Thought for the day: the philosophical challenge of medically unexplained syndromes.

In the most nitty-gritty, pragmatic terms, a single patient presenting with medically unexplained symptoms, or MUS, can lead to a frustrating series of experiences for the primary care clinician or primary care team as well as for the patient.1,2 Perhaps the latent power inherent in such frustration can be rechannelled fruitfully by reframing the wall we are up against in this kind of clinical situation. Whether we know it or not, everything we understand is appreciated within a frame, and that frame cannot but have philosophical underpinnings. In this light, America has always been the land of pragmatism, yet at the far reaches of practical thinking we can discover non-linear, unusual wisdom that takes us beyond our usual practical logic. In 1844, for example, the iconic American philosopher Ralph Waldo Emerson wrote that ‘Every wall is a door.’3 But a door to what? In 2001, the poet Wendell Berry wrote that patience is our door from time to eternity.4 Faced with an exceptional clinical puzzle in which our habitual approaches of differential diagnosis and treatment are stymied, we are invited as it were to embark upon an unexpected journey. This is indeed a potential step or series of steps from our time-bound world to a timeless world where other rules apply. We are forced, for one thing, to slow down; we are required, for another, to be more present to our patient, and to begin to follow our nose and to ask questions that are not quite in our routine repertoire. In other words, we move in these circumstances from the relationship described by Martin Buber as ‘I–It’ to the relationship he called ‘I–Thou.’5,6 ‘I–Thou’ is where deeper healing is possible, and where all initiation happens; healing and initiation that apply not only to the patient, but also to the provider. The hunter, one might say, is captured by the game, and the word ‘game’ here, needless to say, takes on a double meaning. Sooner or later, illness is one of those mysteries that will indeed initiate us, if we give it the chance. No doctor, no matter how rational and competent he or she may be, stands above this mystery and is immune to it. The presentation of bodily distress syndrome is quite often an initiatory trigger, an entry point into the I–Thou world of mystery, where listening to the patient and to one's own hunches, one's own intuitive self, come into play in a whole new set of ways. It offers the opportunity to embark upon a mutual journey of inquiry and dialogue with the patient in a far more profound mode than usual. It is not as if we drop the quest for clarity, for making the unknown known, but rather we approach it with a growing respect for the unknown. The unknown will yield its treasures and its insights at its own pace, not our own. And our wish for certainty becomes sobered by the sense of uncertainty that we grow able to bear more patiently. This becomes clearer in the clinical situations where we recognise that our clinical models and skills are just not up to the task at hand. The wonderful spiritual writer Henri Nouwen, a Catholic priest, taught at the University of Notre Dame in Indiana for several years. He reports that a colleague mused to him, ‘I have often walked across the campus to try to get down to work, but have detoured again and again to speak with a student or someone else. It's eventually dawned on me that the detours are my work.’7 The detours on the way to solving a clinical problem are as much our work as anything else, although that goes against our own impatient pragmatism. They are an integral part of the process of the wall becoming a door. They help us to begin to embrace the process as just as worthy and meaningful as the goal that we seek. The Eastern traditions have tended to cultivate a greater regard for the sacred mysteries, and for the limited ability of our rational selves to comprehend them, than those in Western culture. In Zen Buddhism, for instance, ‘not knowing’ is valued at least as highly as ‘knowing.’ And in Zen we are faced with a set of ‘koans’, enigmatic sayings or stories, that embody the mystery of life and that the student of Zen is invited to ponder. One such tale recounts how the master asks for his rhino fan, the fan made from the ivory of the rhino's tusk. The disciple replies sheepishly, ‘I am sorry, the rhino fan is broken.’ The master smiles and shouts to his student, ‘Well then, bring me the rhino!’8 The medically unexplained symptoms that a desperate patient brings to you are your own broken rhino fan. This apparent failure presents a fundamental challenge. If we are open to this challenge, rather than indulging in our frequent and understandable manoeuvres to avoid it, this can quickly become a doorway through which the living rhino can enter. The rhino itself, in contrast to the relic of the fan, is the mystery of life, the dynamism of the I–Thou relationship. It cannot be identified or captured by our categories. And the bond that is forged between doctor and patient when even a fragment of this life enters the room during the arduous mutual search to find a solution to this particular patient's pain is perhaps as precious an accomplishment as complete relief from the pain itself. Furthermore, this bond lays the groundwork for many good things, including the patient developing new inner resources for coping. A Sufi saying expresses all of this in a more extreme way than any of us in our results-oriented world would want to accept wholeheartedly: ‘A solved problem is as useful to a man's mind as a broken sword on the battlefield.’9 This startling statement contains a point that we overlook at our own peril, and to our own slowly growing discomfort. When we fully bypass its wisdom, we become walking recipes for burnout. We learn to be more effective doctors when we embrace its insight at least to some degree, when we come to love the journey to a solution as much as the solution itself. This is true pragmatism, the type that Emerson would no doubt fully endorse.