How often do our patients “yes” us to death and then ignore our advice?

They seem to understand us in the office, they may even be able to repeat back to us every word we’ve said, if asked, so what happens when they go home? Why would a diabetic eat cake every night and a cardiac patient continue to smoke? They don’t appear to have a death wish, so what is happening?

One day in the 1950’s, when my Baba was forty-eight years old, her doctor told her she must quit smoking immediately, or she would lose her legs. She had been smoking since she was sixteen, but she left his office that day and never smoked another cigarette again. Just like that. She carried that noxious, half-empty pack of Salem cigarettes in her purse for nearly twenty years—just in case. But she never touched them. And her legs served her well until her death in 1996, at the age of 87.

Why doesn’t that happen anymore? I can’t count how many patients I’ve told not to smoke while on birth control pills. I tell them if they can’t stop smoking, then stop taking the hormones. I have even given them real life examples: the twenty-eight year old with a clot in her leg, and the thirty-three year old with bilateral pulmonary emboli—that she waited two weeks for hospital admission because she wasn’t insured yet, and nearly died. Or the twenty-two year old with a cerebral embolus who will never walk again. I’ve even invited young women to spend five minutes in our wheelchair and imagine they will never get out of it.

I tell them, and they say, “I know.”

But they don’t know.

They have processed the intellectual information in their brains, but they have not let it in. It does not touch them where their souls live. They have not allowed it to be a tangible truth. It is simply more data amid an overabundance of other data, and it does not penetrate their hearts. Unless they have lived through real adversity, bad outcomes are not real. And sometimes, not even then.

We exist on such a superficial plane in most of our experience. Barraged by a quanta of instantaneous bits of information: masses of text messages, news clips, emails, and thirty-second meetups with family, coworkers, and friends. It is next to impossible to have an authentic encounter. By and large, we relate to each other as objects, not as individuals.

And then there is the underlying assumption that medicine can fix anything. Humans can fix anything, and life will always go on. Nothing serious will ever really happen to “me”. Even today, with all the calls to action, petitions to sign, marches to support, climate issues to protest, even with all our “heart-felt” sympathy and intellectual understanding of events and a war in Ukraine, it’s so hard to believe, deep inside, that anything irreparable will ever happen.

Maybe that’s where my Baba had it different. She lived through not one, but two World Wars. She watched her family and her people exterminated. And she came to this country with nothing at all.

So, when her doctor told her something bad was going to happen to her, she believed him.

Because she knew, in her heart, that bad things do happen. That people die. That life breaks down, if you’re not careful—and sometimes, even if you are. She considered herself very fortunate to have gotten the warning in time to save her legs. Even though she carried those smelly old cigarettes with her for decades—just in case.

Our challenge as physicians to reach our patients only worsens every year. With EMRs, “productivity” requirements, and as we are forced to treat our patients like consumers instead of patients—instead of humans. Borrowing from the philosopher Martin Buber, especially in medicine, this “I-It” relationship is demoralizing for both sides. We can’t touch our patients anymore; we can’t make them hear us. How can they, when we only have eight minutes with them, and we spend most of that time staring at a tablet? Even with a scribe, our attention is divided and we cannot be fully present to the human in our office. It’s no wonder they are not fully present to us.

The problem did not start with EMRs and productivity measures.

Our entire society, in its unflinching progression toward appearance over substance, quantity over quality, and its relentless march toward inauthenticity, finds it perfectly acceptable to relate only to the surface of each other. So it is no surprise that it inspires the same in medicine, and ultimately in our treatment of and by our patients.

In a culture which proceeds at breakneck speed, faster than the heart can process, a whole dimension of reality ceases to register in our beings. Most of life becomes relegated to our thoughts, and to our current intellectual constructs, until we humans come to live almost entirely in our minds. We have effectively distracted ourselves from the “larger, intangible reality.” It leaves in its wake a hole, crying out to be filled. A perfect breeding ground for depression, frustration, dissatisfaction, and emptiness.

And indeed, we have more patients on psych meds and more physicians depressed and burned out. As the sense of meaninglessness in our lives increases, the hunger to fill ourselves with excesses, like nicotine, alcohol, and drugs also increases, and we are not open to hearing they are bad for our health. Patients are not listening to their doctors. We, as a society, are not listening to each other. We are not even listening to ourselves.

There is an old proverb about a Western traveler on safari in Africa. He pushed his guides to move more quickly to their destination, but after a few days, suddenly, the Africans sat down and would go no further. The impatient Westerner asked, “why have we stopped?”

“We have been traveling a very long way,” the guides replied. “We must wait for our souls to catch up.”