Psychosomatics 42:94-99, April 2001
© 2001 The Academy of Psychosomatic Medicine
George L. Engel, M.D., 1913–1999
Remembering His Life and Work; Rediscovering His Soul
Peter A. Engel, M.D.
Received June 29, 2000; revised October 18, 2000; accepted October 20, 2000. From the VA Medical Center, Albany, NY, and The Department of Medicine, Albany Medical College. Address correspondence to Dr. Peter Engle, Geriatrics and Extended Care, VA Medical Center, Albany, NY 12208; email: Peter.Engel{at}med.va.gov
Key Words: Engel, GL • Biopsychosocial Model • Illusory Memory
George Engel gave and received much from a nurturing community of family, colleagues, friends, students, fellows, and patients. His marriage to Evelyn of nearly 60 years was one of boundless love and continuing discovery. His life and contributions grew from the human bonds he recognized as so important to the diagnosis, healing, and comforting of others.
My father had an extraordinary intellect, intense curiosity and a creative disregard for the conventional boundaries of scientific thinking. I admired him for this, but more importantly, in his last years I found a growing love between us as father and son. As he became more openly affectionate, I recognized that his compassionate nature directed the intellectual passions of an extraordinarily productive academic career. My father's death on November 26, 1999, severed the bond between us. But within days of his death I had an experience that would have intrigued and pleased him. I came to believe that I had been with my father when he died. This vivid, detailed memory, in fact, is illusory. I was home at the time more than 200 miles away, but I am completely unpersuaded by this verifiable fact. The sorrow of this memory is sweet and intense, and the bond, though severed, feels stronger than ever.
I would like to honor my father's memory using two perspectives: first, a biographical account of his life, and second, an examination of my illusory memory and its implications. My father learned much about human behavior through self-observation and reflection on his inner life. Here, in the connections between father and son, is an opportunity to examine the phenomenologies of grief and memory, to consider the concept of the soul, and to relate all three to my father's work. My father would be pleased if these musings suggested new perspectives from which to understand illness and disease and a better means to care for and about patients. These were the passions of his soul.
The Biography
George Engel was raised in New York City, attended Dartmouth College, graduated from Johns Hopkins Medical School in 1938, and completed a 2 year rotating internship at Mount Sinai Hospital in New York. In 1941, while a Fellow in Medicine at the Peter Bent Brigham Hospital in Boston, he met John Romano, who recruited him to the University of Cincinnati and then to Rochester in 1946. There he received dual appointments in the Departments of Medicine and Psychiatry. Dr. Engel completed training at the Institute for Psychoanalysis in Chicago in 1955. Although he formally retired in 1979, he continued to teach, write, and travel for nearly 20 more years.
From his initial pioneering work with Romano on the clinical and electroencephalographic aspects of delirium, Dr. Engel's scholarship and research broadened into explorations of psychogenic pain, fainting, ulcerative colitis, psychosomatic medicine, psychoanalysis, psychophysiological aspects of human behavior, human development, medical education, and the biopsychosocial model. His scholarly work occurred largely in the context of his long and distinguished career as a teacher and physician. In 1946 he launched the introductory psychiatry course for second-year medical students. Over the years this course evolved into a curriculum and later a book, Psychological Development in Health and Disease. The same year he and Romano introduced the Medical Psychiatry Liaison Fellowship. Dr. Engel directed this program for 33 years, during which time he mentored more than 150 fellows.
George Engel became widely known as an innovative thinker, lucid scientific writer, and an outstanding teacher. His most effective teaching evolved from the General Medical Clerkship at Strong Memorial Hospital. It was in this setting that he and his colleagues demonstrated the extraordinary power of the interview as a diagnostic and therapeutic instrument. The General Medical Clerkship became a signature of the Rochester experience that placed the patient rather than the disease at the center of medical education. In countless teaching interviews, Dr. Engel displayed his vibrant curiosity, his depth of caring for others, and his keen observational abilities. Dr. Engel often brought unique insights to a clinical situation that no one recognized but, once revealed, made sense to everyone.
