The Anatomy of Hope: How People Prevail in the Face of Illnessby Jerome Groopman
Basing his views on lessons learned from treating cancer patients, on his own experience as a patient, and on mind-body research, Dr. Groopman (Harvard Medical School) explains the role of hope in healing. He is the author of other popular works on medicine. Annotation © 2004 Book News, Inc., Portland, OR See more details below
Basing his views on lessons learned from treating cancer patients, on his own experience as a patient, and on mind-body research, Dr. Groopman (Harvard Medical School) explains the role of hope in healing. He is the author of other popular works on medicine. Annotation © 2004 Book News, Inc., Portland, OR
“Provocative and important . . . a book about healing and life . . . Groopman . . . writes with a clear, crisp, unpretentious prose that keeps the reader interested and the pages turning. Like Oliver Sacks and Atul Gawande, he is a master storyteller who uses the examples of real patients to explain the mysteries of medicine.”
–Boston Sunday Globe
“The Anatomy of Hope sings with compassion and honesty.”
“Here is a man who has seen many deaths and many miracles and who writes about them with vigor and faith in the power of individuals to change their fates and in some power larger than all of us as well.”
–Los Angeles Times Book Review
“This book is the guide and the promise that all of us–patients and doctors alike–have been seeking, in the quest for hope amid the trials and fears of illness.”
–SHERWIN B. NULAND, M.D.
“The kind of hope–the kind of love–that shines through this book’s pages . . . will undoubtedly save many other patients and their families, in body and in spirit.”
–The Washington Post Book World
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The Anatomy of HopeHow People Prevail in the Face of Illness
By Jerome Groopman
Random HouseCopyright © 2003 Jerome Groopman, M.D.,
All right reserved.
IntroductionThe Anatomy of Hope
Why do some people find hope despite facing severe illness, while others do not? And can hope actually change the course of a malady, helping patients to prevail?
I looked for the answers in the lives of several extraordinary patients I cared for over the past thirty years. They led me on a journey of discovery from a point where hope was absent to a place where it could not be lost. Along the way, I learned the difference between true hope and false hope, and describe times when I foolishly thought the latter was justified. There were also instances when patients asserted their right to hope and I wrongly believed they had no reason to do so. Because they held on to hope even when I could not, they survived. And one woman of deep faith showed me that even when there is no longer hope for the body, there is always hope for the soul. Each person helped me see another dimension of the anatomy of hope.
Hope is one of our central emotions, but we are often at a loss when asked to define it. Many of us confuse hope with optimism, a prevailing attitude that "things turn out for the best." But hope differs from optimism. Hope does not arise from being told to "think positively," or from hearing an overly rosy forecast. Hope, unlike optimism, is rooted in unalloyed reality. Although there is no uniform definition of hope, I found one that seemed to capture what my patients had taught me. Hope is the elevating feeling we experience when we see-in the mind's eye-a path to a better future. Hope acknowledges the significant obstacles and deep pitfalls along that path. True hope has no room for delusion.
Clear-eyed, hope gives us the courage to confront our circumstances and the capacity to surmount them. For all my patients, hope, true hope, has proved as important as any medication I might prescribe or any procedure I might perform. Only well into my career did I come to realize this. During my training in medical school classrooms and on hospital teaching rounds, we saw patients as fascinating puzzles. Making a diagnosis and finding the optimal therapy were essentially detective work. We mined the stories of patients' lives for clues. Family background, experiences at the workplace, travel, personal habits, and relationships all gave hints to solving the clinical mystery. The family history provided information about inherited genes and how they predisposed people to one disorder or another; the workplace suggested potential exposure to carcinogenic chemicals or poisonous metals; travel could bring contact with arcane pathogens that populate far regions of the world; habits like smoking and drinking could promote pathology; and relationships helped uncover sexually transmitted diseases like syphilis, HIV, and gonorrhea.
Solving a complex case and identifying the best treatment is indeed an exhilarating intellectual exercise. But the background and stories of patients' lives give doctors the opportunity to probe another mystery: How do hope, and despair, factor into the equation of healing?
