kahlo's life and accomplishments as a vehicle for understanding what medical students' future patients may experience when diagnosed with a serious or fatal illness. Frida Kahlo's life as well as her art has a particular resonance for medical students because of Kahlo's desire to become a physician. After her accident, her all but shattered body miraculously survived, which is quite extraordinary when you consider this was 1925 and her spine was broken in three places, her right leg had 11 fractures, her right foot was crushed, and a steel handrail literally skewered her pelvis and vagina. The massive medical records written throughout her life include documentation of 32 surgical procedures during her short life and career. Although her turbulent marriage to fellow artist Diego Rivera was not predictive of a peaceful marital life, Kahlo's personal journey of pain, suffering, and loss were transformative for her emotional healing and for telling her truth, even if it was not pretty. Her work and her life were chosen especially because of her courage to depict her life with honesty and grit, and her story of the power of human resilience is one that can't be ignored.
Findings
The themes identified from the students' papers are included in Table 1. Table 2 documents quotes from medical students that showed a different reaction to her work and her life story. It should be noted that although very few did not relate to her artistic or personal story, the majority of learners documented that the story and artwork of Frida Kahlo was powerful. They indicated that they found her life story and paintings inspirational and relevant to the patient experience of serious illness. It is hoped that their insights will be remembered when they begin to work directly with patients.
Themes Identified from Students' Papers
Quotes from Medical Students Showing a Different Reaction to Frida Kahlo's Work and Life Story
Conclusion
Initial data from this pilot study show that the life story of Frida Kahlo and her artwork can be a vehicle for offering opportunities to discuss difficult topics in patient care, including pain, loss, and suffering. Kahlo's personal story is also a potent model of overcoming adversity—adversity that medical students will learn about when they practice medicine. According to one student: “Frida Kahlo is the ultimate symbol that we are able to rise above the hardships and constraints that life places upon us to lead our best lives and make our mark on the world.” Not a bad philosophy for all of us.
Suffering: Attending to Others, as well as Ourselves
Jia Jennifer Ding, MD
As a second-year Ob/Gyn resident, I am often asked why I chose my field. Without a beat, I call to mind my own invigorating experiences as a third-year medical student, running around with my team between emergency cesarean sections and hemorrhaging patients. I felt the greatest sense of urgency while also maintaining the composure and patience necessary to handle complex psychosocial issues such as homelessness and polysubstance abuse, which often involved a multidisciplinary approach. I was amazed by the sheer physicality of the work, but even more so by the rapid intellectual processing and swift yet deep bonds formed between provider and patient in this highly intimate field. Now, as a resident, a typical 14-hour shift includes back-to-back deliveries and cesarean sections, numerous emergency room patients, and endless pages to answer, often at the expense of one's own lunch and bathroom breaks. I chose Ob/Gyn because I stand physically and emotionally at the forefront of patient care, the first pair of hands on a new life or the harbinger of devastating news to an oncology patient. However, even as a second-year resident, I am realizing that this job is not without significant personal suffering. Without the ability to recognize suffering, develop resilience, and commit to self-care, I worry that the fire that drew me to Ob/Gyn can easily be snuffed out.
A successful resident can sleep anywhere, anytime, for whatever duration of time allowed. This can often seem contrary to the laws of biology by skirting circadian rhythms or the laws of physics by napping in precarious positions, but the physical demands of our work make it such that we are always behind on sleep. Even with duty hour limits, we work twice as many hours as the average employee. Twenty-four hour shifts are especially grueling, and multitasking becomes less and less successful—and safe—with each passing hour. However, even more so than the physical demands of our work, the emotional tolls within Ob/Gyn are often acute and all encompassing.
Obstetrics is one of the rare fields within medicine where pain is not always seen as a danger sign or symptom of illness, but rather something natural and even beautiful. However, helping a mother through an agonizing labor can easily send one's own cortisol levels through the roof. Even more devastating is the regularity with which we diagnose miscarriages and poor pregnancy outcomes. I remember taking care of a patient who had finally become pregnant after years of fertility treatment. As I examined her and determined that her cervix had dilated well before the point of viability, I shook at the prospect of disappointing and shattering her with my news. I had to steel myself to discuss her prognosis as her physician, citing numbers and facts, when all I wanted to do was to hold her as a friend and share in her pain. Finally, on the labor floor, the culmination of months of a mother's anticipation can often play out differently than planned, and managing a patient's expectations in the midst of fetal distress can be a charged and stressful situation. Similarly, in gynecology, the sensitivity and care required to discuss delicate topics such as postmenopausal sexual function and complex reproductive choices can leave one feeling drained and exhausted. We show up every day and give our all, but sometimes this means we don't have enough of ourselves left at the end of a particularly challenging shift to take care of ourselves or our loved ones outside of the hospital. Gym memberships go unused and groceries neglected for takeout, phone calls with friends and family become harder and harder to schedule, and, worse, precious sleep becomes invaded with anxious thoughts of our sickest patients. When these pivotal moments arise, having the self-awareness to check in and assess our own status honestly, and seeking help when needed, is not only beneficial, but vital to our surviving residency and sustaining the lifelong career ahead.
