Empathy: Are We Asking For Too Much?

As my daughter approached the stage toting her miniature violin, I could feel a flutter in my chest.  My palms were sweaty and my feet started to tremble.  I hesitated while she played the first note.  My heart soared with each rhythmic movement of her bow.  I caught my breath when she reached the most difficult portion, and exhaled calmly as she nailed it.  At the end, I elatedly stood and clapped with the rest of the crowd.

I have learned just about everything I know about empathy by being a husband and father.  In no other relationship have I so acutely felt the joys and pains of another person.  Triumph, despair, guilt, surprise.  Each emotion transcending the flesh and glomming on to those in closest proximity.

But empathy, like parenting, is hard.  You have little say over what befalls your children from day to day, yet feel each painful barb.  The loss of control can be maddening for those practiced in manipulating their surroundings.  You wear your heart on your sleeve unprotected.  I suspect this is one of the main reasons many decide not to procreate.

So I find it rather ironic that we stress empathy as a character trait to idealize in our physicians.  Few among us have the emotional fortitude to process such tumultuous emotions on a grand scale.  I dare say the majority of human beings would be paralyzed by the difficult and frequently overwhelming nature of illness.  Everyday.  With every patient.  All the time.

Empathy is an act of selflessness given as a gift to those we love most.

I think it is time to ask our doctors for what they are capable of.

Kindness, patience, humility.

And occasionally.  Very occasionally.

Empathy.

Gotcha

It was a little game we played.

My shoes squeaked quietly down the hallway of the nursing home as I approached her room.  I knocked gently trying to avoid any particular rhythm or dissonance.

Go away!

Her voice was at once stern, and then followed by peels of laughter.  She only saved such greetings for me.  And I tried to trip her up.  I varied my visits by time and pattern.  Sometimes I knocked, and others I would call out in a distorted voice.  She always knew.

She was recovering quickly and would be discharged soon.

The rest of my visits that day were not as positive.  The gentleman next door was concerned with service issues.  He decried the quality of the food, and demanded a faster response to his call light.  I didn't have the heart to explain that as the physician, I had little control over these issues.

The woman on the floor above was dying a slow, uncivilized death due to Alzheimer's.  I huddled with her family, and discussed the gruesome details.  Her body was fading away much in the same way as her mind.  She lost every ounce of extra weight.  Her voice had diminished to a nonsensical whisper.  She was no longer capable of making the difficult decisions that were left to her befuddled family.  They signed the necessary paperwork with both hope and sadness.  Hope that the end would ultimately be dignified, and sadness that her time was indeed near.

Cancer is an ugly term.  But it was chemotherapy that sickened the young man at the end of the hall.  He spent a week in the nursing home between hospitalizations.  His family couldn't manage the vomiting and intravenous fluids.  He peered through the window at the first ray of sunlight on a cold winter's day.  He didn't feel much like talking.

I left the facility two hours after stepping foot into the front atrium.  I felt as if I had already been working a full day.  But there was a certain lightness nonetheless.

Because just before leaving, I crept up to her door, knocked yet one more time, and waited gleefully.

Come in.

I paused for a moment and then joyously replied.

Gotcha.

I could hear her laughter echo past me and through the hallway as I exited the building.  

Just Be

It all started with the tip of my tongue.  Really.  I was chewing on dark chocolate chocolate chips with a vigor that was maybe a touch inappropriate for such a snack.  I bit down firmly and felt immediate pain sear through my mouth where the tooth overzealously punctured the soft tissue.

I bit my tongue.

Which wouldn't have seemed so calamitous if it had not been one of many bodily malfunctions that had recently befallen me.  A growth the size of a marble called a chalazion has grown under my eye lid.  My hairline continues to recede.  All of the sudden, out of nowhere, I have acne far surpassing that which befuddled me as a teenager.

My joints hurt every time I exercise.  My ankle now makes a clicking noise while jogging.  The connective tissue holding my abdomen in place has started to falter.

