Month: March 2018
Dear gentle readers:
I’ve recently developed a sort of pen-pal relationship with someone who’s been mentoring me as I perform the role of writer-in-residence at the University of Calgary medical school.
He is an unusual mentor.
Is that the right adjective for an adviser who has been dead for twenty-four centuries?
Nevertheless, the man is alive and well in the letters below.
I recently shared these epistles as part of a presentation on empathy, medicine and writing, given to the Family Medicine grand rounds group, and the Health Humanities journal club at the U of C medical school. Thanks so much to everyone who offered feedback, suggestions and thoughtful discussion.
Before I get to the letters … a brief disclaimer. Most of you will know that I am not a physician: I have attended exactly four medical classes and the resulting knowledge is summarized in exactly twelve pages of notes in a Staples scribbler.
So if you are a health care practitioner, please consider the letters below as food for thought. Gruel for the soul. My correspondent and I toss out our ideas on empathy, hoping they will spark discussion, or spark ideas on incorporating narrative into the practice of medicine.
Which is a subject I’ve been exploring. To any physicians reading this – I would be delighted to speak with you about incorporating narrative into your practice or pedagogical strategies. Let me know if you’d like to chat.
We could, perhaps, meet for coffee near the stony Greek man in the Health Science Center atrium.
If you’d like to follow up on some of the ideas I discuss, take a look at the reading list at the end of the post.
But let’s get to the letters. Be forewarned: they are lengthy. Feel free to peruse or skim.
I hate to disturb you, but I was walking past you the other day in the Health Sciences building and as it happened I was thinking about empathy and medicine and writing. And I was overcome with the feeling that you might understand this three-pronged interest. Maybe because I had recently perused some of the Hippocratic writings.
Now, I know that these texts – even, possibly the Oath itself – are likely written not just by you but by several of your like-minded peers, but still, it would seem you had an interest in writing. Didn’t Plato find fault with you for writing things down? So that instead of memorizing a fact, we just set it down on paper, or should I say, chisel it into a stone, relieving us from the responsibility of actually knowing … anything? Although I would argue that the act of writing, for a physician, can open a few doors, but that’s a topic for another letter.
I picture you in your cloudy firmament, drinking wine, eating a balanced diet of citrus and lean meat, reading the marks I’ve made on this newfangled material called paper.
I realize this is a long shot, Hippocrates, but I did want to ask you about the idea of empathy. Pardon my dabbling with your language, but the word comes from the Greek “en” meaning “in” and “pathos” meaning suffering or feeling.
The word is quite new, but I suspect you felt it, those three syllables of in and pathos. You felt them wordlessly, didn’t you? Even as you held your hand against the damp skin of a feverish child. Didn’t you once write: “Where there is love for the man, there is also love for the art?”
I believe empathy existed back in your century, on your home island of Cos, even without the solidity of a word to define it, just a jiggling mass, a yolk and a white of meaning, yet to be enclosed by the pearly crust of syllables. I’d like to think you’ve reflected about connections between in-pathos, medicine and writing.
If you could just tell me you’ll help, Hippocrates. Or just send me a sign. I could use a sign just now – do you ever get that … dreary feeling? But I should dash – there’s the dog; he’s creaking to his feet and shuffling to the door.
All the best,
Dear Miss Chamberlin,
How lovely to hear from you. I so seldom receive correspondence from the earthy set. How quaint that you picture me perched on a cloud. How quaint that you think I recorded my cases by hacking them into a stone, when papyrus and skins were at hand. Here is my own historical context, blown to the four winds … Can you imagine how this makes me feel? I will give you a hint. Overlooked. Forgotten. Blurred.
Do you also believe the legends about me? That I once burned down the Temple of Kos? That I convinced King Perdiccas to fall out of love with his mother? That I refused to help the poor Persians combat the plague?
Well now, that one might be true… But the point is, I am skeptical. Do you really understand empathy? Have you poked it, prodded it, felt its brow? You offer its etymology, but can you even define it?
Until then, I must, as you say, “dash.”
By all the gods and more,
PS … if you feel “dreary,” as you put it, I suggest softening the body with warm compresses.
PPS … you mention dog, but do take care with this treatment – boiling rather than roasting will produce a meat that is light and will cleanse the body in a downward fashion.
I’m honored that you would respond to my letter… I must confess I had tossed it into the postal box as one tosses a bottle into the ocean.
I should also apologize for my clichéd vision of your environment… I do see how that would make you feel misunderstood, or, as you put it, blurred.