Recognizing burnout and suffering is not always straightforward, in others much less ourselves. Often, the first sign of stress and exhaustion is the erosion of patience and empathy. Recently, on one of my hardest rotations, I delivered a patient with a history of pre-pregnancy hypertension and took care of her postpartum. Rounding the next day, I confused another patient's elevated blood pressure for hers and ordered unnecessary testing. However, even worse than making this mistake, when the nurse questioned my actions, I did not take the time to double-check the records and stood firm in my erroneous assumptions of clinical situation. When I realized my blunder, shame overwhelmed me, and despite apologizing profusely to this nurse and realizing no harm had come to my patient, I knew that my professional relationship with this nurse had suffered potentially irreparable damage. It was one thing to have made a mistake in reading a patient's chart, but I realized that the greater error was in my lack of regard and patience in hearing a colleague's concerns. Patient care is at its best when we communicate effectively and respect all members of the care team, but the more tired we are, the easier it is to rely on our internal assumptions instead of taking the time to listen to others' perspectives. These wake-up calls are necessary and important for self-intervention and self-reflection. Once one realizes the need for extra self-care and attention, it is up to the individual to look internally or externally for rejuvenation and support.
As someone highly dependent on my friends and family to regularly debrief and decompress with, I can feel my own edginess build up when I haven't checked in with my support network for a while. Even though these conversations take effort and time, I always feel better afterwards, knowing that my friends and I are trying our best in our individual fields, growing by making mistakes and reflecting upon them. We remind each other of our identities prior to our careers and how maintaining our humanity within our distinct challenges makes us stronger health care providers. I also try to build in regular runs and swims as a way to remove myself physically from work and reconnect with the outdoors. The feeling of diving into a pool with no access to electronic medical records, pagers, or e-mails is the most liberating sensation, and with each lap, I feel myself regaining calmness and confidence. By maintaining my interests and identity outside of medicine, I fuel my ability to attend better as a physician and friend to my colleagues in the hospital because I can bring a healthier frame of mind to handle tough situations.
Training in a kind and supportive environment with an awareness of burnout and a priority on preventative wellness is essential in combating suffering. I look forward to working every day as I am able to spend time with my friends and mentors, learning from them and celebrating their life moments as well as the excellent care we take pride in providing. In our residency program, we have instituted various wellness initiatives, including regular mindfulness exercises, discussing healthy eating, promoting exercise, and engaging in artistic endeavors such as participating in paint nights and book clubs. Our training program also includes numerous mentoring relationships, and the closeness in which we interact allows for easier identification of individual or group suffering. I love the culture within my training program, and I know that between my co-residents, midwives, nurses, and attendings I have grown close to that I can find the help and support I need around every corner.
Without sharing in our patients' suffering and reaching the very limits of our physical and emotional capacity in patient care, we would not be satisfied in our own work. However, equally important is our ability to recognize suffering in ourselves, address our own needs as they arise, and support patients and colleagues alike during difficult times.
Acknowledgments
I would like to thank my mentor Elizabeth Kettyle, CNM, MSN, MPH, Clinical Teaching Associate in Ob/Gyn at the Warren Alpert Medical School, Brown University, Providence, Rhode Island, for all of her help in developing and editing this piece, as well as for her endless patience, teaching, and friendship.
Mindfulness and Self-Compassion: Contemplative Approaches to the Cessation of Suffering
Eric S. Thompson, PhD
Suffering is a universal condition of living. However, each experience of suffering is pluralistic—no two experiences or conceptualizations of it are the same. Yet, we all do not want to suffer. Pain and suffering drive us to draw on our unique resources, including cognitive and affective resources, and attempt to alleviate suffering in ourselves and others. While teaching a graduate-level counseling theories course, I asked the group to take a moment and define suffering and to describe how they use strengths and resources to manage and cope with suffering. Patterns emerged, but no two answers were the same: “I give it to God”; “Take a walk”; “Meditate”; “Call family or friends.”
