The Role of Mutual Influence in Medical Practice

Thomas Molloy, MD FACC

I

he idea that medicine is both a science and an art can be traced back to the origins of Western medicine and the writings of Hippocrates and Galen. Writing in 400 BC, Hippocrates, whose sources included earlier Pythagorean and Egyptian medical teaching states,

In truth, some practitioners are mediocre while others greatly excel: but this would not be so, if there were no such thing as an art of medicine, and nothing had been investigated or discovered in it.[1]

Galen in 200 AD, became a master surgeon repairing injured gladiators and later became the personal physician to Marcus Aurelius. Trained in both philosophy and medicine, his extensive medical writings became the canon for Western Medicine for 1200 years. He maintained that medicine was a kind of practical and productive art, one that returned something that previously existed well to its prior state. He told students who wished to study medicine that they should first study other practical arts. He considered learning to repair a house to be useful training for repairing a human body. In a letter to a student, he recommends,

Now would be an appropriate time for you to carry over the method you learned in the case of the arts in the work prior to this one and apply it to the art you hope to establish … a health producing art.[2]

Both of these master physicians understood that something more than scientific knowledge is required to practice medicine well. Other influences and capabilities are essential. Even the best science can have a bad outcome if the practitioner’s methods are wrong or are applied poorly. In practice, a doctor must be able to perceive and assess multiple changing parameters, and to respond to them skillfully, much in the way a master craftsman works. This ‘art of medicine’ can sometimes be learned from working with more experienced practitioners and can sometimes be learned from working directly with patients themselves.

Without practical experience science and art seem separate and unrelated, like two opposing approaches to understanding. From inside, each of these ways of approaching the world has its own consistent internal logic. Would it be possible to learn from them both? After all, to do anything well, even making a simple meal for someone requires some science and some art.

II

The science of medicine has evolved rapidly in recent times. Health and illness, medications and interventions are now evaluated in large controlled clinical trials and have produced evidence-based recommendations for the population as a whole and for subgroups with specific medical issues. While the established conditions of our external life have allowed medical knowledge to expand dramatically, these same external conditions have not always supported the parallel development of an art of medicine; an art of creating and adapting best practices for unique patients whose characteristics may be different from patients studied in clinical trials.

While all people share the same basic anatomy and physiology, each patient’s personal anatomy will have unique variations and each patient’s physiologic response to medications and interventions cannot always be predicted. Even more variable is the psychological make-up and prior imprinting of each individual patient, their stories and their subconscious responses to new situations and new information. It takes time and a working knowledge of both general patterns and specific variations to create and to adapt over time a working plan for treatment of the particular problems unique to each patient.

Many doctors today, without enough time and without a clear intention, miss the opportunity to develop a therapeutic relationship with patients. If doctors do not feel this special sense of obligation to patients and do not take responsibility for their role in the patients’ health, their “being” as doctors will not develop and the patients themselves may feel abandoned.

Gurdjieff voices this commonly held ambivalence about doctors, “For our sins, God has sent us two kinds of physicians, one to help us to die, the other to prevent us from living.”[3]

III

In my daily medical practice, when I find myself guiding a patient through all of the events that have brought them to the present moment when an important medical decision needs to be made and I help them review aspects of their personal situation that could influence their choices and some of the possible outcomes from their decision, what are the sources I rely on to guide me?

This is a scenario that occurs several times every day as I care for patients. Over time I have gradually realized that whatever information I present will influence my patient’s decision in ways that I may not even realize. As their doctor I am taking an important personal role in their decision-making process. I will bear some responsibility for the results of those decisions and must be prepared to help them interpret and understand the results.

When I explain to them the issues that need to be addressed, how independent and impartial is my advice? Are my intentions and recommendations in accordance with my conscience? Are they able to understand everything I am telling them? Have they been given enough time and all the information they need in order to make a reasonable decision? If the information they have seems incomplete, am I able to fill in the missing pieces? Do I in fact have enough information to make a good recommendation? What if I am missing something?

Some of these questions will not be easy for me to answer, but the window for some decisions is limited and at some point, we choose together a course of action based on everything known so far, with some awareness that not everything can be known or predicted. When these patients return to me for follow-up visits, we see some of the results of our decisions and I learn something new each time. The results of these decisions inform me, both when I need to help them again and also when I need to help another patient. Each new decision-making moment is informed by the results of past decisions.

IV

My influence in this process is not just what is exchanged in words. There are a whole host of influences that are brought by my presence. My posture, tone of voice, facial expression, subtle gestures and movements all reveal an inner state and are communicating to my patient something about the care and quality of attention that they and the decision in front of them are being given. These same subtle clues manifested nonverbally by the patient communicate to me something important about what they understand and their level of trust in the ongoing process.

These subtle exchanges usually occur just below the level of my conscious awareness, but they can have a profound impact on how a decision is made. They can either help guide a patient toward the realization of their next choice, or they can distract patients from arriving at a clear determination of what they want and what they expect.