Time is passing.  I am getting older.  Yet my mind has thankfully lagged behind my body.  I wake up each morning feeling like a much younger man.  There are a thousand tasks to be performed, a thousand opportunities, and I chase after each one of them.  Enthralled by the possibilities, I rarely stop running until the day is over and I collapse into bed.  Six hours later the alarm sounds, and it starts again.

This makes me happy.

For the most part.  The problem that comes with an awareness of the possibilities is the realization that time is finite.  There are projects that I will never finish.  Relationships that will never be rekindled.  The past is gone and the future diminishes even as these precious moments pass.

And just when I seem to have gotten myself into lather, I feel a soft tugging on my shirtsleeve.  I peer down into my daughter's soulful brown eyes.

Dad, dad, you're spacing out again.

My son is dancing a silent jig on the other side of me, listening to music that only he can hear.

They both need me so much right now.

Maybe it's time to give up on all this thinking.

And just be.

Insults

It hit me today while on hold with an insurance company to get a preauthorization.  The call took thirty minutes.  The medication was denied.  And I knew that I was going to get an earful from the patient when I delivered the bad news.  As I dialed the phone number, a disturbing and yet all to familiar feeling overtook me.

Helplessness, powerlessness, impotence.

I struggle with these feelings daily.  In the beginning of my career, they were spurred by the complexity of disease, the willfulness of bad luck.  Battling the human condition was a long, difficult slog fraught with trap doors and missteps.  Many patients improved, but others suffered.  And I often suffered with them.

Years of practice brought a hard earned humility, the wisdom of acceptance.  I learned to rejoice when interventions were beneficial, and comfort when a kind heart was all I had to offer.  I felt great peace in this middle ground.

These were the battle scars that I carried proudly.  My wariness was never a sign of failure, it was the toughness and patience developed by the skilled art of warfare.   I wore my badge proudly.

Yet these feelings have returned, even more powerful than before.

My enemy, however, is no longer the thoughtful, wily adversary of the past.  Instead of the foibles of humanity, I am hereangued with a litany of administrative tasks with no trace of nobility.  Preauthorizations, face to face, peer to peer, meaningful use, ICD, CPT.  The list goes on.

A long line of administrators, insurance employees, and government workers await my attention.  They tell me that my care plans are incorrect.  Improbable.  Not covered.  Out of the question.

And as my blood pressure rises and my temperature boils, I see no silver lining.  No lesson learned.  

I always expected that I would be bludgeoned by the awe-inspiring task of practicing medicine.

Not broken by a thousand, tiny, thoughtless insults.

Extraordinary

He squeezed into the elevator just as the door was closing.  There was a lightness about him, an excitement.  His jacket was newly pressed and uncomfortably free of nicks or stains.   He stood at attention with perfect posture.  There was no sign that working at this early hour on a Sunday morning, nor even being awake, was something out of the ordinary.  Extraordinary.

He glanced over at my tattered lab jacket without trying to seem obvious.  I'd like to think that it was the gray color (as opposed to his white) that gave me away as an attending physician.  More likely it was the telltale signs of aging that I have been doing my best not to notice.  I slumped against the back wall and waited for the doors to open.  My eyes flickered and closed for a moment, but opened quickly.

I was drawn to him.  The energy emanated from his body, and pinned me into the deepest corners of the elevator.  I couldn't decide whether to envy or pity him.  A young intern, he was at the mere beginning of his medical journey.   He couldn't yet fathom the degree of wonderment and heartbreak he would experience over the next few years.  The joy and the guilt.  The triumph and the disappointment.

There is a whole world ahead of him.  A world I have become strangely accustomed to.  Racing into the hospital on a Sunday morning is no longer novel or extraordinary.  It is part of my weekly routine.  I get up early and round at the hospital and nursing homes in order to be back home before the kids awake.  There is no excitement.

No wonder.

