The Bridge

Authors:
Ohad Avny, MD; Assaf Moriah; and Aya Rice

Citation:
Avny O, Moriah A, Rice A. The bridge. Consultant. 2018;58(6):e187.

Tom was a frequent visitor to my clinic. He was 28 years old, married, and the proud father of a newborn son. His quality of life had not yet been affected by his prediabetes or obesity, but rather by his at times debilitating anxiety and panic attacks, particularly when exercising. He adamantly refused to take antianxiety medication, and despite his having made significant progress through extensive psychotherapy, his anxiety had persisted. He came to me in search of a primary care physician who could affirm the psychosomatic nature of most of his symptoms, thus avoiding unnecessary tests that would only exacerbate his somatic symptoms.

Our repeated clinical encounters over the months focused on his anxiety attacks, to which I responded with medical explanations about anxiety, by addressing his somatic concerns, and by encouraging him. Still, his awareness and understanding of his anxiety diagnosis were not translating into real relief.

I knew that instances like these sometimes led me to a lack of patience with my patients as a result of my sense of helplessness and frustration with my inability to alleviate their suffering, compounded by my dire lack of time to address their deeper emotional concerns in my clinic. This unease led me to introduce an experimental treatment plan that unfolded over time. This intervention was not carefully planned out; it came from somewhere quite unconscious within me, the very place where I felt Tom’s story reached me. Only in hindsight, when collecting the pieces of this narrative, did I come to conceptualize what my intuition had led me to do.

At the time, I had been mentoring medical students who were guiding patients trying to change their lifestyle habits. One motivated student, Assaf, agreed to my proposal of inviting Tom to a series of joint exercise sessions. Soon afterward, sharing this plan with a psychologist during a chance meeting with her in the hallway led us to formulate these exercise sessions as a kind of cognitive behavioral therapy (CBT). During the sessions, Tom would gradually be exposed to the trigger of his panic attacks, thus inducing desensitization of exercise as a trigger to his anxiety and hopefully causing it to lose its destructive grip on his well-being. In CBT and mindfulness, one learns to create a little space between the thought or situation and the reaction. This space is where new adaptive and helpful thoughts and perspectives have the chance to question the old pathological narrative and begin to break the automatic dysfunctional pattern.

Tom had come from a family in which medical treatment for emotional issues was taboo. Thus, he repeatedly rebuffed all of my suggestions for medical treatment for his anxiety. He was, however, open to my idea of meeting with a medical student who could “walk him through his anxiety.” Tom and Assaf met every week for 90 minutes of exercising together, for a period of 3 months. I provided Assaf with supervision for the case, and Tom continued to visit me as his personal physician every 2 weeks.

Tom discussed his anxiety with me before the first exercise session. He was worried that he might have a panic attack while exercising with Assaf, and he was relieved to hear that Assaf was medically trained for such a situation. Assaf also was anxious before his first meeting with Tom. He downloaded an intake form from the internet and used it as a guide for his first meeting. “Luckily,” Assaf later told me, “I think Tom was even more anxious than me, so he didn’t even notice how nervous I was and answered all of my personal questions.”

And so the journey began.

As the weeks and months passed, the relationship between Tom and Assaf solidified. They both reported significant and increasingly open and informal conversations between them. When asked to reflect on his experience, Tom later wrote, “Until I met Assaf, apart from my doctor and my psychotherapist I had no one who was really involved in my story—I mean, someone who embraced me in a familiar and trusting way and encouraged me that all is well, and that I am normal.” And Assaf wrote, “I identified with Tom’s lack of confidence, since existential angst has also been my companion during periods of my life. Tom was a reflection for me—I saw a talented individual suffering from what I could clearly identify as subjective sources that were unfounded in reality.”

A parallel process seemed to be transpiring between Assaf and Tom: Assaf’s overwhelming emotions in meeting his first patient dramatically decreased as he realized, as he put it, “We’re just two human beings sharing our stories, our problems, our lives, and our thoughts.”

Several weeks into the treatment plan, Tom became open to trying antianxiety medication. The effect was profoundly positive. Simultaneously, the exercise partners had increased the pace of their walk into a run; Tom almost did not notice the change. He had experienced no medical emergencies or overt anxiety events. When the 3 months came to completion, there were at least 3 individuals whose lives had been deeply touched and interconnected.

In summarizing the intervention, Tom shared the following:

The collaborative support of Assaf and Dr Avny steered the ship I was sailing to a totally different destination. From years of being in survival mode, I transitioned to something completely different. My quality of life improved, let’s say, from 20% to 90%. It is important to realize that every player in this treatment plan was essential—my therapist, my physician, Assaf—and mostly because of their genuineness and humanity. Each element was crucial in shaping my attitude toward the medication, which proved to be critical in my improvement. My approach toward medication initially had been firmly negative and judgmental. Yet in this roundabout way, a new path was created. Something that seemed set in stone became more flexible, as if my moving body helped soften my inner rigidity.

As I consider the various components of this ad hoc experiment, a few questions remain open for me. Perhaps Tom’s improvement can be attributed not to the CBT intervention or to the antianxiety medication, but instead to the well-established connection between exercise and improved mood and decreased anxiety.¹ Or perhaps it was the authentic encounter between Tom and Assaf that facilitated the changes. It seemed they were deeply engaged in what the philosopher Martin Buber termed an “I-Thou” relationship—one in which the other is not separated by discrete bounds.² This was something I could not fully offer my patient under the conditions in which we met at the clinic. As Tom summarized in the end, “I wish everyone had someone to hear them out the way Assaf did during these 3 months. How much less suffering there might be in the world.”

In reflecting on this case, I realized that my own limitations and frustrations as a physician, together with my sincere care for my patient, motivated me to seek another path, one that would eventually bring together the various players in a way I had never done before. Through this collaborative format, a bridge was created—one that I could not create on my own. Ultimately, it was a series of bridges, interconnected and mutually influential: a bridge that connected physician and patient; a bridge between an experienced physician with a challenging caseload and a motivated student; a bridge between 2 young men facing existential dilemmas; a bridge between a medical student’s education and a formative clinical experience in patient-centered care³; and most importantly, a bridge within Tom himself, one that he created and crossed, toward significantly greater wholeness.

Ohad Avny, MD, is a physician at Clalit Health Services and is on the faculty in the Department of Family Medicine at Hebrew University Hadassah Medical School in Jerusalem, Israel.

Assaf Moriah is a medical student at Hebrew University Hadassah Medical School in Jerusalem, Israel.

Aya Rice is a clinical psychologist, PhD candidate, at Haifa University in Haifa, Israel.

REFERENCES:

1. Swan J, Hyland P. A review of the beneficial mental health effects of exercise and recommendations for future research. Psychol Soc. 2012;5(1):1-15.
2. Buber M. I and Thou. Kaufmann W, trans. New York, NY: Charles Scribner’s Sons; 1970.
3. Moser EM, Stagnaro-Green A. Teaching behavior change concepts and skills during the third-year medicine clerkship. Acad Med. 2009;84(7):851-858.