20 May

The practice of medicine is full of rituals.

As part of everyday life, rituals help. Repetitive and reproducible, they pro- vide pathways for action, especially when we do not quite know what to do. We turn to established rituals in dealing with moments in the cycle of life—death, marriage, and other passages, for those rituals are tested and re- fined by use. Religious liturgy is, of course, a ritual; it provides a set of prayers, in a certain order, with prescribed responses, and all of these ele- ments help both the novice and the experienced.

The practice of medicine is full of rituals that help both the novice and the experienced physician. The method of taking the medical history is a ritual. It has an order and a way of expanding the questioning, is reproducible from patient to patient, is accepted by both the physician and the patient, and it works. If one is a novice, the history-taking “ritual” provides the structure for collecting and handling information. An experienced physician, even a tired one, can fall back on this ritual to guide the transaction.

The questions we ask and the problem-oriented system are among the rituals of diagnosis. Anticipating what can go wrong and instructing the patient, “Call me if you’re not better by tomorrow” are treatment rituals. Some physicians, when they take their leave of patients, automatically, rit- ualistically, say, “I hope you feel better,” a valediction not unlike a blessing.

There are rituals by which physicians communicate with one another: presenting the history, findings on patients’ physical examinations, and test results, all leading to a diagnosis. As we listen and identify unanswered questions and issues, we can quickly focus.

But rituals sometimes can get in the way of original thinking. If, as physi-cians, we routinely obtain an electrocardiogram to rule out a heart problem and the test is normal, we may stop the diagnostic pursuit prematurely and squander the opportunity to enter into a productive conversation with the patient and explore the other possible causes of chest pain, including the human side. Bursztajn and his colleagues reflect: “Technical procedures, valuable as they are when there is a rational basis for using them, are in- voked mindlessly and automatically, as rituals to reassure anxious physi- cians. Precise laboratory measurement is accepted as a substitute for a complex, elusive reality that may be understood only with patience and sensitivity.”1

Rituals do not replace thoughtful discourse. Asking the patient to sign a permit for an operation does not substitute for talking about her fears. Speaking with a family about a “do not resuscitate” direction for their co- matose parent does not substitute for a long talk about the meaning of their impending loss.

Certain rituals are missing in most medical settings. When someone dies in the hospital or nursing home after a long illness, a physician or nurse “pronounces the person dead,” invasive tubes are removed, and the pa- tient’s body is moved to the institutional morgue to await transport to a fu- neral home. To address the loss for staff who have cared for the patient, an additional ritual can provide meaning to the entire experience and allow them to move on. Together they could recite a brief liturgy—no need to call it a “prayer”—acknowledging the worth of the deceased, the privilege of caring for him, and their own loss.

After a patient dies, another ritual helps to complete the chapter of care.

When writing the survivors to express sympathy, we also declare what the relationship meant to us. In our letter, we may comment on some of the pa- tient’s special qualities. We may write, “You did all you possibly could. I hope that the many good memories you have of him will ease your grief in the months to come. Please let me know if I can help.” We acknowledge the family’s relationship to the patient and the magnitude of their loss. We offer our availability, for their drama is not yet over. Such letters can help to prevent their appropriate grief from turning into prolonged depression.

Coupled with the best rituals from medicine are the personal rituals of the patient and those derived from the patient’s family, ethnic, and reli- gious background. As potential resources, they all help.

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