The Measure of Our Days: A Spiritual Exploration of Illness

AN INTRODUCTION TO
The Measure of Our Days

Jerome Groopman's The Measure of Our Days is about what we can learn about living from the experience of severe catastrophic illness. Dr. Groopman has gained a rare understanding of the value of confronting one's mortality, both for the person who is ill and for his or her loved ones. The eight patients he profiles vary widely in their personalities and in their illnesses, yet each of them ultimately demonstrate heroism, strength, and the power to alter their lives no matter what their prognosis.

These tales of illness also illuminate the physician's role as healer, confessor, teacher, and friend. Dr. Groopman is an accomplished and thoughtful physician, one who is willing to engage in relationships with his patients that transcend office visits and hospital rounds. Still, it is the patient who wages the real battle against illness, and Groopman shows us how each of his patients develops his or her own combat strategy: Kirk, the venture capitalist, approaches his cancer as aggressively as he would pursue a risky investment; Debbie, a follower of New Age philosophies, turns to the Tao for treatment; Alex, a Swiss architect, draws strength from the devotion of his partner; and Elliott takes comfort in a "gut" feeling that he will survive a dangerous bone marrow transplant. Some of Groopman's patients lose their fight with death, but the resources they develop during their ordeals greatly enhance the remainder of their lives and the lives of those who love them.

The phrase "the measure of our days" comes from a Psalm of David and suggests the limit of our time on earth. To the uninitiated, it may seem that patients undergoing treatment for life-threatening illness measure their lives in doses of medicine, amounts of radiation, months between treatments, odds for survival. In fact, though, these eight portraits show that with guidance from physicians like Groopman, days lived in the shadow of death can be characterized by the counting of blessings.

Jerome Groopman, M.D., is the Dina and Raphael Recanati Professor of Medicine at Harvard Medical School, and the chief of Experimental Medicine at Beth Israel Deaconess Medical Center in Boston. He is one of the world's leading researchers in cancer and AIDS; his laboratory helped to develop the new protease inhibitors for the treatment of AIDS, and in January of 1998 his laboratory identified another gene that appears to play a role in breast cancer. Groopman has written widely for such publications as The New York Times, The Boston Globe, The New Yorker, and The New Republic, and he and his work have been featured in The Wall Street Journal, Time, and The New York Times. He lives with his family in Brookline, Massachusetts.

You often make an effort to put yourself in your patients' shoes, to try to understand what they're going through. How does this kind of empathy help you treat your patients better? Wouldn't it be easier to disconnect from them emotionally?

By putting one's self into one's patient's shoes, one both better understands, or attempts to understand, the forces that inform his or her decisions and also meld the background and knowledge in terms of trying to help guide the best path in diagnosis and treatment. Although it might seem "easier" to disconnect emotionally, it would also impair my ability to care for patients, medically and certainly spiritually.

As a physician, patients and their families rely on you for answers to their many questions. What happens when you don't have an answer? How do you maintain a patient's confidence that he or she is receiving the best treatment despite the limitations of your medical knowledge?

Honesty is the best guide with regard to moving into unknown areas of diagnosis and treatment. Nonetheless, it is a harrowing experience for both patient and physician. This is illustrated within the "Alex" story, where he develops high fevers and is increasingly debilitated and I am not initially able to pinpoint the cause. One should always be ready to call upon colleagues and to suggest second opinions when one is at the limits of his or her medical knowledge.

With the great advances being made in medicine every year, you must feel compelled to keep patients alive as long as possible, in hopes that an effective new treatment will be discovered. How do you decide when it's time to stop fighting a disease, and turn to palliative care instead?

It is a complex decision when to turn to palliative care in lieu of continuing the fight. It is important to understand the time frame of science and the realistic clinical translation of laboratory discoveries with regard to recommending comfort measures versus continuing with often toxic and debilitating therapies in the hope that a new and more effective treatment will be available. It is an individual decision and it is also a decision that requires an acute level of vigilance with regard to laboratory science.

Most of your patients are young, and facing premature death. But is death always an evil, a force to be conquered?

Life is sacred, and death, for the young, when premature, is in some sense a violation of that sanctity. On the other hand, when a person has reached an age of fruition and feels that he or she has accomplished what he set out to do, death is certainly a natural part of the continuum of life.

You mention that you treated some of the earliest AIDS patients. What was it like to be faced with a completely unknown and incurable illness? Do you feel now as if you are "familiar" with AIDS and cancer?

It was confusing and exhilarating to be faced with a completely unknown and incurable illness. Confusing because we were not sure how to care for the patients medically, and also frankly worried about potential contagion to ourselves. It was also exhilarating because it is a unique opportunity in the life of a physician to confront a new and uncharacterized disease, and to have the intellectual and technical resources to try to decipher its cause and try to develop therapies to save the lives of so many young patients in need. I am certainly now "familiar" with AIDS and cancer.

