Another’s Shoes
Narratives of Empathy and Medicine
Abstract
Whenever I think of empathy as a concept, I often go back to a quote from Atticus Finch in Harper Lee’s To Kill a Mockingbird: “You never really know a person…until you climb into their skin and walk around in it.” Until you walk in another’s shoes.
Conceptualizations of empathy in medicine vary widely across (and even within) the current literature. Yet in spite of this imprecision, measures of “empathy” have been consistently shown to be strong predictors of patient outcomes including enhanced patient-doctor relationship, satisfaction for both patient and doctor, diagnostic accuracy, and ‘patient enablement.’ In medical education, there is a dire need to reframe how empathy is taught, from both a theoretical and experiential standpoint. When measuring by the Jefferson Scale of Physician Empathy (JSPE), medical students actually exhibit lower JSPE scores after going through clinical rotations during their third year of their medical education. This project offers insight into how practicing physicians and nurses conceptualize and integrate “empathy” into their practice through an exploration of their experiences during a series of interviews, which have been adapted here as the following short stories. Just as remarkable case studies are used as teaching aids in many medical institutions, this project highlights through a short narrative format key experiences which informed interviewees’ practice of empathy. Aiming to show that an adaptive model of empathy may be necessary to encompass the wide range of patient-provider interactions in which empathy is an essential component, I hope that those affiliated with or interested in medicine can learn from the key concepts within medical empathetic frameworks found in the following stories.
The Double-Edged Sword
Author’s note: This narrative speaks to physician compassion-burnout, illustrating that the empathetic tool truly is a double-edged sword in medical practice. Many definitions of empathy in the current literature (see Moudatsou et al., 2020) include clauses reflecting a lack of connection accompanying theoretical understanding of the patient’s emotions, though in real practice this may not be possible in all situations. It’s not only the emotions of the patient which have an impact on the healthcare provider, but in the case of loss of a patient the relationship between family and physician becomes important as well.
I walk in the door, but I’m still not really home. Not yet.
I think she sees it in my face—that today was hard, that all I want to do is really just collapse onto the couch and to be held like a child and to close my eyes and not see the sick kids who I couldn’t save. The families whose world broke today.
My wife turns on an episode America’s Next Top Model—her choice, not mine, but it means she plans on being here for at least a little while—and slips a frozen Tikka Masala into the microwave.
I don’t hear the ding when it finishes. Part of me was still back with the sick children, or sick child, really. It’s hard to keep your distance, and I usually walk the line pretty well, but today I can still feel their pain and grief inside of me, burrowing its way in and becoming my own. Well not the kid’s—he had morphine. This is the pain of a family that has lost a child. That kind of grief never quite leaves, and I wonder if mine will? Every time we lose, it hurts, but this one feels different. I think everyone in that room could’ve used some morphine, actually.
It’s funny the things that stick with you. He was such a good kid, and acted every inch the typical 11 year old boy, almost like 11 year olds haven’t changed since I was that age: he was 4 foot 8, his favorite car was a blue Mustang, when he grew up he wanted to be a quarterback like Mahomes (they were from Kansas City), he watched…
“John? Are you there?”
Em looked at me pointedly, and her scrunched-up little eyebrows showed the concern clearly in her face. And maybe this time, she’s right to be. “Yeah, sorry. I think I’m just a little tired today, it was a—oh.”
Her finger was pointed towards my waist, and I looked down to see what she was looking at. The Tikka Masala was sitting in my lap, apparently. The orange sauce had begun to recongeal as it fell back to room temperature, forming a kind of messy, thick paste with chunks of chicken embedded in it, the little bubbles that formed while it was heating having long since popped left little empty pits in the surface like craters on the surface of the moon. Empty.
His death was a distressing and sudden one. It actually looked like he might recover for a while, but a few days ago he took a sharp turn, veering away from leaving through the hospital doors and toward lying in a bed in the pediatric palliative care unit. A series of crises, one after another, and suddenly you go from walking around throwing the ball with your dad to aggressive chemo to relapse to pneumonia to –
Em sighed, probably because Tyra gave the girl a 6. No idea if she deserved it.
-death.
