The Empathy of Age

I am intrigued by the concept of empathy. Variously defined as caring, psychological identification, or even sharing another person’s feelings, it is nevertheless a quality incumbent upon those of us in the health profession in whatever capacity.

Empathy is a word that has, in some minds, become synonymous with other altruistic traits such as sympathy, compassion, or even pity, but it is broader than those -and perhaps that is what makes it so valuable -so unique as a descriptor. Sympathy, for example, is more restricted in emphasis: more of a feeling of concern for another who is in need; compassion, on the other hand is what we may feel when another requires our help –a motivator.

Empathy encompasses these, and more. I like the definition in Wikipedia: Empathy is the capacity to understand or feel what another person is experiencing from within the other person’s frame of reference.

But is empathy something like a genetic gift? Something that pushes those who possess it to self-select into the helping professions? Or is it more like courage: you don’t know if you have it until it becomes necessary?

No, apparently it can be taught –although I must say I must have missed that lecture in medical school because, along with things like ethics and cultural safety, it was an assumed quantity. If you were going to be a doctor, that meant you had it… But, like St. Thomas Aquinas’ understanding of Time, it was an entity that was only definable when you didn’t try -or the philosopher Krishnamurti’s objection to naming God, because it confined the concept…

Over the years, though, I have tried to confine it –or at least experience its various manifestations. And although these are no doubt legion, I am still thirsty. Readers of these essays have perhaps already had their fill of my insatiable insistence on the art of listening before speaking (For example: https://musingsonwomenshealth.wordpress.com/2015/06/30/when-silence-is-golden/ ) But I’m afraid there was yet another news article that caught my eye: http://www.bbc.co.uk/news/magazine-33287727  and I thought I’d try it out at the first opportunity. I’m always looking for new tricks.

Radical listening –that sounded easy. And familiar: “…be present to what’s really going on within – to the unique feelings and needs a person is experiencing at that very moment” and, in practice, “Let people have their say, hold back from interrupting and even reflect back what they’ve told you so they knew you were really listening.” Perhaps that’s what I have been doing all along, but not consciously aware of it, though. Or maybe not –maybe all doctors think they listen, but possibly what we are actually listening to is ourselves –our prepared judgements, our sure and certain feeling that we have the answers. Or, at least an answer… Science uses inductive methods: start with the data and then establish a theory that seems to fit. But maybe, despite our protestations to the contrary, we sometimes resort to a type of deductive reasoning: start with a theory and then make the data fit -or at least search around until we find some that do. Because if we don’t have an answer… what good are we?

Time for awareness. I thought I’d start with someone with a relatively common problem –a non-gendered one so I could more easily slip into their shoes, as it were. I scanned my list of patients for the day but none seemed suitable. I simply could not easily cohabit a mind filled with fibroids or endometriosis.

Loren was different. A woman with persisting hot flushes seemed initially excludable from my naïvely chosen criteria, and yet it soon became apparent that the hot flushes were a sort of proxy. She was a young looking 62 with barely a wrinkle on her face. Fashionably thin and elegantly dressed, she seemed to have ignored the years that have exiled so many others -stranded them, as it were, on a foreign, uninviting coast. No, Loren was a professor at one of the universities here in the city, and much in demand both for her human rights advocacy and her several books on the subject that seemed to be quoted whenever federal immigration policies were in the news.

“I get these hot feelings in the most unfortunate circumstances, doctor. They usually occur when I’m in a social situation where my reaction to them would be noticeable –giving a lecture, for example. Or an interview. I’ve never embarrassed easily, but if some commentator manages it, I find myself almost overwhelmed by a need to wipe my forhead –not a sign of strength.”

She paused, no doubt waiting to judge my reaction as to whether that was a common feature. Mentally rubbing my hands and determined to try my new tricks, I smiled reassuringly. “So these hot flushes occur in social situations where to acknowledge them would be awkward..?”

She nodded, and then as if she’d been given permission to speak again: “I’m worried, frankly. I never used to be like this.” She considered it briefly, and her eyes turned inward for a moment. “I’m beginning to see it as a type of physiological dementia –a sort of bodily facsimile… an early protoype of things to come…”

The thought seemed to bother her and she studied my face for a refutation. “I can see you’re worried, Loren,” I replied slowly. “I’ve never heard hot flushes described as a type of nascent dementia, though.” Good; I was proud of that succinct encapsulation of her thoughts and looked at her contentedly. This wasn’t so hard.

