Speaking From The Heart

It’s an honor to be with you today.

I’m here as a palliative medicine physician, but I was always first a writer and someone who loved language. I think that’s why I became a palliative medicine physician, because conversations are my procedures and words are my tools.

Interestingly, I grew up in a home with a tremendous amount of silence around important topics. My parents and I didn’t really talk about feelings. We didn’t talk about some of the things that an ordinary parent-child relationship might talk about.

But one thing I’m so grateful my parents discussed with me early on was mortality. They taught me about mortality through poetry and the Hindu scriptures.

My father read to me from the Bhagavad Gita, one of the highest forms of literary art in India. Through those readings, I first learned how to think about being mortal and how to live with purpose.

What I really took away from those early readings with my father was how beautiful, important and essential language is, and how elemental it can be in the space between two people, whether they are a father and daughter or a patient and doctor.

One line I’ll never forget taught me about metaphor, but also showed me that there was something within me that deeply wanted to write:

“The soul wears the body like a coat and discards it at the time of death.”

Through listening to language like this, I learned about the great tradition I came from and that my parents came from. I also learned how to use language to fill spaces that might otherwise be uncomfortable, and how to use literature and writing to convey things that might be difficult or awkward in a one-to-one conversation.

But when I became a physician, my love of language and reverence for the spoken word fell away.

I began speaking to patients the way I wrote about them in a medical record, using words like “metastasis” and “end stage.” I hid behind euphemisms and participated in silence when I really needed to step forward and use language thoughtfully and precisely.

I needed to help my patients understand that a disease might be worsening, and help them understand what that could mean for their lives and what they wanted those lives to look like within this new landscape.

Dying of cancer became, “You have a poor prognosis.”

Instead of talking about the significance of a CT scan that showed a body ablaze with cancer in all its organs, I talked about the next steps in treatment. I lost the ability to pause and articulate what it meant to see what I saw on the screen.

I spoke in long, meandering sentences that danced around the truth rather than holding the truth in my heart and conveying it concisely and compassionately.

I thought being a medical professional meant using phrases like “poor prognosis.” Why else had I gone to school and learned those terms?

But I didn’t understand how much I had left my patients’ suffering by the wayside because of the imprecision of my language and my fear of the words I needed to use.

I never gave up reading and writing, even during the brutal days of my residency. But I was stopped in my tracks one day when I read the following passage from Cheryl Strayed’s novel Torch, and I recognized myself in it:

“The doctor didn’t say cancer. At least she didn’t hear him say it. She heard him say oranges and peas and radishes and ovaries and lungs and liver. He said tumors were growing like wildfire along her spine. He talked for a long time in simple terms, but she could not understand what he was saying. What does this mean exactly? Her voice was reasonable beyond reason.”

When I read that passage in a work of fiction by a writer I deeply admire, I recognized my mistakes.

I realized that to become the kind of doctor I wanted to be, I had to return to my roots. I needed to be professional and use my medical knowledge, but I had to deliver that knowledge differently, with the reverence for language I had learned as a child.

My parents were God-fearing and deeply spiritual. They couldn’t necessarily talk to me about sex, drugs and rock and roll, but they gave me a beautiful way to talk about and embrace mortality.

In palliative medicine, conversations are what I do.

I enter spaces filled with fear and anguish, along with tiny moments of joy and deep meaning. All of it can feel overwhelming.

I had to learn during my training that no one was necessarily going to teach me how to enter that space and be fully human with my patients. I needed to be more than the professional doctor. I needed to meet them within a well of suffering that I think all of us have and can access.

Through this, I learned that conversations are less about handing over information, such as the results of a CT scan and the next steps someone will take, and much more about fracturing euphemisms and excavating meaning from the words we commonly use.

What does it mean to be sick? What does it mean to be a fighter? What does it mean to be awaiting a miracle? What does it mean to want “everything done”?

It meant entering into the difficulty of those words and trying to understand how people were using them, what they actually meant and what they stood for, rather than taking them at face value and moving on to the next step.

Just as I read the Gita and the poetry of Kabir and Mirabai as a young child, or had my father read them to me, I had to learn to read conversations closely as a physician.

Human illness can be seen as a text, and so can the body.

For me, this became about more than telling and listening to stories. It meant putting on my writer’s hat and becoming an accidental linguist.

It meant looking at my patients as characters with complex lives whose stories I needed to enter through the portal of language.

