The Reciprocity of Recognition — What Medicine Exposes about Self and Other

Mrs. N. announced triumphantly that she had become a U.S. citizen. Her husband — on whose English she depended, though she'd arrived from Albania 5 years earlier — said, “She took the test, and then she said the words with her hand like this.” He put his hand over his heart. She grinned and blushed, seeming younger than her 50 years. When she answered one of my questions with a quick “79,” I startled. Wait a minute, I thought, she doesn't speak English.

It was then that she shyly pointed to the hearing aid in her left ear. I remembered in a flash how hard the social worker and I had worked to arrange an ENT evaluation despite Mrs. N.'s lack of insurance and citizenship. I remembered the couple barging into my office some weeks later, terrified, crying, breathless, convinced that she was going to die. They had been told she needed an MRI to rule out a brain tumor, but they'd left the ENT clinic believing she had a brain tumor. Happily, I could reassure them otherwise. Now, hearing her say “79,” I realized that she was hearing and on her way to speaking fluent English. I wasn't surprised to find her blood pressure normal, her dizzy spells and headaches gone.

Thanks to Mrs. N., I also saw something within myself that I treasure and cultivate and can sometimes claim: the leaning-forward internist, the sleeves-rolled-up doctor. With the ascendance of practice-based learning and its emphasis on self-assessment and lifelong learning, medicine has come to value the capacity of practice to provide a mirror not only for occasional self-reflection but for constant self-sight. And while I saw this picture of myself, my patient saw the complementary picture of herself: someone worth another person's and a hospital's vigorous efforts on her behalf, the triumphant and hearing new American on the verge of a better life.

Over the time I've been this woman's doctor, I have learned her moods, her preferences, material facts about her body, her ways of communicating, the politics of the country where she grew up and where her mother still lives. I know about profound sadness and losses in her early life. I have used my curiosity, imagination, scientific knowledge, and hypothesis-generating and -testing to build differential diagnoses for hearing loss, headaches, dizziness, anxiety, grief, and homesickness and to use these in her care.

She watched me in similarly intense ways. The flicker of a facial expression, the tempo of the touch on a belly, the time spent gazing at the tympanic membrane said something to her. The highly attentive person, patient or doctor, offers an exposing, magnifying, perhaps truth-telling mirror to the other and receives one in return.

After seeing Mrs. N., I made a pilgrimage to the Metropolitan Museum of Art in New York to visit a self-portrait of Rembrandt that was on loan from London's Kenwood House. I know the Rembrandt self-portraits in New York — the Met's magisterial 1660 burnished and formal head-and-shoulders composition of the artist dressed in black velvet toque and dark brown high-collared coat (see first image). He looks worried, uneasy, lines creasing his brow, mouth set. The Frick Collection's earlier self-portrait shows an aristocrat, dressed in brocade, saffron sash encircling ample middle, hand on silver-headed staff. He looks resolute, depicted as powerful, but gives the sly impression of being an imposter.

Now I stood before the Kenwood self-portrait for half an hour, shifting from near to far, from left to center to right. Rembrandt sits squarely facing forward, a large man, shoulders slumped, framed from head to lap. His brow is clear, his expression solemn and frank, his hands, painted without focus, hold brushes and palette (see second image). The lit and shadowed face is a continent spanning time zones, as if a day were coursing across its surface. To me, the gaze connotes contemplation, maybe disillusion, but not fear. It seems a face of gravity, a man in possession of himself, in his studio, at home.

On the Met's first floor are four self-portraits of Rembrandt in his 20s. Two tiny pen-and-ink cartoons depict a wild-haired kid, grumpy in one, elated in the other. Two small oils show a gauzy halo of golden-tipped curls, eyes in the shadows, an expression of surprise, hope, expectation, with-held glee.

As soon as I could, I wrote a description of my visit with the Albanian couple. After that morning I understood something valuable about medical practice's dividends of sight. I realized I'd brought myself to the Rembrandt self-portraits out of some wordless drive, a magnetic attraction to see this effort, this representing of the self for the sake of others. We others then behold the work, take in the accomplishment of self-depiction, and propose that perhaps, within our own limits, we can do that, too.

It was only in writing about Mrs. N.'s visit that I could get to the heart of the matter. The act of representing the morning in words is what enabled me to see it. This is the power of writing. Novelist Henry James wrote that “to `put' things is very exactly and responsibly and interminably to do them.”¹ One does not do, James suggests, until one puts; for James, this means putting into words. One's experience becomes visible when given form. Philosopher Hans-Georg Gadamer proposes that language — in words, pictures, gestures — not only prefigures thought but is the only way that thought is revealed at all; literary scholars, aesthetic theorists, and phenomenologists agree.^2,3 Experience without mediation through representation is evanescent, not because it's forgotten, but because without material form — painting, story, poem — it cannot be beheld, and so it's as if it never happened.^4,5

In representing my office scene in writing, I placed the Albanian couple and myself in one frame, rendering us as a mutually influencing “system” of care. Without writing, I would not have realized how the memory of my patient's needless terror and bureaucratic hurdles intruded into our visit, perhaps intensifying my sense of our collective triumph in restoring her hearing. Representing those interior events within my consciousness enabled me to see what goes on within my self as a clinician, as patients no doubt write illness narratives to make visible aspects of their own situation.

The contact between doctor and patient provides the ground for reciprocal recognition. Each comes to know things about the other that help the other, while being granted a view of self. Through the power of attentive medical practice, patients will see themselves in their doctor's gaze. They not only will come to know what is the matter with them biologically but will come to wonder what matters to them, what their fears and strengths are. As a dividend, the physician sees his or her reflection in the patient's gaze and comes to wonder about what matters for himself or herself. Both doctor and patient accrue a gallery of self-portraits, capturing time coursing across the surface of their lives.

Interior, other-directed, inter-subjective, imaginative, cognitive, and aesthetic, this vision endures, deepens, becomes contradictory and complex, enables a rare view of the self. It also offers a rare view of medicine, its “profession” here enacted by the Albanian man with his hand on his heart depicting his wife's oath, its “reflection” experienced by the reciprocal sight of self-in-other enjoyed by my patient and me.

Rembrandt pictured himself with youthful buoyancy, restless worry, and finally at home in his work. Through his art, he exposed these dimensions to and for us, sharpening our sight, our capacity to see and comprehend. What is true when Rembrandt exposes what he is as an artist is true of us as we expose what we are as doctors: that which makes one artist, that which makes one doctor are the things that make the self.