Seeming and Being Empathetic

“The most important thing is sincerity. Once you can fake that, you’ve got it made.”
– George Burns

The Empathy Exams is a good piece about medical actors. You should read it.

Most of the communication skills classes I took in medical school eschewed outside actors in favor of role-plays among different medical students – where one of us was the doctor and the other the patient. I can’t say we took these entirely seriously.

I remember one skit, performed in front of the entire class, where a female classmate (playing the doctor) was supposed to present me (the patient) with my test results. She chickened out at the last second and asked if we could switch places, which we did.

So I introduced myself as Dr. Alexander, she introduced herself as Mrs. Murphy, and we briefly talked about her imaginary family and how her imaginary husband was doing. Then I checked my script – written by the professor when he was still expecting a male patient – and found I was supposed to be diagnosing prostate cancer. So I shrugged and thought “what the hell” and diagnosed her with prostate cancer. She, consummate actress that she was, nearly jumped out of her chair: “I can’t have prostate cancer!” Totally deadpan, I answered “That’s what everyone always says – it can’t possibly happen to me.”

Needless to say, we didn’t get much empathy-teaching done that session. Other popular failure modes for our role-plays included actors being silly or overdramatic (“NO! YOU HAVE RUINED MY LIFE WITH YOUR STUPID DIAGNOSIS! I WILL SUE YOU FOR EVERYTHING YOU ARE WORTH!”), deliberately obtuse (“Severe heart failure? Does that mean I can’t go through with my plan to run a double marathon up and down Mt. Everest?”), or just giggling the whole session about our classmates being asked to play husband and wife couples (yes, 25 – 30 year old medical students giggle about pretend marriages exactly the same as schoolchildren).

But the few times we had professional medical actors – usually during exams – were Serious Business. I especially remember my USMLE2CS, a big licensing exam. The Kaplan test prep book (of course there are Kaplan test prep books that teach you empathy) gave a variety of somewhat cargo-cultish seeming advice, like suggestions to use ‘transition sentences’: “Now I am going to wash my hands”, or “Now I am going to ask you questions about your smoking habits”. The general feeling among us students was that the medical actors were dangerous beasts for whom any deviation from script, anything other than the preprogrammed responses, would produce fits of emotion followed by examination failure.

Ms. Jamison’s article confirms what I suspected: that the actors and actresses also feel uncomfortable and stilted by their fixed lines.

So we get this very interesting situation where both sides are trying to stick to a script of awkward preprogrammed responses while avoiding all real human emotion. And when they succeed, we declare victory and say we have taught how to connect to people.

II.

The thing is, I know why this happens. It makes perfect sense from the inside.

Most people have a story of some doctor who treated them brusquely or unkindly. If you don’t have one yourself, you probably hear about it in the media. It’s a legitimate problem. Eventually someone tells medical schools “Hey, a lot of doctors are jerks. Fix this.”

It is possible that a parent, getting the chance to raise a child from infancy and spend nearly every waking moment with them, might be able to rescue someone otherwise fated to become a jerk. Might be able to teach them to read other people’s feelings, to connect with them, and to express that connection in a socially acceptable way.

A professor who gets six one-hour sessions with a class of two hundred? Not likely.

So since they can’t teach actual empathy, they teach programmed responses. The patient is in pain? You say “I see you look like you’re in pain. That must be really hard.” Patient is depressed? You say “I see you look like you’re depressed. That must be really hard.” Patient is bleeding from a huge gaping wound in her abdomen? You say “I see you look like you’re bleeding from a huge gaping wound in your abdomen. That must be really hard.” St. Francis of Assisi it is not, but the point is that it’s grade-able by rubric. When the actor clutched her abdomen and screamed, did the student say “I see you look like you’re in pain?” A plus plus! Did they say something else? Time for remedial training.

I recently learned that standardized tests are written by a team consisting of psychologists and lawyers. The psychologists are there to choose questions that test the appropriate skills. The lawyers are there to make sure all the questions will stand up in court when someone sues the standardized test company because their kid got a bad score.

That same article explains the effect this has on what sort of questions are allowed. You can’t ask “What was the moral of this story?” or “What is the symbolism here?” because if the issue was brought before a judge, and counsel for the prosecution says that the story symbolized the ennui of modern life, and counsel for the defense says that the story symbolized the sorrow of mortality, no one can really prove their case beyond just “Well, that was how it seemed to me, c’mon, look at the text!” So all questions must be obviously based on things in the text: you can only ask if a story was about ennui if it the sentence “This story is about ennui” is somewhere in the story.

I imagine a counterfactual world where doctors are not taught empathy through programmed scripts, and not graded by rubric. A medical student meets a medical actor, and the student tells the actor she has cancer, and there is some sincere discussion afterwards, one human being to another. And then the grader decides if the student was properly empathetic, if she would genuinely want him as her doctor…

…and then if the student fails, he accuses the examiner of racism, and says she ruined his promising medical career. And the examiner doesn’t have a leg to stand on, because she just didn’t feel the student was empathetic enough, and the examiner’s feelings aren’t going to be any kind of a defense.

(if you think this is a purely hypothetical concern, think again)

But a rubric that says to give plus one point if the student says “I see you look like you’re in pain”, minus one point otherwise – that will provide a defense.

And then if doctors are still jerks, the medical school can just shrug and say “Well, we taught them empathy! They even passed our exams! See! A plus plus! It’s not our fault if they don’t use their training!”

III.

But maybe it’s good preparation. Because actual caring is not enough. You also have to pretend to care.

I remember, one of my first few months of internship, listening to a patient – not a PTSD patient or anything, just someone presenting with something totally different like bipolar disorder or drug addiction – explain the brutal abuse he suffered as a child. And the whole time, I was thinking “Oh god oh god this is the worst thing I’ve ever heard I want to go home and cry.”