Since the 1950s Dr. Engel recognized that the prevailing biomedical model of disease left no room for the social, psychological, and behavioral dimensions of illness. As his thinking evolved he proposed an alternative biopsychosocial model in a seminal 1977 article in the journal Science.1 Here was a new framework for patient care, teaching, and research. At its core is the application of disciplined scientific investigation to the human domain of illness and disease. The value of the biopsychosocial model is now widely recognized and its impact is reflected in increased attention to interviewing skills at medical schools around the country.
In his later years, with a gentling of his intellect, he became more openly affectionate and tender, now ready to accept the help he needed. He was no less witty, mischievous, optimistic or kind. His integrity remained exemplary; his pleasure in sharing his roses, doodles, and mementos continued. He was no less inquisitive and maintained a remarkable capacity for self observation. "Why," he asked in his last year, "do ophthalmologists test vision only with stationary targets when it is moving targets that I can't see?" But my father saw perfectly well the love and community at the foundation of medicine. Being scientific in this human domain, he knew, would generate new insights into the nature of disease and the human condition and would strengthen our capacity to help others.
The Illusory Memory
Although best known for his biopsychosocial model, my father devoted much of his scientific career to the investigation of human relationships in the context of health, disease, and loss. My experience with my father's death, an intensely personal loss, reifies much of his work. The illusory memory occurred in the context of this loss, 3 days after his death while I was dressing in my bedroom. Its intensity and reality were astonishing and the context notable because I had been in this room when I first learned that he had died. In reflecting on this memory and using the method my father taught I have been able to discover its meaning and, in the larger sense, to embrace his memory.
Before dawn on the morning of November 26, the day after Thanksgiving, my father called me to his bedroom. He was in his larger old apartment at the Highlands, not the cramped assisted-living unit he had occupied for the last 8 months. I walked from the study across the hall to his bedroom where he was in bed to my right, surrounded by my mother's paintings and family photos. Facing him, I sat on the bed and embraced him. I told him how much I loved him. He told me that he loved me and was proud of me. Then life took leave of him, leaving me in sorrow and wonder at the privilege of the moment.
The visual and emotional elements of this memory are vivid and intense, whereas our communication seemed more a sequence of thoughts than a conversation. At the moment of his death the narrative stopped, suspended here; nothing further needed to happen. In its flaws and distortions the memory is immensely comforting, and the strong sense of being with him remains.
This memory includes two feeling states that are intellectually contradictory but emotionally compatible: the belief that these events occurred and the sense of knowing that they did not. My experience is comparable to those of bereaved survivors who commonly see, hear, or sense the presence of the deceased.2–4 These hallucinations and a certainty that the person is no longer alive occur simultaneously. Largely unexplored are the personal meaning of these sensory phenomena and the association of illusory memories with grief.
In his last publication my father offered a conceptual background in which to study and understand human illness and disease that is similarly applicable in the exploration of illusory memories as a phenomenon of grief.
As a profession and as an institution, medicine owes its origin to three distinctively human attributes. First, we humans are aware of death and its inevitability and realize that feeling and/or looking bad ("sick") may be its portent. Second, we suffer when our interpersonal bonds are sundered and feel solace when they are reestablished. Third, we are capable of examining our own inner life and experience and of communicating such to others via a spoken and written language. Critical for all three and for the work of the physician is the distinctively human capability of using words to communicate both what is being observed in the outer world and what is being experienced within the inner world.... Surely, as scientists dedicated to organizing our experiences and formulating observation, we should be careful to define science in such a way as to be able to include verbal reporting as legitimate data.5
Using the illusory memory as legitimate data of my inner world, let us see where this leads.
Each element of this memory is derived from my life experiences. In my dad's last 2 years I held him many times. I told him I loved him with nearly every phone call. He said the same to me. Several times he said he was proud of me. During my last visit to his old apartment, I went to his bedroom, held him, and kissed him good night. Each of these events bears a common emotional tone.
Other fragments of the memory are drawn from my work as a physician. Twice I was at the side of a patient at the moment of death. The first patient, a youthful man in his forties with a high-grade glioma died while we were visiting him on rounds. The second patient, a man in his early fifties with metastatic prostate cancer, told me that his unwelcome assignment was "to die with dignity." To this task he brought an exemplary vitality and wit. He died while I was standing arm and arm with his family, his nurse, and the hospital chaplain. At this moment I sensed that the organizing, life-force was taking its leave and presumably going elsewhere, a notion the chaplain endorsed as he spoke of the spirit and soul.