Instead there is a gentle quietness.  A certainly that comes from years of sparring with health and disease.  An acceptance of both the hardships and joy involved in spending one's time contending with the human condition.

As the door opened, I awoke from my reverie, and sprung towards the hallway and the ICU.  I patted him firmly on the shoulder as I passed by.

I caught one last glimpse of him as I turned the corner.

He was still standing in the elevator doorway,

his face a strange mix of confusion and pride.  

Home

It was a short trip from the hospital to the nursing home.  I luxuriated in the mid-morning sun.  Wisps of fresh air snuck through the cracks of my barely opened windows.  Although I had just gotten credentials at this particular facility, the path I drove was all to familiar.  I turned my head as I passed the elementary school that I had attended as a child.

As I stared at the playground, a long buried memory percolated to the forefront of my consciousness. I must have been around 8 years old, a little after my father died.  I am playing by myself on the jungle gym, and glance longingly at the street in front of me. I am overtaken by a great sense of loneliness.   I want to run down the street.  I want to go home. 

"Home", at that time, was the building I lived in. 

Many years later, my mom remarried and we moved from Evanston (the city I was born in) to the neighboring town of Winnetka.  A mere 13 years old, feeling myself the center of the universe, I resisted the move wholeheartedly.  For years I mourned the departure from my beloved city.  Only a few miles apart, the emotional distance seemed immense. 

I pined for my old neighborhood.  I dreamed of riding my bike down the old streets to my favorite places.  I was so in love, that years later, I returned to build a family.   

"Home", at that time, was the town I was born in. 

As I got older, I found solace not in places or things, but in people.  My interest turned to the amorphous task of building relationships.  Acquaintances, friends, lovers.  People and personalities became a currency by which to measure happiness.  I bathed in the luscious glow of humanity.  I gave and I took.  

"Home" became the people I surrounded myself with.

Recently, I have begun to believe that "home" is something much more personal, more internal.  Maybe it is a construct based on those people, places, and things that make us feel most connected, most safe.  

And driving by my childhood elementary school this sunny afternoon, on my way to the nursing facility, which will be followed by a jog with my wife, and then a walk to pick up the kids...

I feel as if, for possibly just this fleeting moment,

I have finally come home. 

Dystopia

He had been educated at the finest universities.  He had graduated cum laude, or whatever the term is they use nowadays to signify distinction.  His pedigree was squeaky-clean.

But as he haltingly entered the dark building at the end of an otherwise unexceptional suburban street, he felt more like a criminal than a scholar.  His office was drab.  Each room a glow with the artificial light provided by an incandescent bulb.  He often wondered whether the lack of windows was to keep the light from piercing the imperturbable darkness or to trap the terror in.

He knew his place.  He was the last stop on a frightful train line that ended in horror.  There was no solace.  His clients never dreamed of needing his services, and yet they came.  Without fail, they averted their eyes to hide the excruciating pain and loss.  He met them in life's basement.  In a lonesome quagmire, he helped them wade through the morass.

In his younger years. his work clung to his back even outside the office.  He awoke from nightmares of the vilest kind.  Remnants of the day stuck to his clothing.  He tried to scrub and scrub but they refused to fade away.  A sort of blackness pervaded his waking hours.

It was in this acrid garden that a certain soullessness grew and flourished.  He found that he could approach his clients with a coldness that became rather comforting.  Empathy wouldn't pull them through the manure laden pit that they found themselves trapped in.  His voice, certain and clinical, could.

As the years passed, his body bent and his haired thinned.  Years of tumult left scars that were far passed the point of healing.  From time to time he found himself wandering through the office on the weekends, or in the evening when no one in particular was scheduled to visit.

He sometimes felt lost amongst his family and friends.  He occasionally had bouts of agoraphobia at home with all the light and windows.

He left the office cautiously everyday and found the outside world to be a place that was no longer black nor white but filled with incomprehensible shades of gray.

And that terrified him.

Most of all.