And then he finished his story and I had to say something. And I didn’t want to say “Oh god oh god this is the worst thing I’ve ever heard I want to go home and cry”, because I was supposed to be Competent Medical Professional, and Competent Medical Professionals don’t go home and cry every time they hear a sad story.

And I also didn’t want to say “Okay, I’ll tick ‘yes’ to the child abuse checkbox; moving on to the next item, have you ever smoked marijuana?”

And I also didn’t want to say “I’m sorry”, because various Head Honchos in the hospital have launched a crusade against the word ‘sorry’ because it sounds like an admission of fault.

And I also didn’t want to say “I see you look upset about being brutally abused as a child. That must be very hard for you.” Because then I would have shown up on his Tumblr the next day.

(I see these stories all the time. “I really opened my heart to this doctor, told him every last detail of the brutal abuse I suffered as a child, and he just sat there and said ‘You look very upset’. YOU F@#KING THINK SO? You think I’m upset about being beaten every time my father was drunk, beaten so bad I was afraid I’d broken bones? I’m sure glad I spent however much money to talk to you so you could tell me I looked upset! Because I need a privileged abled white guy to judge my opinions as valid, otherwise they don’t count, right? Man, doctors are all the same, they just respond to your pain with a stock phrase because they don’t think anyone with an illness can really be human.” Doctors read these, and we’re sorry, but empathy is hard.)

There was a sense in which I had already transgressed; I had forced him to bring up this event from his life because “was patient abused as a child?” was a box on my Medical History Taking Rubric. If he had brought it up for some reason – to get my help in arresting the abuser, to ask for charity, even to seek psychotherapy – we could have pursued that reason and it would have defused the moment. Instead it got brought up for no reason that I had to ask, and once asked, he had to tell me. It floated there in the air, a brute fact. The fact that I actually cared quite a lot didn’t make the socially necessary ritual of Pretending To Care any easier.

So I said: “Gaaaaaaaaaah!”

This may, in retrospect, not have been the most appropriate comment. My only excuse was that all these complicated thoughts about what I did and didn’t want to say were mostly after the fact, and at the time, I just heard this horrible story about child abuse, and my gut reaction was “Gaaaaaaaaaah!”. And my brain’s filter, which is usually pretty good, failed to catch me in time to do anything but give my gut reaction.

And my patient was mildly startled, and I quickly deflected the encounter through the deft manuever of moving on to ask if he had ever smoked marijuana.

IV.

Jamison writes:

Empathy isn’t just something that happens to us—a meteor shower of synapses firing across the brain—it’s also a choice we make: to pay attention, to extend ourselves. It’s made of exertion, that dowdier cousin of impulse. Sometimes we care for another because we know we should, or because it’s asked for, but this doesn’t make our caring hollow. The act of choosing simply means we’ve committed ourselves to a set of behaviors greater than the sum of our individual inclinations: I will listen to his sadness, even when I’m deep in my own. To say “going through the motions”—this isn’t reduction so much as acknowledgment of the effort—the labor, the motions, the dance—of getting inside another person’s state of heart or mind.

Partners, parents, siblings, children of a sick person – they probably need to exert themselves to cultivate empathy. They’re going to have to put up with a sick person 24/7, long after their initial burst of compassion has worn off.

Nurses probably need to exert themselves to cultivate empathy as well. They have to deal with sick patients through every moment of their hospital stay, respond to their pleas, deal with their sometimes disgusting bodily issues.

But as a new resident, I have it easy. In my interactions with patients, empathy is not a scarce resource, doesn’t require exertion or extension. My interactions with patients are short and emotionally fraught – getting someone with excruciating abdominal pain to lie still long enough to examine them, telling someone they have a very serious disease, having to hear the details of a history of child abuse. It’s not hard to remain empathetic for a twenty minute appointment after telling someone they have cancer, when you know you won’t be called on to do anything more strenuous than prescribe a medication. Heck, it would be hard not to feel empathy in that situation.

What requires exertion is channeling the impulse. Neither repressing it entirely to avoid awkwardness, nor just letting it all out in an unfiltered “Gaaaaaaah!”

I am getting better at this. One of my mentors taught me the important technique of having a tissue box near me at all times. If someone gets into an emotional situation, I unobtrusively place the tissue box closer to them, which signals that I suspect they’re upset and I’m okay with it, without bludgeoning them over the head with the fact. Sometimes questions work: “Are you okay?”, “Is there anything I can do to help?”, “Do you want to talk about this more, or do you want to move on?”

And part of what I had to do was unlearn my habits from communication classes and empathy exams. In the exams your goal is always very virtue-ethics-y: to demonstrate that you are The Kind Of Doctor Who Feels Empathy. In real life, your goal is consequentialist: there’s a person in pain in front of you, and you need to figure out how to help them. In what I think is C. S. Lewis’ phrase, you need to get out of your own head and do what’s best for the patient. Which sometimes involves reference to the content of my own head – all psychiatrists know that the therapeutic relationship is one of the most powerful weapons in medicine – but only if the patient cares what’s in there.

Which they very often don’t. Now if I get a patient like the one who told the child abuse story, I’ll be more likely to just put on my best Concerned Face and ask something like “How are you doing with that now?” And a surprising amount of the time, the patient will say “I’ve put that behind me, it’s not really an issue anymore.”

I don’t know if, on the deepest level, that’s true. If I were doing psychoanalysis, I’d want to pick and prod at that claim. But in the context of a medical history? I push the tissue box toward them in case they need it, wait a couple of seconds to see if anything else is coming out, and then say “Okay, and can you tell me if you ever smoked marijuana?”