Observing the action of these influences is difficult. It requires that I remain vigilant and receptive, that the rhythms of my perception correspond to the rhythms of the patient’s presentation, and that my own attitude and way of communicating corresponds to the patient’s ability to perceive, while accepting as impartially as possible what we each bring to the encounter.

Approached in this way, I have found that some influences are very large and weigh heavily on the decision-making process while others are lighter and quicker but are just as important. To be more intentional about this study feels important. I wish to understand and to include these influences in a way that serves the aim of each medical encounter.

V

In his talks and writings, Gurdjieff presents a more inclusive model for medical practice, one that makes use of more ancient forms of scientific intelligence and that makes greater demands on the level of a doctor’s being.

One of the most important principles of this now largely forgotten medical science is the recognition of multiple centers, or “brains,” with equal intelligence in the body, that operate using different ‘languages’ and are designed to take responsibility for different priorities. Using this ancient medical system Gurdjieff calls humans “three-brained beings.” As opposed to initiative coming from only one brain (head, heart or instinct), and typically with each one unaware of the others, all three brains are meant to work in parallel with each other, to be aware of each other and to influence and help each other. In this system ‘health’ depends on an equal role and harmonious association of these multiple centers. The art of medicine in this system is to assist the natural unfolding of these centers and their relationships and to prevent anything from harming this process.

Thinking, feeling, sensation and instinct each bring additional layers to our awareness when attention includes them. Each of these forms of cognition needs to be exercised and respected by the others. Each has its own unique logic and language that is different from the others and that takes time and effort to be understood. Each has the possibility to grow in power and intelligence and to lead the whole organism when called on. When they have been freed from other functions which are not natural to them and are recognized and valued, they can serve a larger aim, one that they contribute to conceiving. A definite amount of time is needed for each brain to become free from unnecessary tensions. A deeper functioning of these different modes of cognition can only take place when coarser, noisier vibrations become still. In a completely relaxed and receptive state, each brain can discriminate small, subtle differences as well as the effects of larger forces arriving from great distances.

In every state of man there are seven independent sensations.[4]

Every impression has connections to multiple centers, and if I do not become entangled in their content, but continue to stay vigilant, they can help me to approach a more comprehensive and interconnected sensation including both myself and the patient I am trying to help. This movement of re-integration and re-membering of these different modes of cognition allows a hidden multicentered intelligence of the body to begin to unfold naturally and organically, like a seedling in response to favorable conditions and attention.

Is it possible to see, to feel and to sense more deeply from multiple centers without becoming entangled in the identifications that capture my attention? In a passage whose ostensible meaning is to share a simple ‘secret’ to prolonging life, Gurdjieff gives this advice,

Not to give oneself up to the associations resulting from the functioning of one brain alone … acquire the capacity for what is called ‘harmonious association.’[5]

VI

Only rigorous preparation can make it possible to perform skillfully in the midst of daily challenges. I begin each day sitting quietly and learning to become completely still, bringing attention to each independent part of the body, draining it of unnecessary tensions and associations, returning it towards its original nature. I simply sense each center’s functioning, how it receives and absorbs materials corresponding to its nature, what parts of my anatomy participate and what processes are included. I refuse the temptation to give in to associations. I stay with sensation. My aim is for a global sensation that includes all the different parts and processes without favoring one or the other. As each detail becomes recognized and respected by my attention, I sense how they grow and unfold.

I see how I begin each day starting from zero, struggling with broken connections, survival habits, and a limited understanding of what is needed. The work to awaken is difficult. I am discovering within my own organism previously unrecognized centers of intelligence which have functioned for many years almost completely subconsciously. With compassion and attention these different centers or brains gradually begin to awaken and to recognize their own importance. With confidence in their own strength, they learn to respect the strengths of the others. They all are gradually learning a common language in which to share their perceptions and attitudes toward life. A synergistic chemistry occurs when they begin to work together.

In my office, seeing my first patient of the day, everything changes from the moment I say the words, “How are you?” Exercises are abandoned as all of my attention is called to join with the patient; to accompany them and guide them as they navigate unfamiliar territory and difficult choices. We enter into a work together charting a pathway toward achieving and maintaining optimal health. The results of my preparations are put to the test as I put into practice every mode of cognition and skill at my disposal.

VII

Can ancient and more inclusive forms of scientific intelligence and ideas about the synergy of science and art in medicine make a contribution to the daily care of patients that come to us each day for help? If humans are in fact already interacting with each other from multiple centers, albeit subconsciously and ineffectively if not harmfully, the work to understand these influences and to begin to make them conscious and intentional has great importance and gives an entirely new dimension of meaning to the relationship between doctors and patients. Doctors trained to recognize the mutual influence between multiple centers within themselves and the mutual influence between patients and doctors will be able to receive impressions of these interactions and to include them in their daily work, and we could even say, when understood correctly, that it gives them the possibility to care for their patients with three brains instead of just one. □

Thomas Molloy MD FACC is a cardiologist working in a multispecialty group practice. Before medical school at SUNY Stony Brook he studied art at the Rhode Island School of Design, worked on a crew framing houses at Chardavogne Barn, and began his participation in groups studying the ideas of Gurdjieff. He is an active member of the New York Gurdjieff Foundation.