For nearly three decades I have practiced hematology and oncology, caring for patients with cancer, blood diseases, HIV, and hepatitis C. I have also labored in my laboratory, studying the genes and proteins that these disorders derange. During much of that time, at the bedside and at the laboratory bench, I failed to consider the impact of hope on my patients' illness. Yes, I gave the customary nod to it, but then I would focus squarely on interpreting their laboratory reports, reading their CAT scans, and studying their biopsies-all essential to diagnosis and treatment, but incomplete. What was missing had to be learned from experience. I had to be tested-not on paper but by overcoming adversity, both as physician and as patient.
A vast popular literature exists contending that positive emotions affect the body in health and disease. Much of it is vague, unsubstantiated, merely wishful thinking. These books depict hope as a magic wand in a fairy tale that will, by itself, miraculously restore a patient. As a rational scientist, trained to decode the sequence of DNA and decipher the function of proteins, I fled the fairy-tale claims of hope. In effect, I slammed the door on hope and closed off my mind to seriously considering it as a catalyst in the crucible of cure.
Personal experience opened my mind. For some nineteen years after failed spine surgery, I lived in a labyrinth of relapsing pain and debility. Then, through a series of chance circumstances, I found an exit. I felt I had been given back my life. I recognized that only hope could have made my recovery possible. Rekindled hope gave me the courage to embark on an arduous and contrarian treatment program, and the resilience to endure it.
Without hope, I would have been locked forever in that prison of pain. But I also sensed that hope had done more than push me to take a chance and not give up. It seemed to exert potent and palpable effects not only on my psychology but on my physiology.
As a scientist, I distrusted my own experience, and set out on a personal journey to discover whether the energizing feeling of hope can in fact contribute to recovery. I found that there is an authentic biology of hope. But how far does it reach? And what are its limits? Researchers are learning that a change in mind-set has the power to alter neurochemistry. Belief and expectation-the key elements of hope-can block pain by releasing the brain's endorphins and enkephalins, mimicking the effects of morphine. In some cases, hope can also have important effects on fundamental physiological processes like respiration, circulation, and motor function. During the course of an illness, then, hope can be imagined as a domino effect, a chain reaction in which each link makes improvement more likely. It changes us profoundly in spirit and in body.
Every day I look for hope, for my patients, for my loved ones, and for myself. It is an ongoing search. Here I tell what I have found.
In July 1975, I entered my fourth and final year of medical school at Columbia University in New York City. I had completed all my required courses except surgery and was eager to engage in its drama.
Surgeons acted boldly and decisively. They achieved cures, opening an intestinal blockage, repairing a torn artery, draining a deep abscess, and made the patient whole again. Their art required extraordinary precision and self-control, a discipline of body and mind that was most evident in the operating room, because even minor mistakes-too much pressure on a scalpel, too little tension on a suture, too deep probing of a tissue-could spell disaster. In the hospital, surgeons were viewed as the emperors of the clinical staff, their every command obeyed. We students were their foot soldiers. I was intoxicated with the idea of being part of their world.
The surgical team I joined was headed by Dr. William Foster. Foster was a tall, imposing man with sharp features like cut timber. His rounds began at dawn, followed by two or three surgeries that lasted until late afternoon. As is typical in a teaching hospital, all of Dr. Foster's patients were assigned to medical students who learned the basics of diagnosis and treatment by following cases. Not long after I began the course, I was designated as the student to help care for Esther Weinberg, a young woman who had a mass in her left breast.
Esther Weinberg was twenty-nine years old, full-bodied, with almond-brown eyes. She was a member of the Orthodox Jewish community in Washington Heights, the neighborhood adjoining Columbia's medical school. When I entered her room, Esther was lying on the bed, reading from a small prayer book. Her head was covered by a blue kerchief in the typical sign of modesty among married Orthodox women, whose hair, as a manifestation of their beauty, is not to be seen by men other than their husbands.
"I'm Jerry Groopman, Dr. Foster's student," I said by way of introduction. I wore the uniform of the medical student, a short, starched white jacket with my name on a badge over the right breast pocket. The badge conspicuously lacked the initials "M.D." Esther quickly took my measure, her eyes lingering over my name badge.
I did not reach out to shake her hand. Men do not touch strictly Orthodox women, even in a casual way.