Suffering can be a catalyst for adaptive or maladaptive change. It can shape identities, and in my case it laid the groundwork for me to pursue contemplative practices and develop an identity as a clinician. While playing football in high school, I was blindsided by a particularly powerful blow and landed with a broken thoracic vertebra. Gratefully the injury left me with the ability to walk, but it created a long and difficult recovery process. The process of overcoming the injury, the sudden and intrusive experience of the new limits of my body, and letting go of star athlete dreams led me to search for ways to cope with the mental and physical suffering associated with the injury. The complex care I received to regain my strength and balance revealed to me the powerful role contemporary Western medicine has to ease suffering and reduce pain. When the pain came back, even after diligently following the treatment plan, I looked to contemplative practices as an additional support. As I regained strength through physical therapy, I began to read books on topics related to the practice of mindfulness of breathing and the Four Immeasurables, 1 which include compassion practices. As the weeks passed, I became more proficient in the exercises contained in the contemplative books. The mindfulness practices emphasized nonjudgmental, bare, focused attention to objects, including pain and breath. In addition, the practices related to the cultivation of compassion differed from the mindfulness practices. The Four Immeasurables, including compassion meditation, were more discursive in nature, utilizing imagination and affect to train the mind and heart to care about the suffering of the self and others. In the face of suffering, mindfulness practices focused on being with all experiences presented before me, while the compassion practices focused on the cultivation of a genuine aspiration for me to emerge from suffering and its causes.
While applying the mindfulness of breathing practices, I remember reaching a point where the pain would come and go, but there was so much relaxation and space that I did not need to react. At times when pain arose and I needed to respond, I would engage in the mindfulness and compassion breathing exercises. I would experience a warmth that would co-exist or even replace the often-sharp sensations shooting through my nervous system. I began to stop anticipating the pain and instead focused on the rise and fall of my abdomen. Instead of worrying or over-ruminating about my new challenge, mindfulness practices allowed me to sit with the pain; the compassion meditation helped prevent my mind from getting too distressed about the injury and life changes. Through cultivating a heartfelt drive to connect with and emerge from the suffering, I was buffered from over-identifying with the injury and from slipping into despair. Compassion meditation kept me inspired to take care of myself during the recovery process. As I regained full strength, I found that these practices not only reduced my suffering, but provided a direction toward an enduring happiness and underlying strength that has helped me flourish as a person and professional. These simple yet powerful mindfulness exercises helped me through a challenging recovery and set me on a course of exploring how contemplative practices and clinical practices enhance each other.
The approaches that traditional science-based medicine use to ease and heal patients differ philosophically from contemplative-based traditions. 1 The philosophical foundation of traditional Western medicine is rooted in a clinically objective, materialistic, and quantitative focus where much of the healing process and the reduction of suffering occurs independently from human experience. 2 The various tools developed to enhance the practice of Western modern medicine tend to be physically based (e.g., medication, surgery, etc.). Western medicine uses a deductive approach to solve problems through data collection, observation, and hypothesis testing. The focus on physical and material medicine changed the course of humanity with countless breakthroughs in medicine that eased suffering. Yet, while we are materially better off than 100 years ago, there is an increase in severe mental-health diagnoses, major depression, post-traumatic stress disorder, and other illnesses that affect both mind and body. Contemplative traditions share the goal of reducing suffering and can be complementary to modern medicine by using experiential modalities that focus on the reduction of suffering through rigorously examining personal experience. By systematically and rigorously examining personal experience through mindfulness practices, one begins to discern the causes and conditions necessary for happiness or suffering to arise and dissipate.
The cultivation of mental balance through the practice of mindfulness and self-compassion are contemplative approaches that have been accepted methods of reducing our experiences of suffering. Contemplative approaches to reducing suffering tend to be holistic in nature and are part of a vast theoretical system with many practices and approaches. While there are many specific techniques available to reduce suffering, a common pitfall in beginning contemplative practice is to achieve the most vivid and intense peak spiritual experience possible. Yet, without a solid and stable foundation these vivid experiences cannot be sustained. An alternative approach to contemplative practices considers an interaction between relaxation, stability, and vividness. 1 In this application of mindfulness and compassion, one learns to train attention by first emphasizing relaxation. This is accomplished through activities that help train the parasympathetic nervous system and counterbalances cumulative effects of one's allostatic load. Such activities include mindfulness of breath, progressive relaxation, self-care, and lifestyle changes.