She sighed, but I wasn’t sure whether it was out of satisfaction at finally being heard, or frustration. “And words don’t come as easily as they used to any more. I’ve been blaming it on the hot flushes because the two seem… coeval.” She glanced at me, her eyes frightened birds huddling in their cages. “Like just now –I couldn’t think of another word that meant ‘at the same time’ quickly enough, so I substituted ‘coeval’…”

Another long pause; I wondered whether this was the time to reiterate –the word ‘regurgitate’ entered my head and I almost smiled, but her face looked so anguished I decided to go for it. “Words don’t come easily anymore –and you blame it on your hot flushes… I like the word ‘coeval’ I have to say.” I blushed at my amateurish attempt at precis this time…

She didn’t sigh this time, but I could tell her eyes were about to leave their nest. “I suppose all of us experience this after a certain age…” She diverted her attention to the picture of a peasant woman leading a horse that hung on the opposite wall. “But words have been my world, and their loss –or at least their current drying up to a trickle- terrifies me.” She continued to stare at the picture, as if the answer lay in the coloured sketch, its almost random lines a reminder of her words. Suddenly she turned to stare at me. No, to study my reaction. I could sense her dividing me into grids, mathematically precise areas for analysis. “Hormones didn’t help before… Do you think it would help to go back on them?”

It was a plea, begging for an answer. A solution. Anything to give her hope. It was going to be hard to stick with my radical listening approach… Or had I already done it? I tried to smile intelligently at her, tried to find some words to help, but like her, I was struggling. “Words…” I started hesitantly, aware that I was blushing at my sudden blank. It was like my head was an empty screen. “…don’t come easily to you anymore…” The look of frustration at my repeated attempts to incorporate her own words into my response was becoming glaringly obvious, and I could almost feel her anger. I sighed and abandoned my tactics. “Words don’t come easily to any of us after a certain age, and its not only embarrassing, it’s frightening. They are my world as well –they’ve been what have defined me not only as an explicator of the arcane, but also as a person. Words are friends I’ve called on whenever the need arose. They’re still there, but as with you, the words that arrive in response are often friends of friends. Acquaintances from books I’ve read and long since forgotten. Clumsy words. Opaque words with only approximate relevance that people merely skip over when they hear them, thinking I’m just being clever. Metaphorical.

“And then the words, like branches floating past in a slowly moving river, make way for others –more familiar, perhaps, but moving all the same. And the conversation continues with probably only me who noticed all the substitutions…”

Loren sat back in her chair with a look of satisfaction on her face. Her eyes, caged once again, sat twinkling at me from their lairs. “You know,” she said, apparently finding her words with ease, “I should go to doctors more frequently.” And with that, she reached across the desk and squeezed my hand. “That’s all I needed to…” -a slight pause, almost unnoticeable- “assimilate…”

We looked at each other and smiled. We were of an age.

Trust

Like time, trust is a difficult concept –easy enough to conceptualize, perhaps, but hard to define. To categorize. To understand. It is slippery, and slides through the fingers like water. As St. Thomas Aquinas said of time, you know what it is until someone asks you to be more specific. It is something, however, that seems to be essential  in many of our interactions –arguably none more so than in Medicine.

As a doctor, I could be accused of a confirmation bias I suppose –after all there are other relationships that require a high degree of whatever we understand to be involved in the concept of trust that might seem too numerous to list. That is true enough; trust pervades all levels of our daily lives, but I suspect we are likely more fastidious in entrusting our very existence –or the quality thereof- to an unknown person, especially since the interaction involves an unequal power relationship.

But it is a necessary trap, isn’t it? Sickness can be incapacitating and so we usually seek to alleviate it if possible, or mitigate the effects if not. Patients –the etymology of the word derives from the present participle of the Latin word suggesting ‘undergo’, or ‘suffer’- understandably seek what power they can exercise beforehand. If they have to place themselves in the hands of someone else, often a stranger, they can avail themselves of  information about the doctor beforehand. There are rating systems online that canvas opinions of interactions and results from the doctor in question to help with the decision. They may pre-engender that elusive trust -or at least, facilitate it in what are often constrained and inadequate time limits of a consultation visit.

My reputation –or lack of it- is therefore already packaged for a patient to open or discard as she sees fit. I am a sort of book already read and critiqued by someone else, dependent on the rating, even though I am –as is everybody else- a work in progress. The last chapters are yet to be written. But I have no such prescient knowledge about my patients –no way of knowing them beforehand. I must take what I get and write the next page…

And yet, that is not always the case: some, you get to know and enjoy; Sonia was one of those. I had seen her on and off for years, albeit at intervals that verged on epochs –often so long, in fact, that I sometimes assumed she was dividing her loyalty amongst several doctors. Sonia, I had realized long ago, saw medical opinions as bouquets from which she felt quite comfortable in selecting the most appealing flower.