I think of his family again. I can’t stop thinking about the sound his mom made when I broke the news. And I know it isn’t right that I feel so gutted, because the challenges they’ll face are ones that I won’t have to come home to.
My son is asleep upstairs.
I barely tasted the tikka masala. For the first time all week, what I really felt like was having a drink. ANTM just made me think of AML.
Good Doctor
Author’s note: This story is adapted from a short narrative collected during one of my interviews. A holistic practice of empathy takes into account the cultural context of the patient—assumptions, especially when the patient comes from a cultural background different from the physician, become dangerous and can severely damage the physician-patient relationship.
You probably wouldn’t have guessed it from looking at him, but he was really a pretty nice guy. I don’t know if it’s that his eyes were just a little too close together, or that the face built around them was just kind of narrow to begin with. Not that I’m particularly attractive, either, and I’d never say these things out loud—it’s just you can’t really help but notice these things, can you? The narrowness of his frontal bone and general cranial area meant that when he looked straight on at you it was like he was looking down at you, even when his head was tilted back and you could see just a little inside the openings of his nostrils. He didn’t do this often, mostly only when he was really thinking about something pretty hard.
I’d been shadowing him for almost a week, mostly on outpatient rounds where he’d spend enough time with patients to get to know them better (a lot of them he already knew, it seemed like), but not so much that it was like he was just shooting bull or wasting time. Some people I’d shadowed would really talk, and you’d know within about five seconds of meeting them that they’d chat your ear off if you gave them the chance. He wasn’t the biggest talker, but it was clear that he cared about his patients and made an effort to connect with them. He’d ask about their family, how the dog was, what their plans for the holidays were. I thought it an admirable quality that he didn’t assume everyone was doing Christmas. It was pretty P.C. for a white guy his age.
We were with a small family—a Black family—at outpatient when things sort of went off the rails. Now this is Cleveland, so it’s not like he never sees Black patients and just started calling everyone “ my brotha” and adopting a terrible imitation of a Black urban vernacular or something terrible, but he did really fuck this one up. Royally.
So the patient is the mom, and she has sickle cell, but the dad is there, and maybe an older sister and a son.
He’s looking down at the paper, seated across from them. Between me and everybody else, the room is pretty crowded, but he quickly goes on ahead and blithely makes it even smaller. “Well, your lab results are back, and they look mostly pretty good. Your white blood cell counts are a little low, but that’s not unusual for African-American populations.”
I could see from their reactions what was about to happen before they started laying into him. He was still clueless. I wanted to get out of there.
“African-American? Why would you assume I’m African-American?”
“Ohh my god.”
Dad is shaking his head, but it’s mostly mom and the sister who are about to rip this guy a new one. The son I think glances at me to see my take, but I’m doing my best to look absolutely neutral and completely unassociated with the good doctor and I don’t meet his eyes. I was still planning on asking him for a reference, but it wasn’t my place to jump in here on his behalf. Though it would’ve probably prevented what happened next.
Doc clearly doesn’t know how to handle this onslaught, he looks puzzled and I’m already cringing as I watch him come up with about the worst immediate response possible: “Sorry, but what ARE you?”
Understandably, this set them off worse than before. I was visibly squirming at this point.
“We’re Black, sir. We don’t even have relatives from Africa. Black and African-American isn’t the same.” Amidst the cacophony brought on by that last microaggression (I wondered if he even knew what microaggressions were?), the son was surprisingly calm. He sounded more tired or disappointed than incensed, like he’d done this a couple times before. And to be fair, he probably had.
We hung back in the room for a minute after they left. As I watched the doctor run his hand through his hair, head tilted back, I didn’t wonder for a second why black patients have higher health outcomes when treated by black doctors. Just being in the room and having to see that made me feel worse walking out than when I walked in.
Earned Intimacy
Author’s note: I had never encountered this concept, which speaks to an awareness of the needs of a patient and their family through developing the patient-provider relationship, before engaging in this project. Developing a level of intimacy that allows for this awareness has to be done with care, considering the vulnerability of the patient and the potential for the provider to unintentionally exploit it. The term is drawn from a key interview I had with a nurse practitioner who works in pediatric palliative care. During our conversation, she told a story that had been shared with her which resembles the one I’ve written below.