Esther's eyes returned to my name badge, then to my face. I guessed at what was crossing her mind: whether my not shaking her hand indicated that I was Jewish and knowledgeable of the Orthodox prohibition, or simply an impolite student. "Groopman" was Dutch in origin, not a giveaway. Dr. Foster had described Esther as anxious, and I felt that disclosing our shared heritage would put her at ease.
"Shalom aleichem," I said, the traditional greeting of "Peace be with you."
Instead of offering a welcoming smile, her face drew tight.
Following protocol, I began the clinical interview, which includes taking a family and social history. Esther Weinberg, née Siegman, was born in Europe in 1946. Her family was from Leipzig, Germany, and of its more than one hundred members, only her parents had survived the Nazi camps. The Siegmans immigrated to America in the early 1950s. Esther married at the age of nineteen, had her first child-a girl-a year after the wedding, and then twin girls eighteen months later. Her father died of a stroke not long after. Over the last year, she had worked as the personal secretary for the owner of a cleaning service in midtown Manhattan; her job was strictly clerical, without exposure to toxic solvents that can be carcinogenic.
One of the primary risk factors for breast cancer is a family history of the disease. Esther had limited knowledge of those who had perished in the war, but she recalled no afflicted relatives. Another major risk is prolonged and uninterrupted exposure to estrogen, which occurs when menarche, the onset of menses, happens at a very young age, or when pregnancy occurs later in life or not at all. But Esther had entered puberty at thirteen, a typical time, and carried and nursed three children in her twenties. This early motherhood would, if anything, lower her risk for breast cancer.
I conducted the physical examination that I was taught to perform specifically on women, to convey a sense of propriety and respect for their body. I covered each breast in turn as I palpated for irregularities. I was taken aback by what I found. The mass in her left breast was very large, about the size of a golf ball, easily felt above the nipple. There were many lymph nodes in the left armpit, also large and rock-hard.
For a cancer to grow to this size, and to spread into the adjoining lymph nodes, takes many months, if not years. Its prognosis, dictated by the dimensions of the tumor and the numbers of lymph nodes containing metastatic deposits, was very poor. How could a seemingly attentive young woman have waited so long to consult a doctor?
I did not ask. Dr. Foster strictly defined boundaries for students on his surgical team. Our role was to observe and learn, to do only what he told us to do.
"We will be making rounds with Dr. Foster later in the day," I said. "I wish you the best with the surgery."
"God willing" was her reply.
I started to leave.
Esther called after me, "Can I talk to you?"
"Of course," I said. A patient choosing to talk to us students made us feel very much like the doctors we wanted to be.
"Maybe later," she said uncertainly.
That afternoon, William Foster stood at the foot of Esther Weinberg's bed, flanked on his left by his three students, and on his right by the team's two residents. The waning July daylight cast long shadows across the room. I summarized the reason for admission, the physical findings, and the planned procedure, directing my words to Dr. Foster. The mass was almost certainly malignant, and it appeared to be quite advanced; it would first be treated by surgery, followed by chemotherapy. I went on with my charge as a student, reviewing for the team what Mrs. Weinberg had been told by Dr. Foster in his office about the impending operation. After she was anesthetized in the operating room, a biopsy would be taken of the mass, and if it proved to be malignant, as expected, a radical mastectomy would be performed right away. This was the approach handed down from William Halsted, an eminent surgeon who practiced in the early 1900s at Johns Hopkins. Dr. Foster nodded and walked deliberately to the left side of the bed. He held Esther Weinberg's hand in his. He asked if she had any questions about the impending operation.
"Will Dr. Groopman be with me when I wake up after the surgery? I'd like him there."
Dr. Foster shot me a brief, quizzical look.
I was unsure why Esther wanted me at her side when she regained consciousness. I studied her face for a clue, but it revealed none.
"Mr. Groopman, like every student, follows his patients from the time of admission into the operating room and then through postoperative care. Be assured that I will discuss fully with you what we found at surgery and what next steps need to be taken."
Excerpted from The Anatomy of Hope by Jerome Groopman Copyright © 2003 by Jerome Groopman, M.D.,. Excerpted by permission.
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