Fleshing Out

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She suffered with an anxiety disorder as well as hard-to-explain, intermittent physical symptoms that seemed confined to one side of her body. Through multiple office visits, our comfort with each other grew, and her insightfulness and willingness to engage in therapy became apparent. Careful probing about her hyper-vigilance and avoidance behaviors led to an amazing revelation – a childhood incident in which she had disobeyed her parents and had been slightly injured on one side. The physical damage was minimal, but the emotional damage had manifested all these years later as one-sided pain and a specific fear of roadways and driving.

As a physician who does clinical care and as one who teaches young physicians, I think of flesh as both the covering of our bodies – our skin – and also more completely as the deeper layers – subcutaneous connective tissue, fat layers, muscles, and eventually all the internal organs. Our flesh is a moment-to-moment miracle, each part sustaining itself through the help of other specialized flesh, regenerating itself, but also in myriad ways failing us through dysfunction, weakness, and pain. I have seen so much illness and so many ways for the human body to fall into “dis-ease” that I have come to the realization, which I often share with patients and their families, that it is truly a daily miracle that any of us have relatively good health at any time.

Moreover, as my patient with the one-sided pain reveals, there is more to flesh than flesh. The subtle details of the so-called “history of present illness” are crucial for accurate diagnosis of disease. This is where “flesh” becomes a verb, as in “to flesh something out” and, as Merriam-Webster continues, “to give it substance, or to make it fuller or more nearly complete.” Clinicians and therapists need to flesh out the patient’s story. The skilled clinician learns through trial and error to probe for key details that the patient may or may not share consciously. About the person with an upper GI bleed, the clinician needs to ask: Were they perhaps taking some over-the-counter anti-inflammatory that they neglected to mention? Or perhaps they use alcohol daily and were remiss in mentioning this? Key clues need to be uncovered if they are not volunteered.

A major part of my work in attempting to help folks heal is to help flesh out uncomfortable physical and emotional details. Fleshing out the details – with open-ended questions, subtle prompts and probings – and uncovering underlying ambivalence, submersed motivations, and unrealized connections, these are the essence of a therapeutic relationship. Fleshing out each person’s unique story is the essence of my work.

Fleshing out stories as a way to heal flesh – these two meanings of “flesh” bring to my mind a shtick from Monty Python. In their movie The Holy Grail, a hapless and silly knight is caught in a hopeless battle. One limb after the other is hacked from his body, spewing ridiculous fountains of blood that phase him not at all. With each mortal injury, the knight declares defiantly, “It’s just a flesh wound.” As silly as this scene is, the absurdist humor touches on something profound. Sometimes, when our flesh fails us, our spirit can still remain vital. Terrible injuries are sometimes “just” flesh wounds. Our physical wounds can be minor in comparison with other human wounds – emotional, psychological, and spiritual – wounds that are much harder to see and treat.

Modern allopathic medicine, the dominant school of medicine in our country, does an outstanding job with acute maladies of the flesh – treating acute infections with high-powered antibiotics and surgically correcting broken body parts. However, much to my dismay, allopathic medicine does a poor job at treating a whole host of other physical maladies – such as chronic pain and autoimmune disorders. There is much that we do not understand, and a tincture of time is often a physician’s best maneuver – therapeutically and diagnostically.

With the exception of some specialties – for example, family medicine and palliative care – allopathic medicine does not do particularly well with non-physical ailments either. It seems incapable of treating metaphorical and un-measureable soul sicknesses, cancers of the spirit, and psychosocial injuries. I rely on my colleagues in allied health professions to care for countless disease states that baffle conventional medicine.

Unfortunately, in today’s health care environment, harried clinicians spend less and less time with patients, due to productivity demands and documentation concerns. The story behind a patient’s physical symptom, what appears to be just a flesh wound, is not fleshed out to its psychosocial-spiritual depth. A physical symptom is treated as something to be medicated, something to be masked with a powerful pill.

As a teacher of young doctors, I try to do better than that. Following the advice of Parker Palmer in Courage to Teach, I try to know, or at least be on speaking terms with, my own inner teacher. And I try to help my students learn to do the same – learn to flesh out their own skills, needs, blind spots, and motivations – to seek the unknown unknowns as well as the known unknowns. Indeed, we must each flesh out our own identity and integrity, our authentic self, in order to be the best healers we can be. ~~~

Keith Dickerson, MD, is on faculty at St. Mary’s Family Medicine Residency in Grand Junction, CO, where he lives with his wife and daughter. There is currently no organized Quaker community there, so he considers IMYM to be his spiritual touchstone/home, and jests that he is currently a free-range Quaker.