The Empathy Exams: Essays Read online

  During my winter of ministrations, I found myself constantly in the hands of doctors. It began with that first nameless man who gave me an abortion the same morning he gave twenty other women their abortions. Gave. It’s a funny word we use, as if it were a present. Once the procedure was done, I was wheeled into a dim room where a man with a long white beard gave me a cup of orange juice. He was like a kid’s drawing of God. I remember resenting how he wouldn’t give me any pain pills until I’d eaten a handful of crackers, but he was kind. His resistance was a kind of care. I felt that. He was looking out for me.

  Dr. G. was the doctor who performed my heart operation. He controlled the catheters from a remote computer. It looked like a spaceship flight cabin. He had a nimble voice and lanky arms and bushy white hair. I liked him. He was a straight talker. He came into the hospital room the day after my operation and explained why the procedure hadn’t worked: they’d burned and burned, but they hadn’t burned the right patch. They’d even cut through my arterial wall to keep looking. But then they’d stopped. Ablating more tissue risked dismantling my circuitry entirely.

  Dr. G. said I could get the procedure again. I could authorize them to ablate more aggressively. The risk was that I’d come out of surgery with a pacemaker. He was very calm when he said this. He pointed at my chest: “On someone thin,” he said, “you’d be able to see the outlines of the box quite clearly.”

  I pictured waking up from general anesthesia to find a metal box above my ribs. I remember being struck by how the doctor had anticipated a question about the pacemaker I hadn’t yet discovered in myself: How easily would I be able to forget it was there? I remember feeling grateful for the calmness in his voice and not offended by it. It didn’t register as callousness. Why?

  Maybe it was just because he was a man. I didn’t need him to be my mother—even for a day—I only needed him to know what he was doing. But I think it was something more. Instead of identifying with my panic—inhabiting my horror at the prospect of a pacemaker—he was helping me understand that even this, the barnacle of a false heart, would be okay. His calmness didn’t make me feel abandoned, it made me feel secure. It offered assurance rather than empathy, or maybe assurance was evidence of empathy, insofar as he understood that assurance, not identification, was what I needed most.

  Empathy is a kind of care but it’s not the only kind of care, and it’s not always enough. I want to think that’s what Dr. G. was thinking. I needed to look at him and see the opposite of my fear, not its echo.

  Every time I met with Dr. M., she began our encounters with a few perfunctory questions about my life—What are you working on these days?—and when she left the room to let me dress, I could hear her voice speaking into a tape recorder in the hallway: Patient is a graduate student in English at Yale. Patient is writing a dissertation on addiction. Patient spent two years living in Iowa. Patient is working on a collection of essays. And then, without fail, at the next appointment, fresh from listening to her old tape, she bullet-pointed a few questions: How were those two years in Iowa? How’s that collection of essays?

  It was a strange intimacy, almost embarrassing, to feel the mechanics of her method so palpable between us: engage the patient, record the details, repeat. I was sketched into CliffsNotes. I hated seeing the puppet strings; they felt unseemly—and without kindness in her voice, the mechanics meant nothing. They pretended we knew each other rather than acknowledging that we didn’t. It’s a tension intrinsic to the surgeon-patient relationship: it’s more invasive than anything but not intimate at all.

  Now I can imagine another kind of tape—a more naked, stuttering tape; a tape that keeps correcting itself, that messes up its dance steps:

  Patient is here for an abortion for a surgery to burn the bad parts of her heart for a medication to fix her heart because the surgery failed. Patient is staying in the hospital for one night three nights five nights until we get this medication right. Patient wonders if people can bring her booze in the hospital likes to eat graham crackers from the nurses’ station. Patient cannot be released until she runs on a treadmill and her heart prints a clean rhythm. Patient recently got an abortion but we don’t understand why she wanted us to know that. Patient didn’t think she hurt at first but then she did. Patient failed to use protection and failed to provide an adequate account of why she didn’t use protection. Patient had a lot of feelings. Partner of patient had the feeling she was making up a lot of feelings. Partner of patient is supportive. Partner of patient is spotted in patient’s hospital bed, repeatedly. Partner of patient is caught kissing patient. Partner of patient is charming.

  Patient is angry disappointed angry her procedure failed. Patient does not want to be on medication. Patient wants to know if she can drink alcohol on this medication. She wants to know how much. She wants to know if two bottles of wine a night is too much if she can get away with a couple of glasses. Patient does not want to get another procedure if it means risking a pacemaker. Patient wants everyone to understand that this surgery is isn’t a big deal; wants everyone to understand she is stupid for crying when everyone else on the ward is sicker than she is; wants everyone to understand her abortion is also about definitely not about the children her ex-boyfriends have had since she broke up with them. Patient wants everyone to understand it wasn’t a choice it would have been easier if it hadn’t been a choice. Patient understands it was her choice to drink while she was pregnant. She understands it was her choice to go to a bar with a little plastic box hanging from her neck, and get so drunk she messed up her heart graph. Patient is patients, plural, meaning she is multiple—mostly grateful but sometimes surly, sometimes full of self-pity. Patient already understands is trying hard to understand she needs to listen up if she wants to hear how everyone is caring for her.

