Book Review

Sacred Space: Stories from a life in medicine

N Engl J Med 1998; 339:206-207July 16, 1998

Article

Sacred Space: Stories from a life in medicine
By Clif Cleaveland. 210 pp. Philadelphia, American College of Physicians, 1998. $21.95. ISBN: 0-943126-64-9

There is a renewed interest in the narratives of patients as recounted by their physicians. These stories of illnesses, often painful in the retelling, reveal much about the nature of the suffering experienced by patients and by the physicians who care for them. I suspect that the renewed focus on the stories of individual patients comes in part as a response to the manner in which medicine has evolved during the past quarter-century. The explosion of scientific information that finally allows us to understand and treat diseases on the basis of cellular and molecular pathophysiology has, at the same time, led to a form of reductionism that focuses on the common features of disease rather than the unique qualities of a patient's illness. It seems that the loss that both physicians and patients have had in this evolution has given new value and meaning to the narratives of patients and their physicians.

Sacred Space: Stories from a Life in Medicine details the career of Clif Cleaveland, a physician who has practiced for most of his career in Chattanooga, Tennessee. He begins his own narrative with the statement, “I cost my parents thirty-seven dollars and fifty cents, that being the charge by the hospital of LaGrange, Georgia, for labor and delivery plus several days of room and board for my mother and me.” That was in 1936; he was graduated from Duke University, attended Oxford University as a Rhodes scholar, received his medical degree from Johns Hopkins University, and did his medical training at Vanderbilt University Hospital. He has little to say about the tribulations of his rigorous medical training or his efforts to cope with the bureaucratic incursions of health care economics. And yet, as my father wrote in an unpublished memoir, “where is there a story that paints a true picture that is not worth reading?”

In a series of sensitive vignettes and stories that cover his career from medical school to his current medical practice, Dr. Cleaveland paints a true picture of “the sacred space,” the circle of caring at “whose center is a terribly sick or injured fellow mortal” and a physician. Many of the narratives, describing patients with unremitting problems such as depression, intractable headache, or severe refractory hypertension, extend over periods of many years and are framed against Cleaveland's understanding of important aspects of his patients' lives that could be revealed only after years of trust, or in one instance, only in a diary left to him after his patient died. Speaking of a patient whose story began with the finding of a nodule on her lower jaw and concluded with visits to her home as she was dying of cancer, he observed,

I began to comprehend the fallacy in the notion that as a physician I “take a history.” Rather, I take in my patient's story, sometimes sequentially, sometimes in scattered, almost random segments. This story, if honored with time and privacy, defines an immediate illness or problem not as some isolated calamity but as part of a continuity of experience. This history speaks to the dreams and fears, regrets and joys of a unique person.

He comments on “the persistent and unflinching awareness of a shared humanity, which finally dissolves all barriers when speaking and listening to one another.”

I found myself formulating my own differential diagnosis as he described some of the illnesses presented by patients in his practice. Some of the short case histories, such as that of a student with thallium poisoning, represent medical detective work that would have made Berton Roueché or Sir Arthur Conan Doyle envious. His touch is consistently light, and many of the stories leave much unsaid; Cleaveland has a deep respect for the sacred space of his patients. These stories from the life of a man who is a dedicated, sensitive physician have much to say about what excellent care means to patients, but equally they have much to say to physicians about the unique rewards of caring for the patient. These are messages for all of us.

Jerome Lowenstein, M.D.
New York University Medical Center, New York, NY 10016