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JOURNAL OF PALLIATIVE MEDICINEVolume 9, Number 4, 2006© Mary Ann Liebert, Inc.

You Have To Know How To Shudder

WILLIAM M. BUCHHOLZ, M.D.

IDO NOT REMEMBER when I first heard that phrasebut I do remember the patient who showed me

it was true. His cancer had metastasized to hisspinal cord leaving him a paraplegic. His painwas controlled with an epidural morphine pump.Lack of visceral metastases kept him here formany months. Ultimately he was able to finishhis book and live to see the galley proofs.

I would visit him at home. We would talkabout his comfort level (“good”), his mood (“I’mcoping”), and his writing (“coming along”). Peri-odically he would shudder. His whole bodywould shake, including his legs and lower torsobelow the level of spinal cord damage.

My first thought was that he was having a sei-zure. But no, the conversation went on withoutinterruption. It might be spasticity from the corddamage; no, his arms trembled as much as hislegs. One by one I considered and dismissed allthe medical explanations I could imagine.

I asked him what was happening, what he felt.He was completely aware of everything; he knewhis body was shuddering. It didn’t bother him—except to make writing harder. He did not feelafraid. He could not control or stop it, but did notfeel out of control. In spite of—or defiance of—his impending death, his paralysis and his unob-tainable dreams, he was not afraid, resentful, ordepressed. He was simply shuddering.

Somewhat after he died I came across an ety-mological fact. In the Hebrew Testament the rootword that was either translated as “fear” or“awe” really meant “to tremble when encounter-ing a force.”

How honest that is, to go directly to our re-sponse to life without filtering it through our

fears or mental constructions of what it might be!Yet, how often can we simply experience lifewithout denying it, filtering it, or attempting tomake it fit into our preconceived notions?

As physicians we are exposed to the rawnessof human suffering daily. It can be as mundaneas the limits arthritic knees place on walking oras profound as the implications of a youngmother whose life is cut short by breast cancer.How do we respond to those events? Do we trem-ble in awe at the expression of Nature? Do wedistance ourselves from human experience byviewing it as a problem to solve? Do we separateourselves from our shared human suffering byrefusing to experience our own pain?

A century ago William Osler wrote the essay“Aequanimitas.”1 He felt that physicians shouldappear imperturbable even if they could not beunmoved by their patients’ illness. Such a rolemodel persists long after it has become self-de-feating. Patients no longer demand it. Physicianscan no longer sustain it without injuring the verycore of what Osler wanted to promote: the physi-cian himself or herself as the instrument of heal-ing.

Equanimity—the ability to be balanced andopen regardless of circumstances—remains at thecenter. The task is not to be dispassionate. Ratherit is to experience deep feelings, even passion,without losing one’s center of balance.

Balance is difficult to maintain. There are somany things that pull us off balance: the desireto please our patients or the people whose ap-proval we seek; the fear of being blamed; worryabout not living up to our own or another’s ex-pectations; the fear of causing harm; the desire to

Hematology & Oncology, Mountain View, California.

Personal Reflection

be praised by others or worse, fear of losing theirrespect.

Being open is even harder. How can we beopen to all the events around us, much less ourown feelings! Is it really possible to be unmovedby patients frightened by the diagnosis of can-cer—particularly when we see our own selves re-flected in their eyes? How can we hope to findequanimity amidst the battle to meet our ownneeds and to serve others?

The answer is simple, but not easy. You can-not remain open or balanced all the time. You can,however, learn to find the center again. Findingit is a process. You must recognize when you arethere, and what pulls you away.

You know you are balanced by the feeling ofease. There is a sense that things are right exactlythe way they are, whether you like it or not, andyou are content in knowing that this is true.

You know you are off balance by the way youreact to events: feeling angry at what is happen-ing; insisting you are right even when you havedoubts; wanting to do more than you really can.

Being open—not just to others’ pain but to ourown—is the most difficult of all. Our very biol-ogy causes us to turn away from pain, much aswe pull our hands from the fire. Our trainingspecifies that we try to take away our patients’pains.

It takes great courage to remain open to pain.The temptation is to shut down, to avoid seeing

it altogether. Yet how can we understand what isneeded to alleviate our patients’ suffering if wecannot know it for what it is? Moreover, how canwe heal ourselves if we do not know where wehurt and what draws us away from our own cen-ters?

We have to learn how to shudder, to tremblein the presence of a force, without turning away.Regardless of our own skills, regardless of thepower of our technology, we will face the in-evitability of death and suffering, circumstancesbeyond our control. Will we react by withdraw-ing or putting a white-coated barrier between usand the patient? Or will we have the heart andthe humility to face our limits and stand in aweof what presents itself to us?

REFERENCE

1. Osler W: Aequanimitas: with Other Addresses to, MedicalStudents, Nurses and Practitioners of medicine. Philadel-phia: Blakiston, 1928.

Address reprint requests to:William M. Buchholz, M.D.

Hematology & Oncology1174 Castro Street, Suite 275

Mountain View, CA 94040

E-mail: drbill@buchholzmedgroup.com

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