Blurred … what a wonderful metaphor! The outline of your body rubbed at, smudged, when someone makes assumptions about you.
But to the matter at hand. Empathy.
It’s a slippery term. I feel sorry for it, actually – it has so much responsibility. Empathy has its evolutionary roots in parenting. The drive to keep a child alive and happy at all costs.
Scholars say empathy is crucial to developing social relationships, being part of a group. It’s key to moral development and possibly altruistic behavior. Philosopher Martha Nussbaum says it’s the foundation of moral citizenship.
Imagine bearing those burdens, shouldering the weight of the world. Never mind the fact that empathy is so often exploited.
Barack Obama once cited empathy as a requirement for supreme court justice nominees.
Corporations ask managers to rate employees’ empathy skills. Researchers are hot on the trail of an inverse correlation between wealth and empathy. Empathy is the answer to everything from economic inequality to bullying to global conflict to product design.
A few years ago Ford had its engineers wear an “Empathy Belly” … Please consider the ergonomics of the driver’s seat from the What to Expect When You’re Expecting point of view.
Here’s conservative commentator Glenn Beck … accusing liberals of empathetic fascism, then, later, calling for empathy for the Black Lives Matter movement – drawing fire from the alt right.
Empathy is smacked about, back and forth, drifting in the wind, its definition a work of creative writing.
But I should apologize, Hippocrates. I have drifted from my purpose – defining empathy. A Herculean task, if you will. There are dozens of definitions out there, but here’s one to get us started.
From neuroscientist Jean Decety: Empathy is the natural capacity to share, understand, and respond with care to the affective states of others.
Not everyone agrees that empathy means sharing an emotion. The Society for General Internal Medicine defines empathy as: “The act of correctly acknowledging the emotional state of another without experiencing that state oneself” (Markakis et al. 1999).
And not everyone would agree that empathy includes responding to others. Some see empathy as passive, a self-satisfied sentiment that leads nowhere.
Affect scholars like Lauren Berlant and Megan Boler suggest that empathy can obscure power imbalances, and is dangerous because it gives you the illusion of knowing just how someone else feels … when you are often so different that relating with any precision is impossible.
Most scholars do agree that empathy is a two-sided coin, both emotional and cognitive.
On the cognitive side, we figure out the intentions, motivations and desires of the other person. You might know this side as theory of mind, or perspective taking.
On the emotional side, feeling with the other person. Like when we cringe, seeing someone in pain. Neuroscientists have done functional MRi studies that show that the same neural circuits get involved in the actual experience of physical pain, as the experience of seeing someone else in pain.
This makes it sound like emotional contagion.
Imagine if you will, Hippocrates, walking down the main street of Athens, and seeing one of your students threatened at knife point.
The student’s face contorts, the eyebrows lift, the eyes widen, the lips part and go rigid. You see his face contorted in fear and you, too, feel fear. You will tell your fellow physicians later that a hot jolt of terror thundered through your chest, and you felt exactly what the student felt as the flesh of the blade pressed against his neck.
But Hippocrates, this would not be exactly true. Psychologist Abigail Marsh says that only a portion of the neural structures involved in the student’s reaction will actually be activated by your vicarious experience of the student’s fear. So you don’t really catch fear like you catch a cold. The student’s feelings resonate in you, but you don’t fully feel their pain.
So what is this thing called empathy, then? We feel someone’s pain, but we don’t quite feel it? Is that not then misleading? Is it dangerous to assume we can hop into another person’s shoes? What good is empathy anyway, if it doesn’t fully enable us to share someone’s pain?
I must call it a night now, Hippocrates, for my head begins to ache. It’s as if a band of metal is being wrapped around my temples.
Now my dog is pushing his kibble around his bowl; I remember when he used to swallow it down whole with the power of a Hoover. Perhaps I’ll try scrambling him some eggs. But first I will go for a walk and try to enjoy the evening air. I hope to hear from you soon.
All the best,
PS … A quick clarification about pets. Please note that dogs nowadays are more likely to end up sleeping on your bed than sitting in a cast iron pot.
PPS … Please call me Jane
Dear Miss Chamberlin:
How strange that I experience a shimmer in my temples, not unlike pain, when you describe the ache in your head. And how quaint that you seek the evening air in order to heal this pain. Taking exercise may help, but I suggest washing your head with copious hot water, followed by a vigorous course of sneezing, to carry off the phlegm. Then a strict regimen of gruel and drinking water, but do not take any wine, not even white… although my neighbor would disagree. She once told me this treatment is like “stumbling about in the dark with a musket.” She is a difficult woman; I fail to understand why she was placed in such proximity to me. She understands medicine but she is obsessed with bandages and soap and compassion.