It also meant looking at myself as a character, a deeply flawed person and physician trying to do her best, able to connect with patients through the oldest tools we have: words.

It meant practicing radical compassion. It meant being radically honest about whatever was happening for a patient.

It meant resisting the urge to fill the room with long, meandering sentences and learning how to say something that might turn a person’s world upside down, but to say it with grace, compassion and as few words as possible.

Earlier in my training, I often stopped conversations when someone told me they were a fighter or wanted everything done. When someone said they were awaiting a miracle, I thought my job as a physician was to cheer them on.

But I often sat in those conversations knowing that the miracle they were waiting for might never happen, based on my medical knowledge. I didn’t know how to tell them that.

I know that in the past, I participated in perpetuating false hope when I could have stepped forward and asked:

“Tell me what a miracle looks like to you.”

“Help me understand what it means when you tell me you’re a fighter.”

“What does that word mean to you?”

“What is worth fighting for?”

“Let me into your life through your words.”

I had to learn to let words become a portal rather than a stopping point in a conversation, and not to assign meanings to them that the patient might not share.

Earlier in my training, when I heard the word “fighter,” I thought, “I don’t know if I can be honest with this person because I might fracture their fighting spirit.”

I now see that if I had paused and asked them to let me into the meaning of that word, I could have had a more human conversation with my patients.

Stepping into linguistic intimacy is one of the greatest privileges of being a doctor, and certainly of being a palliative care doctor.

Now I say things like:

“Tell me what being a fighter means to you.”

“Help me understand what you’re fighting for.”

“Tell me what a miracle looks like.”

“Do you feel that you are suffering?”

“Can you tell me more about what that feels like so that I may help ease it?”

In a sentence, I think palliative medicine is about bridging articulation and action.

It means helping people specify what they mean when they use certain words and articulate certain goals, and then helping them move from where they are now toward a place closer to those goals.

But it also means being honest when we are coming up against a limit.

This is where I returned to the language of spirituality that my parents gave me, one of their greatest gifts.

That language guided me toward a new understanding of words and concepts like acceptance, surrender and the limits of medicine. Those ideas are just as important to reckon with as goals of care, the things we hope for, the things we fight for and the miracles we await.

“The soul wears the body like a coat and discards it at the time of death.”

One of the most beautiful things those lines from our ancient texts capture is that who we are is much more than the bodies we inhabit.

The diseased bodies my patients walk in with are not who I understand them to be.

I draw upon that language, passed down to me through generations, to say things to my patients like:

“I hear that you are a fighter and that you are willing to put yourself through the extreme discomfort of treatment for the possibility of more time. But sometimes it is the body that can no longer fight. One of the hardest things we are asked to do in this human life is accept the limits of medicine and the power of nature over our will.”

I am able to say those things because of the poetry my father read to me when I was young. But it took returning to that poetry for me to become the kind of doctor my patients needed me to be.

In the opening line of her essay “The White Album,” Joan Didion writes, “We tell ourselves stories in order to live.”

To help my patients live well, I have to listen to their stories. I have to listen deeply to the words they use as the scaffolding of those stories.

I need to understand what their well of suffering looks and feels like. I need to be unafraid to step into however they are articulating their suffering so that I might help lessen it.

But this is not a task palliative care should take on alone. It is not even a task medicine should take on alone. It is a task for all of us.

We need to reclaim the language of suffering, loss, grief, anxiety and even joy. We need to reclaim the language of what it means to live well, what we fight for and what we really mean when we say we want medicine to do everything.

Those are linguistic excavations we can all undertake within ourselves and with the people we love.

This will always be part of the work of palliative medicine. I hope beyond hope that it will soon become part of all medicine and nursing.

But I encourage all of you to think about the stories you tell yourselves about your suffering, whether it comes from serious illness or simply from being a human being living a difficult life, which we all face.

Think about the words.

Think about how the people you love use words when they go to their doctors and say that they are fighters.

Ask them, “Tell me what is worth fighting for so that I can be your voice when you cannot speak.”

That close excavation is just as important as advancing medicine technologically. We have to contend with the meaning of what technological advances offer us, both in terms of length of life and quality of life.

We will all walk the people we love through suffering, illness and death.

When we reexamine our relationship to language and consider how we can use it to promote radical honesty, we practice the greatest compassion available to us.

Thank you so much.