When I was a graduate student at the beginning of my PhD program, I went on a longer meditation retreat. I entered into the retreat from the hectic lifestyle of a graduate student. One of my meditation teachers suggested that I focus solely on relaxation for an entire two weeks before beginning more traditional meditation practices. As one develops relaxation skills without lapsing into dullness or sleep, a type of stability emerges. One begins to experience effects of developing contemplative competencies. The object of meditation remains front and center, and the mind does not get pulled away by desires, irritation, or boredom. As one continues to develop relaxation and stability, the body begins to relax more deeply, but the practices tend to draw out greater and greater peak experiences, which can be maintained for longer periods of time.
Two foundational practices to develop relaxation and stability are mindfulness of breath and self-compassion. Contemplative practices such as mindfulness and compassion provide methods to address our experience of suffering. The application of introspection through mindfulness to investigate our experiences directly is believed to result in a reduction of suffering. A growing body of research is showing that programs that promote mindfulness and self-compassion are associated with a reduction of illness in patients and clinical students, including a reduction in pain, anxiety, and severe mental-health disorders such as depression. 3 –6 Mindfulness of breathing applies the principles of mindful nonjudgmental awareness to the tactile sensations of the rising and falling of the abdomen. There are numerous postures to practice meditation: sitting, standing, walking, or lying down. While sitting, one such exercise might proceed as follows: (1) allow awareness to fill the space of your body and pay attention to the tactile field of the body; (2) relax your body, yet maintain an upright posture and relax the areas of your body that are tense; (3) begin by taking three slow deep breaths, maintaining awareness of the sensations of the breath within your body; (4) with the outbreath, release thoughts and tension; follow the breath out for a few feet in front of you as you exhale; and (5) during the inbreath, gently arouse your attention and clearly focus on the sensations of the expanding abdomen. Continue to practice focusing on these tactile sensations and calibrating the quality of your attention. At the end of each breath, you may count one and up through ten. This practice keeps your focus voluntarily on tactile sensations and refines your ability to monitor your flow of mindfulness introspectively.
In addition to the above mindfulness of breath practice aimed at cultivating relaxation and the development of balanced attention, the next practice focuses on self-compassion derived from the Brahmaviharas or Four Immeasurables. 6,7 These are practices intended to develop affective and volitional balance 6,7 and a non-hostile heart. The contemplative cultivation of compassion begins with a recognition that everyone wants to be free of suffering, a fundamental common ground to all beings. When pain arises in the body or mind, a common response is to grasp onto it with our minds, identify with and internalize the suffering, and potentially cause more harm by entering into distressful cognitive and emotional states. Pain may exist in our field of awareness, but we do not have to identify with, elaborate upon, or suppress it. While distress may arise in the mind or body, it does not have to cause additional mental anguish by “getting to” us. The following compassion meditation focuses not on reducing pain or changing the state of suffering, but targets the unhealthy grasping and identification that frequently occurs with pain and suffering. Compassion meditation focuses on how to exist with the pain without attempting to change, suppress, or disassociate from the experience of the suffering. Concurrently, compassion meditation affirms our universal wish to be free of suffering and helps to cultivate a heartfelt spirit of emergence from grasping and identification with suffering. The practice of compassion embeds a genuine yearning that I and others ultimately become free from such suffering and its causes.
We enter into this type of meditation with a spirit of seeking to identify and sit with suffering and its causes, and to emerge from suffering. A typical compassion meditation is as follows. (1) Rest your awareness inside of your body and breathe effortlessly. (2) With a spirit of emergence and seeking to be free in mind, contemplate the various types of suffering from which you seek to be free. Such pain may include suffering of the body or mind, ailments, pain, depression, and so on. Without grasping onto it, notice how whatever suffering comes to mind emerges, exists, and ceases. Explore how you might grasp or identify with this suffering or pain and inquire whether you can provide enough space to sit with whatever suffering arises and avoid engaging or identifying with it. (3) If sadness arises, touch into the sadness lightly then lift off into self-compassion. Just as you released thoughts in the previous practice, simply release the grasping onto the pain and suffering. (4) With each inbreath, imagine drawing in and extinguishing the suffering. Arouse a heart of compassion for yourself with a heartfelt aspiration to be free of suffering. You can even say to yourself, “May I be free from suffering and its causes.” (5) It is ideal to extend compassion to others once generated. If you choose to, you can bring to mind a loved one and any suffering this person might experience. Arouse a heart of compassion and the genuine wish that they also become free from suffering and its causes. Imagine the suffering being extinguished. (6) When ready, release these thought processes and take a few deep centering breaths. Briefly contemplate who you could help with this practice. This practice can be expanded to others—your patients, your friends, and family, and even those you don't know or don't find agreeable. Indeed, we all seek freedom from suffering. ■