Interview #1 with Dr. Robert Magrisso, MD

On  "Spirituality" and Medicine

{This is the first in a series of interviews with Robert Magrisso, Doctor of Internal Medicine, Northwestern Univ. Medical School}

Steven: the obvious place to start is with your background … there are several personal sides to it, and we can't do justice to any of them, but could you say just a little bit to summarize your professional background first? Then we can go on to some of the others.

Bob: Currently I'm a general internist—that's internal medicine—on staff at Evanston Hospital, which is a teaching-affiliate of Northwestern University in private practice. I'm on the staff of Northwestern's medical school. And I also do some practice of palliative care in Hospice, i.e., care of patients who are dying. I went to Albert Einstein College of Medicine. Prior to medical school, I did a Masters degree in biomedical engineering at Johns Hopkins, and was interested at that time in aspects of neurophysiology. And prior to that, my undergraduate degree was in physics.

Steven: and you are now working both with patients and students?

Bob: yes, though the student teaching is with residents and medical students in a clinical setting – at the hospital and in the outpatient setting.

Steven: the other side that I wanted to bring out a bit was your background in “spiritual” or “contemplative explorations”. Piet and I are both uncomfortable emphasizing the term “spirituality” too much, because it’s not well-defined, and in some ways is misleading. But for this interview, those concerns needn’t figure prominently.

Bob:  In 1973, I entered Cafh, which I'll just define as a "spiritual path". I think the issue of characterization and how to characterize these things, is interesting … but essentially that's what we would call it—a spiritual path.

Steven: is that a way of saying that the term "contemplative" is unsuited to characterizing what you were doing?

Bob: well certainly it's a path that involves meditation practice as one of its central aspects. But I guess when I think of "contemplation", I'm not thinking of action as much as much as Cafh emphasizes. I suppose that may be my own limitation in understanding what a contemplative path involves...

Steven: people all have their own notions of what it is, and many of such notions are probably not helpful for our present purposes. So this may be worth hashing out a bit.

Bob: yes, I think so. Shall I talk little more about that now?

Steven: please do.

Bob: the thing that appealed to me about Cafh was the emphasis on meditation and learning how to focus and work with my mind in a different way. But also I was attracted by its emphasis on the application of spiritual ideals in daily life.

Steven: yes.

Bob: so the subject matter of contemplation in Cafh definitely includes daily life behavior, activities, relationships etc. I’ve always liked that phrase "contemplation in action", which seems a better description.

Steven: yes, it's a fair point. I think people tend to associate contemplation with passivity or quiescence or insulation from the world. And none of those really apply to what we mean here. In fact, I don't know what one would be contemplating if one were really that separated from an active, engaged life. It would be rather questionable thing, I think.

Bob: which is how I think it is often stereotyped. "Navel-gazing", contemplating unanswerable questions, etc. … which has nothing to do with the way I’ve actually practiced it or it is taught.

Steven: nor is it like that in the traditions that I teach. The whole idea is that it is based on a more intensified, engaged way of living as a human being … not as an abstract pursuit. In any case, this is a helpful clarification. I'm basically just interested in bringing out the fact that you have a background in that side of engaged living, and then we can go on to discuss how you see it connecting to health and healing, if you think it does. Right now we are just still talking about your personal background.

Bob: all right, so in addition to my professional and contemplative interests, there is my family. Having three children, who are now grown … I've learned enormously from that experience. (Laughs). A humbling experience.

Steven: yes, presumably that too is part of the so-called spiritual path.

Bob: I remember when the children were young, talking to one of my spiritual directors about how difficult it was to practice my path or method, because of the children. And central to Cafh is a concept of renouncement. This is something that we do talk a lot about, because it has so many different sides and meanings. But I remember saying to him something to the effect that it was hard to practice renouncement with children, and he said "well, but that's it! You're sort of missing the point! Just having children is a renouncement, and all the sacrifices etc. that you need to make just to be a parent, that is the path." I mean, there isn't some other path.

Steven: I went through a similar wrenching shift in perspective with my teachers … they kept giving me traditional contemplative methods, and then also assigning me lots of work to do that seemed to me to be an obstacle to my ever actually doing the practices they taught. And it took me quite a while to understand that I was supposed to put those two things together, rather than seeing them in opposition or as separate.

Bob: right, right! (Laughs).

Steven: they thought my protests were very funny, but I was very angry. (Laughs).

Bob: right. Well often it's out of that anger or frustration that some new understanding can arise.

Steven: yes, I think so. Otherwise it would amount to a very self-indulgent and silly thing, a preoccupation.

Bob: I think that sometimes people have the impression that the goal of contemplative practice is to achieve some kind of peace … that it protects one from suffering. And I guess I don't see it that way, I see it as bringing consciousness to one's life—

Steven: yes … and to suffering itself.