She is a short, large woman, with a smile that says relax. Her hair has greyed over the years, but is invariably bunched on the top of her head and artfully fastened with a brightly coloured ribbon no doubt contrived to contrast with her clothes. It is probably a fashion statement; I see it as an idiosyncrasy, but I’m sure that my Rate-Your-Doctor file does not comment favorably on my own tastes in that area. My receptionists certainly don’t.

I have always liked Sonia. She seems to have that rare talent of being able to summarize her concerns succinctly and intelligently –almost as if she had written them down beforehand, memorized the salient features, and then practiced them over and over again until she was satisfied they made sense. Satisfied I would understand how important they were to her. Almost as if she had reused them many times…

But today, her referral letter suggested nothing new: fibroids -benign growths of the muscles of the uterus- with a past history of occasionally heavy periods. I had seen her for this a few years before and she had decided not to do anything about it, confident, as she had said, that the problems would go away with her menopause. I saw her watching me as I scrolled through the letter and the accompanying ultrasound on the computer screen.

I looked up at her from the monitor. She was dressed in a beautiful green, velvety dress like she was about to head for a cocktail party after the consultation. And, true to form, had fastened her long, unruly hair on her head with a neon bright, thick orange ribbon –like a trail marker tied to a bush in a forest… I buried the thought as soon as I noticed her smiling at my glance. “So..?”

“So, I’ve decided I want you to check my fibroids again,” she said as if I’d just canvassed her opinion the week before and was still trying to make up her mind about what to do. “Just my fibroids, that’s all.”

It was so like Sonia to want to help me to focus on the reason for her visit. I pulled up a comparison ultrasound done at her last visit three and a half years ago. She was 52 then and I had encouraged her decision at that time. Fortunately the fibroid –there was only one then and now- had not grown in the interval. But the lining cells of the uterus –the ones that are shed during a period- were now quite remarkably thickened. That had changed! I scanned the blood tests her family doctor had done a few weeks ago and they seemed to indicate that she had probably already gone through her menopause. So any bleeding now would be both unusual as well as worrisome –uterine cancer can present like that. I looked at what she’d told me on her last visit: heavy, but only sporadic bleeding. She’d refused to allow me to sample the cells in the uterus –an often painful but necessary procedure we commonly perform in the office but which could be done in the operating room under an anaesthetic if necessary. She’d promised to decide and come back on another day… But hadn’t.

“What about the bleeding, you had?” I said, mindful of her concerns about the biopsy I had suggested last time.

“You want to do a biopsy, don’t you?” she said with an almost flirtatious smile.

“Well, I’d like to make sure there are no abnormal cells in the uterus. The fibroid hasn’t grown, since we last met, but we never did that biopsy I’d suggested.”

She turned on another sweet smile and shrugged. “I’m sorry about that, but business took me out of town right after I saw you. Anyway, I had one done down in the United States and it was normal.”

I looked through the data her doctor had included with the referral, but I couldn’t find any pathology report or mention of the biopsy. “I can’t find any record of it here,” I said, busily scanning the screen to see if I’d missed anything.

“You won’t find it in there, I don’t think,” she said with a little toss of her head. I looked up. “The doctor down there just phoned me and said everything was okay, but never asked me where to send the results.”

That seemed a little unusual –if only for medicolegal purposes, doctors like to make sure results of tests are sent to the patient’s personal physician. “When was that?” I said, ready to enter it into her notes.

Another shrug. “I don’t know. Three years ago maybe?”

“Are you still bleeding, Sonia?” A simple question, I thought. But her face suddenly hardened. “Because a lot can change in three years…”

Her eyes tightened slightly and she looked at me suspiciously. “No, wait. I’m sure it was more recent…” She closed her eyes for a moment, obviously trying to decide what might be a better answer. She was now angry and her whole body stiffened.

I thought perhaps I could diffuse the situation. “Well, do you think you could ask that American doctor to send me the report of his or her biopsy at least?”

“You don’t trust me, do you doctor?”  She stood up and started to put on her coat. “And after all these years!”

“Sonia, let me just have a look at that report and see what it says…”

“I told you what it said,” she said through tense lips.

“And anyway, if you’re worried about another biopsy, if we have to do one, why don’t we do it in the hospital under a general anaesthetic..?”

Suddenly, her coat was on and she hurried to the door stopping only briefly to face me. Her face was an angry mask as it stared at me with a mixture of indignation and disbelief. “I’ve trusted you all these years to do what was best for me,” it said with a slow, almost sad shake of the head underneath. “But without trust…” She sighed loudly and walked stiffly but determinedly through the door without a backward glance.

Maybe she was right about the trust we shared, but I am still waiting for that report.