Research Letter Practicing healing James Lake Deparment of Psychiatry, University of Arizona, Tucson, AZ, United States When the familiar routines and comforts of living and working in a ‘developed’ country start to feel empty I sometimes travel to remote places to get a fresh perspective on life and for spiritual renewal. A few years ago, depleted by worries about my mother’s precarious health and discouraged by a series of career disappointments, I found myself doubting core beliefs that had led to medical school decades earlier. Could I make a difference to my patients given constraints on health care in the U.S? Was it even possible to do meaningful work in a culture where the practice of medicine seems to be more about filling in blanks on boiler plate electronic documents, managing medication refills efficiently and optimizing work-flow algorithms than listening carefully to what patients are saying and responding to what they are feeling? Given my conflicts, was it ethical for me to continue partici- pating in the impersonal form imposed on patient care by federal regu- latory bodies, academic institutions and corporations? And if I could find a workable compromise that allowed me to ethically practice medicine, could I find enough meaning to sustain myself while doing the heart work of compassionately sitting with humans who suffer? In the midst of my dark night I learned about an opportunity to do medical volunteer work in a remote area of Tibet. I had gone to con- ferences on Tibetan medicine and saw this as a way to remind myself of values that had led to the decision to study medicine, and to find out whether I still held onto them. While in Tibet I kept a journal to process experiences and—I already knew then—to help me remember insights about suffering, what it means to be a physician, and the dif- ference between treating patients and providing a healing space. The following narrative was assembled from journal entries made in Tibet. I hope that others who are also struggling with career disap- pointments and searching for meaning in the vocation of medicine will glean something useful from my journey. I am one of 20 ‘foreign doctors.’ We have come from many coun- tries to a small town located in the foothills of the Himalayas on the frontier of Tibet and Mongolia. We’ve come here to serve the nomads who live in this remote place and to refine our knowledge of “Sowa rigpa” (Tibetan for ‘the science of healing’). On the morning of the first day we tour the hospital where we will spend the next month. We see patients sitting on floors, lying on gurneys in hallways. A 38-year-old man who is receiving Tibetan style acupuncture and IV herbal infusion therapy describes symptoms of malaise and indigestion that started soon after he moved from the high mountain passes to the city in order to ‘get money’ needed to finance his son’s college education in a large Chinese city hundreds of miles away. Before coming here, the man had worked as a yak-herder ‘my heart did not know how to live in a city.’ Since arriving he has not seen his son. Looking askance the man says ‘he is learning now. He doesn’t have time...’ The man doesn’t know where his wife, two young chil- dren and yaks have gone or when he will see them again. From a Western medical perspective many patients we have seen today would be regarded as having ‘ culture-bound syndromes’ reflecting widely shared Tibetan cultural and spiritual beliefs. Some would probably be diagnosed with psychosomatic disorders in which stress, anxiety and depression are experienced as physical symptoms in the absence of an underlying medical disorder. From the perspective of Tibetan medicine many have ‘ wind’ disorders or energetic or spiritual disorders that have led to physical and psychological symptoms. We realize that the high prevalence of ‘ wind’ disorders probably reflects widespread cultural dis- location taking place in Tibet and Mongolia as more and more nomads leave their traditional yak herding roles and move to cities. After a lunch of yak soup and tsampa (a Tibetan staple made from ground barley) we begin to see patients. Attired in traditional Tibetan robes fastened with cloth sashes, dozens of nomads have crowded into the main hospital entrance and the hallways. Several families have brought infants and young children. Some arrived last night and camped in squares of concrete in front of the hospital. We are told the nomads have been expecting the arrival of ‘foreign doctors’ in this season, after the yak herds return from the high mountain passes and before the days grow short. Most mark an ‘X’ at the bottom of a form when told to do so by the receptionist, then sit on a chair or the floor and quietly wait. I pick up a form and notice that instructions are written in Mandarin characters only. Many patients have already been treated with Chinese medicine, Tibetan medicine and Western medicine but have not gotten better. Most are elderly and seek relief from chronic debilitating illnesses such as heart disease, arthritis, cancer and emphysema. Some have lost confidence in Tibetan medicine and have been waiting one year or more for ‘foreign doctors’ to return to cure their maladies. These patients ask for ‘Western pills’ only. Others reject Western medicine as unsafe or ineffective. These patients ask for Tibetan medicine only. Many have physical and psychological symptoms that don’t corre- spond to a disorder described in Western or Tibetan medicine. Every- one is desperate to find any treatment that might alleviate suffering. Daily routine and moments of encounter My days began at 6:30 with a light breakfast consisting of a few plums, a handful of nuts, and green tea made with water boiled in a E-mail address: contact@integrativementalhealth.net https://doi.org/10.1016/j.explore.2019.07.006 1550-8307/© 2019 Elsevier Inc. All rights reserved. ARTICLE IN PRESS Explore 000 (2019) 1À3 Contents lists available at ScienceDirect Explore journal homepage: www.elsevier.com/locate/jsch