But we were speaking of empathy. Allow me to explicate a particular medical case. A female patient from Athens. Let us call her Olive, since she reminded me of an olive tree, silvery and fruitful. She had five sturdy children, although only one of them was a son. I had been treating her quite successfully for a wound in her thigh.
One day I came to her home and was ushered by her slave to the back of the house, all the way to the women’s quarters, and there she was, reclining on her bed. I approached, taking care to walk humbly, with moderate speed, in the manner of a dignified physician. I greeted her in quite an animated manner, though – each patient is different, and this one preferred animated conversation.
“You are looking better each day,” I told her. “One would think you had swallowed an entire cauldron of gruel!”
But she scarcely looked up. I quickly noted that she had all the signs of acute disease: sharp nose, hollow eyes, cold ears, their lobes turned outwards. Vomit the color of leeks, and a fever. Plus, the odor of the humors. I of course recommended gruel from the finest barley, thrice a day, the purest of drinking water, and poultices. I examined her wound, surprised to see that it had surpassed its former state of redness and inflammation.
“Have your daughters not been administering the poultices?” I asked.
“My daughters are here every day without fail,” she said, her voice as frail as a faded reed.
“I do not understand,” I told her. “The poultices should be much more effective.”
At that moment one of the daughters entered the room, and Olive attempted to embrace the girl, saying: “Your husband has released you for a moment, has he?”
The girl turned to me and said, “Is she well? I have meals to cook and children to feed.”
Olive’s inflammation worsened over the next few days, and I sent one of my students around each day, tending Olive with poultices, warm baths and gruel, to ensure it was all done properly, and she did eventually heal. But the process was slow and painful, as if she resented the pink flesh that knit itself to her leg.
I was unable to determine the cause of this delay until I discussed it with my neighbor, here. When I finished the story, my neighbor said, with that impatient jut of her chin, “It’s obvious. Olive wanted the company of her daughters more than she wanted the comfort of good health. Consider how she must have felt. As long as her wound was on fire, her daughters would come to her.” And then, in the manner of a woman who cannot leave well enough alone, she said, “You, Hippo, suffer from an incurable lack of curiosity.” And I said, “What has curiosity to do with Olive?”
Later, having administered a poultice to my dignity, I attempted this exercise of curiosity.
I imagined my former patient, sitting in her quarters at the back of the house, sewing and spinning and whatever it is that women do (I suppose I don’t really know). But I know enough to imagine Olive watching as the last of her girls is married off, and thinking: This is the end of life as I know it. The last one has packed up her chitons and joined her new husband. Who will I talk to? Who will I laugh with? How long the days will seem.
Silence echoing through empty hallways.
I suppose I could have thought more deeply about this woman all those years ago. But she inhabited a world I rarely saw. Should I have attempted to befriend her? Should I have spent more time asking questions?
But I must call it a night, as you say. My neighbor tried to insist that I take dinner with her – Really! I shall remain here, where I can reflect in peace, and ruminate on the value of solitude. The smell of barley stew, coming from my neighbor’s abode, will not distract me from my thoughts.
By all the gods and more,
PS … You mentioned preparing eggs for your animal, so one of the following is true: 1. you are a soft-hearted fool, or 2. Your animal is infirm. In the latter case, I recommend feeding it a gruel of white barley.
PPS … You may call me Hippo, as does my meddlesome neighbor.
I’m so sorry about your headache – perhaps some company would distract you. Would it be so terrible to accept your neighbor’s dinner invitation?
I loved your story of Olive and her daughters – in part because I know what she’s going through, having watched my own two sons walk out the door, and having borne the silent echoes of hallways.
But I suppose I’m projecting myself into her story – her silence would be different from mine, it would have shrouded her entire day, since her life revolved around the home. Her silence would be darker, more claustrophobic.
I was also interested to hear that you imagined the interior monologue of your female patient – her envisioning the end of life as she knew it. The interior monologue is such a writerly gesture. It’s one of the things I love about writing a novel – trying to let go of your own feelings and imagining the interior life of someone living inside a different skin.
In fact, there are studies showing that reading literary novels, which are filled with interior monologues, has been shown to improve cognitive empathy skills. We read the inner lives of characters and we get practice at interpreting the motivations of others – that process known as theory of mind. Reading literary novels, some say, changes the way we employ theory of mind. Through reading, we remember that it’s okay to be unsure about something, to recognize that not every question has a straightforward answer. That one person’s truth is another person’s lie.
