Philosophy of Practice — Or Rather, Philosophy of Communication

Roland Barthes, in his hybrid monograph and mourning memoir, Camera Lucida, reflects:

“A specific photograph, in effect, is never distinguished from its referent (from what it represents), or at least it is not immediately or generally distinguished from its referent... what we see in the photograph are the studium and punctum. The studium is the average affect: the culture and history. The photograph’s punctum is that accident which pricks me (but also bruises me, is poignant to me).”

— Barthes, pp. 5, 26-27

In simpler terms, photographs provide us with a direct window to their subjects. They uniquely bind the signified—the mental image we construct—and the referent—the actual object they depict. This is in contrast to words, where there’s often a gap or displacement between the sender’s intent and the receiver’s interpretation. Photographs, on the other hand, show us ‘how it is,’ capturing reality as perceived in the moment. They can either compel us (studium) or completely, irrevocably puncture us (punctum).

I have seen many, many photographs in my life: few have punctured me. Adeline Grace Moyer was one of those photos.

Dr. Hogan’s account of Adeline’s life, simultaneously beautiful and forcefully poignant, was something I intently listened to. At only 4 years of age, she had defied all odds. Despite having Mosaic Trisomy 9, she was a fierce fashionista, actively engaged with herself and the world she lived in, and had deeply affectionate relationships with her parents. With the short and arduous span of life she was given, Adeline lived it all in full.

But what I really remember that day was the eulogy photo (with her physical bow attached):

That day was when she came back to life. Words no longer created a distance between her and me; she was sitting in my hand, showing herself as fully, intensely, and viscerally human. I can only speak for myself, but when I held this photograph, I felt an immense urge to cry. It reminded me that she had an existence out of this classroom, and that at one time, she and I coexisted together.

It is a tragedy that I only came to know Adeline posthumously, through words and memorial cards. However, she lives through the photo. What I see — what you see — is who she was, is, and will be.

The photograph containing the “be” (or being) is what I’m particularly interested in. Throughout our Medical Humanities sessions, we’ve learned that words, communication, and verbal understanding are critical to holistic patient care. Nevertheless, even with good intentions, words spiral and multiply in meaning, and as a result, dangerous disengagements with language occur. So what are we to do with this precarity, especially when language itself constructs the reality we live in?

For me, at least as a doctor and person, it means stepping back, intently and empathetically observing the scene. A patient may present themselves to me at seemingly their angriest moment: “You’re not listening! You’re just cash-grabbing me!”. What they’re saying is, of course, still important — just because language is flawed doesn’t mean it’s not powerful.

The things I’m more interested in, though, are the baggy, shaken eyes; the tension of their arms; and the contours of resignation on their face. All of this tells me that their anger is masking something more profound: fear. Fear of isolation, fear of their condition, fear of me not listening to them, etc. Standing back and analyzing everything whole — their words, their body, their face — gives me the unique opportunity to realize what I need to immediately address, to see where I have faltered as a physician, and for me to connect with this person as a person (rather than a worded list of symptoms).

I am far from perfect. I have, do, and will make mistakes, both in my personal life and doctorship. In regard to my life as a doctor, what’s important is knowing when I’m wrong and making the active effort to ameliorate that for the patient. The patient has come to see me in their most vulnerable — and oftentimes, their worst — the least I can do is respect that in the highest regard. So when a patient tells me that “I’m not listening to them,” I will observe. I will recognize their statement not as invective, but as a plea to be listened to in a place where they feel most helpless.

And finally, I will approach them with the tools I have available to me: my words (imperfect but resonating), my body language, and my undivided attention. There is so much more to my patient than what they’re here to see me for, and it is my job to let them know I perceive them entirely.

Returning to Barthes, much of his argument surrounds the “Winter Garden” photograph: a picture of his late mother at 5 years old, standing in a garden. Much like a patient’s face will tell me more than I can ever describe in words, he puts his mother’s memory to rest:

“I can not reproduce the Winter Garden photograph here. For you, it would be nothing but an indifferent picture, one of the thousand manifestations of “the ordinary.” For me, it holds everything.”

— Barthes, p. 76

To my future patients in the doctor’s office: I promise you are not ordinary. To me, you hold everything.