“I think you should leave.”
If she was surprised she didn’t show it. A true stoic.
Somehow my body felt dull and hyper-aware, all at the same time. Like I was moving slowly, or maybe less that it was me, but the world around me that had slowed down. I felt that I could take in everything in the room, but my eyes hadn’t moved at all. Mom was crying. I was watching the thin but warm ribbon of sunlight streaming through the gap in the curtains, and the little floating specks of light that were caught there, which I had always told her from the time she was old enough to notice them were fairies while the nurse was still opening her mouth.
“That’s alright. I’ll be outside if you need anything.”
Her words didn’t really register, but that was alright with me for the time that I was in then. She had already heel-turned herself out of there without taking a second to look back, and maybe it wasn’t anything for her to look at anyway. I couldn’t help but look.
She’d probably seen many dead children before.
. . .
Agonal breathing started at about 2pm. At this point, there was very little I could do for the O’Neals except be present until she took her last breath. I’d guess for a girl that size with CF and the amount of fluid in her lungs that she wouldn’t last more than an hour. Probably less, actually. The dad and his mom (she had to be the mom, because there was no way…) seemed to be holding up well, at least as well as could be expected of them. A lot of times this is where the religious families stop praying. The sound gets too distracting.
Some of the other nurses might cry with a family, but that’s never really been my style. It always looks…messy. There’s a line, in my opinion, between the patient and the healthcare team. We’re all close in palliative, and you do get the opportunity to know the families well, and the kids are great, but again, we’re a team of professionals. I won’t allow someone who’s already gone to affect the work I have to do with the next family, who will need me just as much as they did. You have to be able to prioritize the welfare of the child, and it’s hard to do that if your emotions are keeping you back. Luckily for me, I’m not really an emotional person. And I get positive results on symptom and pain management.
She hadn’t gasped or rattled in a while, so I walked up to check on her and see if I could still find a pulse in her wrist. I don’t have big hands, but they fit all the way around hers, as small as they were. I felt something faint from the radial artery, so I looked over at dad and grandmother and gave my best reassuring smile. I don’t have a very warm smile, but we’re under staffed today.
“She’s still with us, but her time is getting pretty short. You can start saying goodbye to her, if you’d like.”
Almost right on cue, she shuddered a little in her bed and let out a croaking sort of heave.
. . .
It felt like she was barely here. I mean, she stood across the room, just over there, but that was about it. I couldn’t find the words for how I was feeling about Sonia right now, but I could feel the hot spurs of anger driving me to speak as I turned towards the nurse,
“Look, you’ve done your job at this point. And that’s all you have to do, and that’s what you’ve given us for the past few weeks. But my daughter is dying, and you’re here but I don’t even know that you know her. Or me, or my mother. And when she goes, she doesn’t need a stranger holding her hand like that.
You haven’t earned intimacy with my daughter, or my family. I think you should leave.”
About the Author
Conor Rork is a senior at Rice University who recently became a Texan again after moving to Houston from Nashville, Tennessee. Conor hopes to pursue medicine after he graduates, and plans to take a year before going back to school to hike the Pacific Crest Trail, travel (safely), and play guitar.
References
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Moudatsou , Maria, Areti Stavropolou , Anastas Philalithis , and Sofia Koukouli. “The Role of Empathy in Health and Social Care Professionals .” Healthcare 8, no. 1 (March 2020): 26–26. https://doi.org/10.3390/healthcare8010026.
Nuila, Ricardo. “Dog Bites.” Best American Short Stories. Houghton Mifflin Harcourt, 2011.
Spencer, John. “Decline in Empathy in Medical Education: How Can We Stop the Rot?” Medical Education 38, no. 9 (2004): 916–18. https://doi.org/10.1111/j.1365-2929.2004.01965.x.
Primary Sources:
Hellsten, Melody B. “Empathy Education and Conceptualization as a Nurse Practitioner.” November 20, 2020.
Mahoney, Donald. “Empathy Education and Conceptualization as a Physician.” November 12, 2020.