But I should leave it there, my friend (I hope I can call you friend). It’s almost evening now, the clouds have rolled in and they unroll like a leaden tarp in the sky.
I should see if my dog will venture outside with me, although I suspect the gesture will be futile. I may try your recipe for barley gruel.
All the best,
PS … Why not pop over and see how your neighbor is getting on?
How quaint that you think it appropriate for me to “pop” over to my neighbor’s abode.
I must confess I do not make friends easily – my neighbor once told me I would find comfort in a wider circle of acquaintances. She once introduced me to a military captain and forced us to debate the virtues of hygiene. Why I tolerate her, I shall never know.
I am intrigued by your ideas on writing and empathy – I was never a writer of poetry or fiction, but I can quote by heart from the illustrious Homer:
“his dear wife, clear and faithful, in his arms,
longed for as the sunwarmed earth is longed for by a swimmer
spent in rough water”
Homer refers to Odysseus and Penelope here, but still, the passage sums up the longing that Olive had for her daughters. I find myself drawn to this particular passage … it’s strange; it swallows me up, drains my limbs until they are limp and unfeeling, the emptiness of open arms, the silence of vacant hallways.
And there, now … how have we returned to Olive? Perhaps because the relationship between patient and physician must be close – almost intimate. Does the patient not put her life into your very hands?
But I was speaking of Homer. This passage is a favorite of mine; it is a passage I wish I had written myself, if I had any such talent. But then, why have I never made the attempt? Is it too late, I wonder, for an old physician? Perhaps I will jot down a note or two on Olive. I will, perhaps, read this to my neighbor … but she would no doubt offer a scathing critique of my ramblings. Perhaps it is best to leave my medical thoughts as thoughts.
By all the gods and more,
PS … What is the age and breed of your domesticated dog?
I must confess, I feel ill equipped to advise you on anything to do with medicine – it’s a bit like telling Shakespeare: Hey, let’s spitball some ideas on sonnets!
So I decided to educate myself a little bit, and I looked at an article on clinical empathy by Jodi Halpern, professor of bioethics and medical humanities.
She echoes your neighbor’s suggestion that curiosity is important in the physician-patient relationship. She suggests thinking of the patient as a story, and being curious about that story, asking questions, reading between the lines, trying to catch all the allusions and suggestions of meaning.
By understanding this story you can better understand the patient’s symptoms, desires and contexts – things that aren’t always said out loud. Like Olive, needing her daughters more than she needed to get well.
So the physician can empathize through deeper listening, building a narrative together with the patient.
Maybe this is what you meant when you said the relationship between patient and physician is intimate … but Halpern doesn’t emphasize intimacy as such. She points out that it’s not easy to feel with patients day in, day out, especially if they’re in the throes of cancer, dementia, and more. Physicians will begin to feel anxious themselves, and this anxiety can get in the way of giving excellent care. It can get in the way of perspective-taking so there’s a sort of vicious cycle. Too much feeling erodes empathy.
Halpern seeks a more practical middle ground: It’s not that physicians should have a deeply emotional relationship with patients, or show deep personal affection … patients want something simpler. They want the physician to see their suffering, really see it. To understand it as real, and to acknowledge that the situation is meaningful, and merits attention.
This process of empathizing has measurable benefits, according to Halpern. An empathetic physician is more likely to be trusted. And patients who trust their physicians, apparently, are more likely to follow a prescribed treatment plans. So in theory, empathy can lead to better health.
I look forward to hearing your thoughts on this, Hippo. Down here, the sun is setting and putting on an amazing display – it is, after all, time for our daily walk.
But how can I disturb my poor old friend? He has not taken to the barley gruel, I’m afraid.
There will be other sunsets.
All the best,
PS … Your neighbor sounds both charming and terrifying. Why do I picture her holding a musket, or tamping a cannon?
PPS .. regarding my dog – he is an Icelandic sheepdog, aged 12 years and ten months.
Your last letter reminds me of a patient, someone I had known since childhood. Allow me to explain.
My friend Lydus had summoned me because of acute pain in his side. I saw immediately that he was critically ill – he no longer resembled himself, and his eyes were hollow.
It was obvious he would die within seven days, so I sought out the finest of barley for his gruel and the purest of drinking water. But only after asking extensive questions about his lifestyle: how many meals did he typically take? What sort of exercise? How much wine did he normally drink? I realized how little I actually knew of Lydus the adult.