Common to every element of this illusory memory is the sense of caring and connection combined with a feeling of loss and re-connection. When my father died, these collective experiences, times, and contexts reassembled themselves into a new coherent memory composed of vivid images and intense feeling.
By ignoring conventional boundaries between emotion and cognition, my experience of normal grief becomes an opportunity to explore the significance of false memories in the context of human relationships. It was these relationships that were so important to my father and essential to his work in the human domain of illness.
Most information on illusory memory and false recognition is derived from formal experimental paradigms employing list learning and word or object recognition. In these studies false recognition is common. It is accentuated by right frontal lobe injury and aging and is frequently accompanied by a sense of "remembering" earlier exposure to items actually presented for the first time. Corresponding dynamic imaging and neurophysiologic studies demonstrate increased frontal lobe activity during recognition tasks, particularly in the right anterior prefrontal cortex, with both correct and illusory responses, an effect that is attenuated with age. These studies implicate the right prefrontal cortex in restructuring the general context of an event and in rejecting irrelevant information.6–9
Delusional misidentifications and memories are also described in individual patients with frontal lobe injuries, but few reports include the patient's personal observations and beliefs about their own delusions.10–12 One unemployed man woke each morning convinced that he must prepare for work, was persuaded otherwise by factual evidence only to repeat the error again the next day. He had suffered frontal injury during an anterior communicating artery aneurysm repair. In this example, an emotionally significant generic memory intruded into consciousness presumably unregulated by normal frontal systems inhibitions.12 In my case the organizing force that reassembled a series of emotionally significant events is the continuing sense of connection with my father. This intrusive illusory memory emerged uncensored or perhaps selectively choreographed by the right anterior prefrontal cortex.
Illusory memories, misperceptions, and misattributions are sufficiently common that I had little difficulty finding another example from my father's own writings.
Reflecting on the death of his identical twin, Frank in 1963, my father recounts his attendance at a meeting of the American College of Physicians 5 years later. A passer-by greeted him "Hi Frank," to which he responded without a second thought.
Only a few minutes later did I realize with amazement that I had been greeted as Frank and yet felt no surprise. But the setting was important....The occasion for my attendance at that meeting was to receive an award, the perfect setting to play out our rivalry. Clearly my wish that he could share (and be put down) by my success was intense enough that for the moment at least I accepted the stranger's error as if Frank were indeed still alive.13
Both his transient delusion and my illusory memory accurately reiterate the emotional fidelity of important human relationships at the expense of temporal and spatial accuracy. Equally important, as my father has emphasized for more than 40 years, is reliable access to data of this type, which is readily available to a curious and caring observer.
Memory research generally measures speed, accuracy, sequencing, and suppression of irrelevant information, all of which are readily quantified. It is far more difficult to determine the significance of experimental memory performance data within the broader context of cognition and emotion and to determine the utility of these capacities to the organism. Does age-related memory decline as conventionally measured, for example, reflect cognitive adaptations to late life? Adaptive functions of memory likely include the capacity to generalize, to encode new data within the context of existing concepts and beliefs, and to retain information critical for survival.14 For these purposes, accuracy and detail may be neither essential nor desirable. Memory distortions of time, fact, and detail may "feel right" and may be comforting as illustrated here. These literal distortions are adaptive in that they support a sense of continuity in important human relationships.
Illusory Memories, Grief, the Soul, and My Father's Work
In his seminal paper on the biospychosocial model, my father suggested that the reductionistic biomedical model originated in a concession of Christian orthodoxy more than 5 centuries ago to permit dissection of the human body.
Such a concession was in keeping with the Christian view of the body as a weak and imperfect vessel for the transfer of the soul from this world to the next. Not surprisingly, the Church's permission to study the human body included a tacit interdiction against corresponding scientific investigation of man's mind and behavior. For in the eyes of the Church these had more to do with religion and the soul and hence properly remained its domain.1
The new model invites scientific exploration of the soul in relation to human bonds and to human suffering when those bonds are sundered.