Bob: and to suffering, yes. And out of that, unfortunately—that's where increased consciousness often comes from.

Steven: yeah. I think that's one of the central ways. This is one of the points that I think the West needs to understand much better than it does currently. Hopefully that will happen over time.

Bob: We are usually so action-oriented that cultivating greater awareness about those actions isn't valued. Action for its own sake is what seems to be valued.

Steven: yeah, which is the other extreme, of course. Here we typically have action for its own sake, and that is something that needs to be mitigated in some way, or reconsidered. An engaged life is one thing, but run-away immersion in distractions or preoccupations is quite another. So personally, just from your own point of view, do you see a connection between what you have been doing in this area of “engaged contemplation”, and in the world of health-related practices? Dealing with patients, etc.—do you see a connection there?

Bob: there are different aspects to medicine. One is the technical side, which involves understanding diseases and biological mechanisms, etc. The other is the human aspect of it, which is about human relationship. And in order to be a better doctor, a good listener, a better communicator … one needs to care about people. And none of those things, I think, occur automatically. So in that respect, my whole … what you might call spiritual practice, has been a practice that’s central to my medical practice. Being aware of small changes, subtle expressions, the way people describe things, I think all of that is improved when one is in a state of mind that is more calm, receptive, interested—just generally not being so self-centered as we usually are, goes a long way in being a better doctor!

Steven: (laughs). Yet, at this point, I think many of our readers would be cheering your comments.

Bob: yes well, I don't mean that to apply just to doctors. We all need to be less self-centered in life.

Steven: yes, of course.

Bob: last year, I worked particularly with a sort of self-created mantra. It came out of some work I was doing with a group of people … and it was very simple. It was the phrase "it's not about me". And this has really been helpful in various situations, not just in medicine but in life, to just say that to myself. It would be like a little opening to a wider view of things.

Steven: yes well, there are precedents for this that are very central to the traditions I teach and study. It returns us to the bigger picture, and in that way is very important. Presumably this applies to the great religious traditions too, it's just a matter of understanding yet—

Bob: yes, and of actually trying to apply it in real time.

Steven: definitely. Now are you saying that this is something you might take up or use as a doctor in your interactions with patients, or are you saying that the patients themselves might benefit from using this?

Bob: well, I'm talking about myself in this case. And another thing I will sometimes do is … particularly if someone is very trying, if my patience is low or … I deal a lot with older patients who may be very slow physically, and may also have some cognitive impairments. I may be running late, behind in my schedule, so I want to rush things along, etc., and so I will sometimes imagine the patient as … well I'll use this notion from Cafh, of the Divine Mother coming in disguise. This is helpful. I can then see things as being a kind of test and opportunity. It helps refocus my mind, drawing me back from all the rush etc., so I can really see the person as a soul—

Steven: i.e., in a sacred perspective—

Bob: yes, rather than as just an impediment to my keeping myself on schedule. So these are examples of the more concrete way the spiritual side applies to my medical practice … others are more subtle.

Steven: does it ever affect your assessment or diagnosis of the patient, or your chosen method of treatment?

Bob: One of the things that it is easy to do in medicine, as in life, is to jump to conclusions quickly … before all the data are in. And in medicine of course, if you do that, it can be very dangerous. Because, you become systematically blind to some possibilities and you just think "it couldn't be that!" So I would at least like to think … I don't want to overstate this, but I would like to think that it makes me be more open to possibilities. One of the things that comes up, since I'm doing a lot of primary care, which means people come in off the street with all kinds of illnesses, many of which are not serious, but some of which truly are—a lot of the work is about separating the serious cases from the less serious. And sometimes the symptoms in these two situations are not all that different. So being open to the possibilities of something being life-threatening, or more serious and trying to detect subtle signs sort of forces me to keep an openness about diagnoses.

Steven: yeah, that makes a lot of sense. On a somewhat related point, I often hear people talking about the difference between treating a disease in treating a patient. And when they are referring to the medical establishment, they sometimes say that doctors too often treat diseases rather than the people. But I often wonder whether that is even possible, to treat the person rather than just the disease? Does that notion really even have a meaning in the medical profession as it’s defined now? Am I being clear here?

Bob: yeah, I have a paperweight on my desk here which I just picked up, which says "the good doctor treats the disease, a great doctor treats the patient."

Steven: yeah, so you think that latter is really a well-defined possibility in the profession has it is constituted now? In a sense I'm referring to the medical technology we have now, the medications, etc. What would it even mean to do that in the present context … aside from what you just described, seeing the person more fully so you get a better diagnosis of the disease?

