His medical treatment has failed to stop the progressive development of his cancer; There is, then, a rhetoric of explaining to patients, and physicians differ greatly in their aptitude and skill in making clinical judgments convincing to patients and their intimate social circle. Alice Alcott's physicians shared much of her explanatory model, except that they recognized that her depression complicated an already very difficult situation. They were willing to accept her denial of disability; Others of the patients we have described fared better at the hands of their physicians. However, Melissa Flowers (article 7), along with several others, experienced a virtually total breakdown in this crucial communicative function of healing. All physicians are faced with the necessity of translating between the enormously complex concepts and findings of medical science and their patient's practical need to know about risk and vulnerability, disorder and treatment. A patient once told me this: We none of us know what to make of risks anymore. We've been told too many different things. If you be just an ordinary person, how can you figure it? This healthier physical and mental functioning carries over into eating and sleeping better. Just through the simple process of meditation, you begin to get a chain reaction, a cascade of health benefits. Meditation is one of the easiest ways to motivate and prove to your body the importance of taking care of every area of your health. And It's Simple Meditation doesn't have to be long, tedious or hard work. You can sit on your sofa, the floor or in your office chair. Physical comfort will help with relaxation. Start with simple meditations and don't worry too much about whether or not you are doing it right. Focus more on just breathing until that focus drifts away, too.

Different people respond differently to different forms of meditation. Dr Eliot has switched objectives from curing his patient's disease to managing the chronic course of suffering. In the end, the doctor's work is to assist his patient to die a good death. This is a traditional task of medicine in the West, although it has been usurped by medical technology's mandate to keep the patient alive at any cost. Gordon Stuart and Hadley Eliot have agreed not to allow Gordon's terminal period to become technologized. Gordon Stuart is assisted to die with dignity in the intimacy of his home. The care of the dying makes the personality of the practitioner and the quality of the patient-doctor relationship the major modes of therapy. Nonetheless, no concern with therapeutic technique can prepare patient or family or practitioner for the final hours. The remarkable quality of the taped interview between Gordon Stuart and Hadley Eliot is the participants' struggle to maintain authenticity, to avoid sentimentalizing or in other ways rendering inauthentic a relationship centered on the most existential of problems. Hadley Eliot has no answers to Gordon Stuart's questions. Nor does Gordon expect, or even want, Hadley to try to answer. What do you eat? What don't you? The world looks so bloody dangerous. Who can say what caused it, my cancer? And the treatment, doc: I'm only a high school graduate, I can't even understand the simplified explanations. This problem in translation between lay and professional cultures, at least in the short run, can only become more difficult as scientific expansion outpaces the diffusion of scientific knowledge in the general public. The media contribute to an immense cloud of misinformation that adds to confusion and fuels inappropriate expectations. The need to explicate scientific development and correct--even debunk--erroneous information that confronts them daily. Today there is in North America a wholly unrealistic popular expectation that all diseases should be treatable and that no medical encounter should lead to a negative outcome.

This inappropriate expectation creates a climate in which great pressures are placed on the practitioner, including an increasing threat of lawsuits for maloccurrence, not just malpractice. Because we're all different. Some like to use mantras and chanting. Others try various breathing styles. Meditation can focus on an image, or empty your mind of all images. What you do during your meditation doesn't really matter that much when you get down to it. What's most important is to simply just take the time to meditate. Keep It Consistent by Meditating Daily Starting with just ten minutes a day can do wonders. Ten minutes can be squeezed into anyone's schedule, and will end up bringing more free time into your life. By investing ten minutes into meditating, you could have an hour of extra time. What this marvelously humane physician provides for his remarkable patient is intense listening. Empathic witnessing is a moral act, not a technical procedure. Dr Eliot's skill lies in his ability to hear Gordon's story, to reflect the power of the questions, to allow his patient to maintain irony and a critical analytic sense, and to build tentative understandings out of the crafting of words in the face of a final assault on the integrity of his body-self. That approach to dying makes a great deal of sense in the context of Gordon Stuart's life; Taking into account their own sensibilities, the practitioner, family, and dying person must work out an appropriate and desired way toward death. The practitioner must not press the patient toward some model of dying that is undesired and invalid in the patient's life. I fear that this happens routinely, and I applaud Gordon Stuart's negative assessment of mechanical models of the stages of dying. There is no single, timeless pathway toward death that is most serviceable for the dying person. An individual's course of death, like that of life, may take dozens of different turns, circle back to the start, or enter a state previously unknown.