As we spoke, I drifted back to the old days, saddling up two chestnut mares with young Lydus and riding up through the hills. The more I drifted, the more I felt the pull of his hollow eyes. As if the edges of my body were beginning to soften, and for a moment, it was me, lying on that bed, my bowels burning, the hot moisture of my body bursting through my flesh and beading on my skin. I averted my eyes from the bedside, but this strange connection to his body would not bend.
After that I could not leave his side; I ate and drank nothing, slept not at all, and sent my students to my other patients.
This would be the last time I attended a friend.
The poor fellow died on the seventh day, as predicted, his breath floating free of his body. I thought I was alone when I shed that tear for him, but no, the man’s servant was behind me in the darkness and he then ran about Athens telling everyone of the physician who felt so deeply for his patients. The physician who sacrificed his own sleep for the well-being of a friend. I was horrified to discover that this made me feel … good.
And I later wondered. Why did I do this? Why did I bend myself into Lydus’s bed? Did the ache of my own bones make me feel like a better physician? A more caring friend? Was I trying to alleviate my own distress upon seeing a suffering friend?
But I must dash – I feel I should set down a few words about Lydus.
By all the gods and more,
PS … I have researched the matter, and the Icelandic sheepdog often reaches the age of 15 – more if indulged with healthy diet and exercise.
PPS … Try sweetening the dog’s gruel with pomegranate.
How wonderful that you’re writing about Lydus. I recently read an article by Rita Charon on the relationship between narrative and medicine. She talks about that feeling of being absorbed by a work of art, like your feeling of being swallowed up by the Homer passage, or lying on Lydus’s bed, and she compares that to the act of opening yourself to the experience of the patient – absorbing their story, if you will. She thinks that reading and writing can help physicians listen, and pay close attention to the situations of patients.
Novelist Zadie Smith talks about literature forcing people to wake up from the sleepwalking of their lives. It can make the familiar seem strange enough that we stop and notice. Like Homer, with the sensation of longing. He stretches it out, extends it into an image that makes you ache, like the exhausted swimmer. Maybe you can add a little Homer when you write about Lydus, or Olive.
But for now I must be off – my dog has a new spring in his step and is asking for another walk. It must be the pomegranates.
As for our conversation about empathy – what can we conclude about our slippery friend? I feel like it was good for both of us to exercise our curiosity and wonder a bit about each other.
This task of wondering recalls the task of Sisyphus.
Hauling the boulder up the hill only to watch it slide back down. It’s difficult, and imperfect.
And yet he keeps on.
Go in peace, Hippocrates, my friend. Go visit your neighbor, brew a delicious gruel, and enjoy your moments of solitude.
All the best,
On narrative medicine:
Charon, Rita Narrative Medicine: Honoring the Stories of Illness.(Oxford UP, 2006). Available through U of C library at https://ebookcentral-proquest-com.ezproxy.lib.ucalgary.ca/lib/ucalgary-ebooks/detail.action?docID=3053606
I pulled information from an excellent anthology on empathy and medicine titled Empathy: From Bench to Bedside (MIT Press, 2014, Ed. Jean Decety). Available at U of C library at https://ebookcentral-proquest-com.ezproxy.lib.ucalgary.ca/lib/ucalgary-ebooks/detail.action?docID=3339367
Individual chapters from From Bench to Bedside:
- On defining and unpacking empathy: “The Nature of Empathy” by Abigail Marsh
- On the role of empathy in clinical settings: “Clinical Empathy in Medical Care” by Jodi Halpern
- Definitions of empathy and its implications to health care professionals: “The Costs of Empathy among Health Professionals” by Ezequiel Gleichgerrcht and Jean Decety
- Unpacking the affective and cognitive sides of empathy: “How Children Develop Empathy: The Contribution of Developmental Affective Neuroscience” by Jean Decety and Kalina J. Michalska
On empathy and literature / empathy & reading as basis for moral citizenship:
Poetic Justice: The Literary Imagination and Public Life by Martha Nussbaum (Beacon Press, 2004). Available in print form at the U of C library.
On empathy and power / the politics of empathy:
Feeling Power: Emotions and Education by Megan Boler. (Taylor & Francis, 1999). Available at U of C library: https://ebookcentral-proquest-com.ezproxy.lib.ucalgary.ca/lib/ucalgary-ebooks/detail.action?docID=214511
Compassion: The Culture and Politics of an Emotion by Lauren Berlant (Taylor & Francis, 2014). Available at U of C library: https://ebookcentral-proquest-com.ezproxy.lib.ucalgary.ca/lib/ucalgary-ebooks/detail.action?docID=3423752