Bob: yes. Well the thing is this: it's definitely possible to treat the patient, in fact you have to. Because the technical aspect of medicine is only a part of it. It's not like … well let's use physics as an example—if you have a physics problem, and I admit I'm thinking of elementary physics here, there is one answer. You can go about getting to it in different ways, but there is still just the one answer. Medicine usually isn't like that. In fact it's always amazing to me how many different ways someone can approach a medical issue. Of course often you come up with things that aren't that different.

I'll give you a simple example. Suppose someone comes in and they're coughing up some phlegm, and they've been doing that for a few days. There's a lot of criticism of doctors over-treating with antibiotics, for things that are viral. So you could just wait it out instead. On the other hand, the patient has come in for an office visit, and they're expecting something. They want some treatment it's going to help them get better, faster. Now how do you deal with that? Note that it is not always entirely clear whether the antibiotics are going to help or not.

That's a very simple, common situation, and there are lots of ways you could deal with it. One way is to just say "look, go home and rest, you don't need any medication, and you'll get better." Another way is to just write out a prescription for an antibiotic. Another way is to actually talk to the patient, find out what they're thinking about, what their fears are, maybe they're afraid to have pneumonia, etc. So you basically address what's in their mind. Because, there is a subjective aspect to everyone's disease! And addressing that can actually go a long way towards doing a better job of taking care of them. I may decide that a patient doesn't need antibiotics, but if he's not better in a few days, then that might be appropriate. So I would write him a prescription and just tell him to fill it only later, if he is not better. It doesn’t seem like a huge difference, but in terms of the way that patient comes away from the session, it is. I can give patients a sense that they’re in control of the situation without being on their own—there are a lot of subtle issues that come out in such cases. Anyway, that's a very simple example of treating the patient rather than just the disease.

Steven: I see … a good answer. That relates to my next question as well, which is how far we can push this to pick up some of the spiritual angles that we are alluding to … do you ever find yourself treating the patient, the human being, by trying to help in a more spiritual way? To help the person on that level, rather than just with respect to some medical problem … is that appropriate? Is it effective? Does it even make sense?

Bob: The answer is "yes" to all of that. Because the attitude that one takes towards their illness makes a big difference in terms of how it goes. Maybe I should be more specific, but the classic distinction is between curing and healing—that you can cure diseases, but you heal people. This goes back to the same point we were just talking about. But some people have diseases or conditions that are not curable. And in fact, not just "some people"—

Steven: but most of us, or even all of us, in one way or another, will eventually be in that condition.

Bob: yes. Not just some, but most of the things we deal with are like that. Helping someone cope better, sometimes it's very specific with very specific recommendations, but other times it may be just attitudinal. One of the things of course, particularly in hospice patients, is the issue of hope. I've really come to appreciate the importance of hope more than ever. But for hope to be real, you have to hope for the right things, hope for things that are realistic. So I would say a spiritual attitude is a big part of my practice, in the sense that people have to learn to accept certain things, not to be defeated by them. They need to have hope that things can get better, and if they don't get better, that even as they get closer to the end there is still love—the love they share with those close to them.

Steven: yes, I think ultimately this is going to be the main thing one can do for anyone ... at one level or another.

Bob: yes, that's right! As a physician, there are certain skills and knowledge that one is trained in and that you offer to people … but there is another human dimension to it that we all have and share, and I think by cultivating that, one becomes a better doctor.  I am reminded of a proverb I learned from another doctor who practiced Cafh.  It was that "a doctor who knows only medicine doesn't even know medicine."

Steven: do these kinds of concerns and perspectives enter the medical profession just in general—I don't mean just your own medical practice but the field at large? Is there a kind of groundswell movement that is interested in them or considering them? Or is it basically still something that hasn't really caught on?

Bob: well there certainly are some movements toward infusing spirituality in medicine. There's the Herbert Benson group, they offer a number of different types of workshops etc., and the Templeton people have put a lot of money into this.  I am part of internet group originated by Rachel Noemi Remen, Finding Meaning in Medicine, which is very grounded and spiritually oriented.  But I'm here in the middle of the country, and I don't sense any huge groundswell toward this. (Laughs.)

Steven: (laughs). Yes.

Bob: there is some interest. But … here's one thing that I find useful—try thinking of medicine as part of our culture. It isn't something separate from our culture. Whichever way our culture is going, is pretty much reflected medicine too. I find it's a better way to look at medicine, rather than seeing it as some sort of separate entity. Maybe something like astrophysics is more a world unto itself, independent of culture. But medicine is … I think about 15% of the economy is health related. So if the culture is including these kinds of things, then medicine is. Mostly I would see what you’re referring to as common in alternative medicine, rather than in the mainstream medicine that I'm a part of.

Steven: so you also doubt that it is being added to the standard medical school curriculum and things of that sort?