The practitioner cannot know in advance where the patient is headed or what is best. In this setting, the practitioner cannot avoid responding to the patient's perspective on risk and vulnerability and to his expectations regarding treatment. But many physicians respond according to an outmoded health education approach that simply configures the problem as lack of effective knowledge. The actual dimensions of the problem are much greater: laymen possess alternative forms of knowledge, not merely insufficient scientific knowledge, as the creationism controversy ominously reveals. How many professionals can fully comprehend today's medical technology and its scientific basis in other fields? Most practitioners can be misled about a subject peripheral to their own area of competence. They, too, may harbor a mix of common sense (which is often scientifically inaccurate and commercially manipulated) and just plain misinformation. Practitioners must first elicit lay knowledge and then present their own models in order to identify questions that require more valid understandings. Furthermore, the practitioner's model--like those of his patients--is often inchoate until it is formally expressed, and it changes over time. Here we have another source of tacit misunderstandings and conflicts. The explanatory model framework is a potentially useful one for remedying this problem. Sounds a little crazy, doesn't it? But try it. You'll see. Once you've established a daily routine of meditation and it becomes a habit, you'll probably find you want to increase your meditation time. Begin by adding another five or ten minutes for just one day's session. Then try the longer sessions a few times a week and ultimately you'll be able to meditate for twenty minutes every day. Maybe even longer. When you start noticing the benefits you're getting, carving out time for longer meditation sessions won't seem like a sacrifice. You might even look forward to it!

The key, like with any good thing, is consistency. The pathway and course of action should emerge from the doctor-patient relationship or should be something determined by the dying person and the family. The practitioner does not (cannot) bring a teleology (a doctrine of final causes and ultimate meaning) from medicine. If such a teleology comes from the physician, it is from a religious or cultural background, not medicine. Not everyone would want to undertake Gordon Stuart's course. Some people would be frightened or otherwise repelled by his self-imposed demand that he be fully conscious of his end; The work of culture is powerful here. Contrast Gordon Stuart's terminal trajectory with that of Dr Song Mingyuan. In Chinese culture, among tradition-oriented families like Dr Song's, the family is the locus of responsibility, and that locus extends to include aspects of the person that in the West are regarded as sacrosanct to the individual. Dr Song turns over to his family all the decisions in the course of his cancer, in spite of the fact that he alone is medically qualified and even an expert on chronic illness. Even the way I have put it is ethnocentric: Dr Song does not turn over responsibility; The explanatory model approach can also help the practitioner disabuse himself and his patients of idealogically oriented and commercially controlled messages aimed at manipulating him and them toward the purchase of commodities that are expensive, unneeded, and dehumanizing. But to accomplish these ends requires that physicians master communicative and interpretive skills in which most are not trained and some have no interest. I shall return to the matter of training in the next article. The practitioner is now ready to engage the patient and family in a negotiation. Of all the tradecraft of the physician, nothing more effectively empowers patients. The very act of negotiation, if it is genuine and not a grudging pseudomutuality, necessitates that at the very least the health professional show respect for the patient's point of view. The real challenge is for the physician to engage in negotiation with the patient as colleagues involved in care as collaboration. The physician can determine points of disagreement and lacunae of information to which he can respond. He must encourage the patient and family members to respond to his model: that means he must be prepared to hear out their criticisms and--what is even more difficult, given the traditional orientation of medical training--he must actively help patient and family to negotiate about areas of conflict.