The abstract soul may be likened to the self, mind, and spirit as distinguished from the material body. The ability to conceptualize the mind and its properties, including awareness, motivation, intent, and deception, has been termed "theory of mind." These abilities in humans have been attributed to the evolutionary enlargement of the prefrontal cortex.4,15,16
The notion of a discrete mind residing in the body is so natural to human thought that it is readily extended to the concept of an enduring soul following death. This soul-body dichotomy is reflected in ideas dating from preliterate cultures through ancient Greece to the 17th century works of Descartes.4,17 Whereas Descartes employed philosophical arguments to invoke the existence of the soul, clinical observations are beginning to identify the neurobiological substrates underlying the personal experience of a nonmaterial self or soul. Auras reported by individuals with partial complex seizures include a range of cognitive-emotional experiences, the most relevant of which is autoscopy, seeing one's body from an external perspective. Out of body experiences also occur in circumstances of extreme stress, such as cardiac arrest and near drowning.18–20 In addition, the concept of a soul may have been reinforced through the millennia by deathbed experiences in which survivors sought to understand the fate of the dying person and by the reappearance of a disembodied presence of the deceased in the hallucinations of normal grief. I sensed the departing life force as I stood at the bedside of my dying patient. In my illusory memory, I was present at the moment my father's soul left his body and something of him passed to me.
I have suggested that illusory memories reflect adaptive neurobiological and cognitive processes that nurture human bonds. Might the same be true of our capacity to conceptualize mind and soul and our inclination to distinguish these so clearly from the body? These qualities of memory and mind that make us so uniquely human cannot be separated from the physical and biological processes that define us.21 The mystery lies in why relationships have become so important to us that biological mechanisms have developed to adapt to loss. Were these processes at work in the memory that gave me so much comfort? These possibilities would have intrigued my father as they do me, and so we maintain a connection that transcends death.
My father spent much of his career seeking a more fundamental understanding of the human experience in health and disease. In a sense his work represents an investigation of the mind and soul. His focus and terminology differed, but he constantly demonstrated the essential importance of relationship and dialogue in the scientific study as well as the care of his fellow human beings. This passage, published in 1988, eloquently reflects these ideas.
To appreciate relationship and dialogue as requirements for scientific study in the clinical setting highlights the natural confluence of the human and the scientific in the clinical encounter itself. It is not just that science is a human activity, it is also that the interpersonal engagement required in the clinical realm rests on comlementary and basic human needs, especially the need to know and understand and the need to feel known and understood. The first, to know and understand, ... is a dimension of being scientific; the second, to feel known and understood, is a dimension of caring and being cared for. Both may be seen as derivative and emergent from biological processes critical for survival.... The need to know and understand originates in the regulatory and self-organizing capabilities of all living organisms to process information from an everchanging environment in order to assure growth,... self-regulation, and survival. In turn, the need to feel known and understood originates.... in the life-long need to feel socially connected with other humans.... The need to know and to understand ultimately achieves its most advanced development in the disciplined curiosity that characterizes scientific thinking. The need to feel known and understood manifests itself in the continuity of human relationships and in the social complementarity between perceived helplessness and the urge to help. Herein then converge the scientific and the caring (samaritan, pastoral) roles of the physician.22
This is the core of the biopsychosocial model. My father's caring lay at the heart of his insatiable passion to know and understand. In reflecting on my father's life and work, our relationship, and my illusory memory of his death, I now know and understand my father better. Even a brief exploration of memory, soul, mind-body dualism, brain function, and human relationships underscores the critical importance of language and relationship as means of access to essential, verifiable information. This may be my father's most important legacy, one that enriches, broadens, and deepens the work of physicians as healers and investigators. In so many aspects of his life, the soul of his work, his creativity, and his expansive thinking touched on this unifying and illuminating gift that he leaves for us.
ACKNOWLEDGMENTS
The author deeply appreciates the thoughtful comments and suggestions from colleagues and friends. I am particularly grateful to my wife, Anna Engel, MD who helped me to see the essential connections between my father's life and work, and my relationship with him.
This essay draws upon the author's contributions to a memorial service for his father at the Interfaith Chapel, University of Rochester, January 29, 2000. Portions of this tribute appeared in the April 2000 issue of the Journal of Developmental and Behavioral Pediatrics, page 163.
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A. S. Dowling
George Engel, M.D. (1913-1999)
Am J Psychiatry,
November 1, 2005;
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2039 - 2039.
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