Bob: I would like to say that it is, and I think that students are quite often interested in that. But we are all caught in this so-called market economy, and the financial pressures are often more dominant than we might like to think. We all work too hard, too long hours.  The technical advances in medicine are really the dominant driving force. In my field—general internal medicine, or primary care, which is one of the lower-paying fields, something like 20% of medical students pursue it. For the most part, specialization and higher-tech aspects of medicine are where the mainstream is going.

Steven: you're basically saying there's more money there.

Bob: yes. There's a lot more money there and medical students are mostly saddled with huge debts.

Steven: but I mean, more money for everyone involved.

Bob: yeah, and in an easier way. But there are always some people who are not motivated by that … maybe that's just the way life is. (Laughs.) There are some areas in the field where people have other priorities, but not in general. I think  the unpopularity of internal medicine (and other primary care specialties)is due to this. There is another side to consider in this, I admit I may be a little cynical here, but when you start getting paid for being "spiritual", somehow there's something about it that seems false.

Steven: (laughs). Yes. Of course people do need to pay their bills and so on, but beyond that, I understand your point and agree. On another point, could you imagine your colleagues, for instance, saying "well, this spiritual stuff may be nice, and perhaps it's even relevant, but it's not really implementable … for most doctors, and even for most patients, it's not really feasible. Only certain people can apply it." Does that sound like a point of view that some people would have, or not?

Bob: I think everyone pays lip service to it, there's no one who would say that learning to be empathetic, listen to your patients, communicate better isn't important. Everyone would agree to it. The problem is … everyone thinks they're already doing it!

Steven: (laughs). Exactly!

Bob: (laughs). That's the difference. To really do this … you have to work with yourself. I certainly do and to develop some form of self-knowledge. Something about the way my mind works, the way I judge people, etc.—I feel I have gained a little deeper understanding through inner work.   I think most people would believe they already have that and therefore they don't need to do this "work". They might not even really understand the way acquisitiveness, for instance, figures in their relationships. That's just an example.

Steven: and an important one.

Bob: yes. But I don't think people, as a general rule, would even think such acquisitiveness is a bad thing. You see what I mean?

Steven: yes. Well, they don't understand the distinction between a selfish grasping, and caring.

Bob: One of the things that I have really been thinking about lately is this issue of a spiritual path, especially as this applies to Cafh. I come to understand it as a process—one puts oneself into this process of inner development, however you want to phrase it, I'm sure there's a Buddhist term for that too—

Steven: yes.

Bob: so it's a process that you work with. And in doing that, one changes—one becomes more aware, relates differently to people, etc. It's really hard to describe this to someone, because unless they have participated in that kind of process, there's no real point of contact.

Steven: yes, I have the same difficulty, and at various levels. It's a major challenge … and this is why WoK exists. We are trying to find ways of explaining this to people who are not sure if there's anything substantive in this kind of exploration, or if they can relate to it, etc.

Bob: It seems to me that the first thing is that you have to engage in the process a little, and if you don't, it doesn't really mean much. And that's part of the difficulty regarding how this does or doesn't fit into mainstream medicine. Of course, things may change, but the whole direction is more and more concerned with understanding biology and particularly genetics—that latter is going to be huge—

Steven: yeah, more than we can even imagine, probably.

Bob: Now understanding that, and working with that on the human level, are equally important. I would like to be able to say that there are just as many developments on the latter side, but I just don't see it happening.  I don't think it cynical to say that re – imbursement is a huge driving force and no one want to pay for the time spent in relationship issues. It may be one of the reasons alternative medicine – which often has an anti scientific bias – is so popular.  Science is good at dealing with the objective, but much less so the subjective world, the world of experience.

Steven: this is a very important point that you're raising, and it comes up in virtually every interview I conduct with people in various fields. Basically the world now is increasingly concerned with brain scans, and neuron-anatomy, and so forth, and not so much with actual minds or persons—actual conscious beings. The trend is to move away from educating and refining awareness, and towards the study of neurological structures that are the "basis" of awareness or of certain types of cognitive functions. And of course all the latter are very important areas of study ... but they seem to be swallowing up all the attention and funding, and in the process, they also increasingly frame and even dominate people's own self-understanding.

Bob: Now we have good technology for seeing these sorts of things. Scans, etc. That's where progress is being made. Perhaps this is just where we are now, and in the longer run it will even out. There's a concept in Cafh, which is not particularly unique to it, that posits a sort of evolution—that the human being, the human race, are all part of some bigger picture, and thus some kind of "evolution". I don't know whether one should take this as literally true or just a good metaphor, whatever … but it helps me at least put the sort of thing you're describing in perspective.

Steven: yes, there’s no need to be pessimistic here. But we should understand what is currently being traded off in the current stage of this "evolutionary" process.

Bob: yes.  It indicates where things are out of balance and especially where new discoveries need to be made.