How much do you rely on your "choosh," or intuition, when treating patients, and how much on the science of medicine? Are you developing more in one direction than another, or can these two approaches to healing evolve mutually?

There is a fine balance between intuition and the science of medicine. Exactly how intuition operates is, of course, not understood, but certainly is informed by factual knowledge and experience. On the other hand, there are times when factual knowledge and experience have to be disregarded in favor of intuition. There is no glib or pat answer to this question, but certainly intuition becomes a more potent force with greater clinical experience.

Lately a lot of attention has been given to the practice of spiritual healing. What do you think of this method of treatment? Would you ever recommend it to a patient?

All patients with illness should practice "spiritual healing." What that means is addressing the needs of the soul in addition to that of the body. There should be no conflict between traditional medicine and "complementary" or "spiritual" medicine or healing. Rather, one should fit well into the other as a partner in the ultimate goal of physical as well as emotional health. What is problematic is when established, and potentially beneficial clinical therapies, are not accessed, or are viewed as antagonistic and there is an effort to accomplish eradication of disease through strictly spiritual avenues. This would be like trying to heal the soul through medication.

Can you comment on recent trends in medical training toward treating the "whole patient?" It seems that until recently, medical students were discouraged from becoming too involved with their patients; this doesn't seem to be your approach at all. Are you an anomaly or does your approach represent a new trend in health care?

It is vital to treat the "whole patient" and to place diagnosis and treatment within the larger context of belief, tradition, and individual social and psychological milieu. This is now a trend that has taken root with regard to the training of medical students. Unfortunately, managed care and changes in the doctor/patient relationship give little time or incentive for such a critical bond to be forged, and for the practice of such "whole patient" care.

1. In what ways has facing death even temporarily improved the lives of the patients profiled here?
2. What makes a good doctor? Compassion? Good medical decisions? Being up on the latest research? Which is the most important of these traits? What other traits are important?
3. A deeply spiritual person, Groopman draws from his religious background in treating his patients. How does this added dimension enhance his medical knowledge?
4. Groopman grew up with the specter of the Holocaust and the damage it did to members of his family. How do you think this legacy of physical and emotional suffering prepared him for a life in medicine? What about the effect of his father's death of a heart attack in front of him while Groopman was still a medical student?
5. In Kirk's story, Groopman asks the question "How rational can our decisions be when we are desperate and feel unprepared to die?" (pp. 18-19) Does the doctor ever have a responsibility to assert his or her will over that of the patient? What should be taken into consideration before a doctor allows a patient to do something that is not medically advisable?
6. What do you think of Cindy's decision to bear a child even though she has AIDS? Was it wrong for her to risk the health of her future child, or does the desire for children, and the certainty that they will be cared for, outweigh that risk? Does she, as an AIDS victim, have the right to bear a child?
7. What do you think of the way Groopman handled Debbie's resistance to radiation therapy? Should he have been more forceful in trying to convince her that it was necessary to her recovery, or does he have a stronger responsibility to honor her belief system?
8. Discuss, in light of the recent controversy over assisted suicides, the plight of Alex, who asked to be allowed to die when he was actually only suffering from an allergic reaction to a drug situation that could be, and was, easily reversed. Does the potential for these types of situations justify the prohibition of assisted suicides?
9. In Elliott's story, Groopman refers to his "choosh," a Yiddish word for a feeling that emanates from the spirit that Elliott will survive his cancer. Does this kind of intuitive, rather than practical, prognosis have a place in medicine? Why or why not?
10. Groopman writes, "There is magic and intimacy in the moment when death appears defeated. It envelops the patient and his doctor in an almost mystical embrace. A powerful force, the force of reclaimed life, flows between you." (p. 97) Death is a force as well; should we avoid it at all costs? When is death the natural, and correct course?
11. Groopman has taken steps to educate himself in the theories and practice of alternative medicine. Does this enhance his effectiveness as a doctor of traditional western medicine?

"As simple and extraordinary as the murmur of the human heart. . . Groopman effectively commingles science and the sacred, head and heart, in his examination of core questions of existence."
—The Boston Globe

"Leaves one grateful for the existence of physicians like Dr. Groopman and books like this one. It's a book to be cherished."
—Rabbi Harold S. Kushner

"Groopman writes with the eye of a poet, the heart of a philosopher, and the voice of a novelist. . . These. . .extraordinary portraits of life against death are informed by the author's grounding in a living biblical vision of teaching and healing."
—Publishers Weekly

"A philosophical and scientific work that is both gently pedagogical and deeply moving."
—Richard Selzer, The Wall Street Journal

"To deal constantly with the worst diseases but to preserve all one's humanity, one's hopefulness, one's dedication to life, makes for an ideal physician; and if that physician can also write beautifully, tenderly, truthfully of his patients, and of his complex, delicate relationships with them, you have a remarkable book, you have The Measure of Our Days."
—Oliver Sacks, M.D.