  Three men waited for me in the hospital during my surgery: my brother and my father and Dave. They sat in the lounge making awkward conversation, and then in the cafeteria making awkward conversation, and then—I’m not sure where they sat, actually, or in what order, because I wasn’t there. But I do know that while they were sitting in the cafeteria a doctor came to find them and told them that the surgeons were going to tear through part of my arterial wall—these were the words they used, Dave said, tear through—and try burning some patches of tissue on the other side. At this point, Dave told me later, he went to the hospital chapel and prayed I wouldn’t die. He prayed in the nook made by the propped-open door because he didn’t want to be seen.

  It wasn’t likely I would die. Dave didn’t know that then. Prayer isn’t about likelihood anyway, it’s about desire—loving someone enough to get on your knees and ask for her to be saved. When he cried in that chapel, it wasn’t empathy—it was something else. His kneeling wasn’t a way to feel my pain but to request that it end.

  I learned to rate Dave on how well he empathized with me. I was constantly poised above an invisible checklist item 31. I wanted him to hurt whenever I hurt, to feel as much as I felt. But it’s exhausting to keep tabs on how much someone is feeling for you. It can make you forget that they feel too.

  I used to believe that hurting would make you more alive to the hurting of others. I used to believe in feeling bad because somebody else did. Now I’m not so sure of either. I know that being in the hospital made me selfish. Getting surgeries made me think mainly about whether I’d have to get another one. When bad things happened to other people, I imagined them happening to me. I didn’t know if this was empathy or theft.

  For example: one September, my brother woke up in a hotel room in Sweden and couldn’t move half his face. He was diagnosed with something called Bell’s palsy. No one really understands why it happens or how to make it better. The doctors gave him a steroid called prednisone that made him sick. He threw up most days around twilight. He sent us a photo. It looked lonely and grainy. His face slumped. His pupil glistened in the flash, bright with the gel he had to put on his eye to keep it from drying out. He couldn’t blink.<
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  I found myself obsessed with his condition. I tried to imagine what it was like to move through the world with an unfamiliar face. I thought about what it would be like to wake up in the morning, in the groggy space where you’ve managed to forget things, to forget your whole life, and then snapping to, realizing: yes, this is how things are. Checking the mirror: still there. I tried to imagine how you’d feel a little crushed, each time, coming out of dreams to another day of being awake with a face not quite your own.

  I spent large portions of each day—pointless, fruitless spans of time—imagining how I would feel if my face was paralyzed too. I stole my brother’s trauma and projected it onto myself like a magic-lantern pattern of light. I obsessed, and told myself this obsession was empathy. But it wasn’t, quite. It was more like inpathy. I wasn’t expatriating myself into another life so much as importing its problems into my own.

  Dave doesn’t believe in feeling bad just because someone else does. This isn’t his notion of support. He believes in listening, and asking questions, and steering clear of assumptions. He thinks imagining someone else’s pain with too much surety can be as damaging as failing to imagine it. He believes in humility. He believes in staying strong enough to stick around. He stayed with me in the hospital, five nights in those crisp white beds, and he lay down with my monitor wires, colored strands carrying the electrical signature of my heart to a small box I held in my hands. I remember lying tangled with him, how much it meant—that he was willing to lie down in the mess of wires, to stay there with me.

  In order to help the med students empathize better with us, we have to empathize with them. I try to think about what makes them fall short of what they’re asked—what nervousness or squeamishness or callousness—and how to speak to their sore spots without bruising them: the one so stiff he shook my hand like we’d just made a business deal; the chipper one so eager to befriend me she didn’t wash her hands at all.

  One day we have a sheet cake delivered for my supervisor’s birthday—dry white layers with ripples of strawberry jelly—and we sit around our conference table eating her cake with plastic forks while she doesn’t eat anything at all. She tells us what kind of syntax we should use when we tell the students about bettering their empathy. We’re supposed to use the “When you … I felt” frame. When you forgot to wash your hands, I felt protective of my body. When you told me eleven wasn’t on the pain scale, I felt dismissed. For the good parts also: When you asked me questions about Will, I felt like you really cared about my loss.

  A 1983 study titled “The Structure of Empathy” found a correlation between empathy and four major personality clusters: sensitivity, nonconformity, even temperedness, and social self-confidence. I like the word structure. It suggests empathy is an edifice we build like a home or office—with architecture and design, scaffolding and electricity. The Chinese character for listen is built like this, a structure of many parts: the characters for ears and eyes, a horizontal line that signifies undivided attention, the swoop and teardrops of heart.

  Rating high for the study’s “sensitivity” cluster feels intuitive. It means agreeing with statements like “I have at one time or another tried my hand at writing poetry” or “I have seen some things so sad they almost made me feel like crying” and disagreeing with statements like: “I really don’t care whether people like me or dislike me.” This last one seems to suggest that empathy might be, at root, a barter, a bid for others’ affection: I care about your pain is another way to say I care if you like me. We care in order to be cared for. We care because we are porous. The feelings of others matter, they are like matter: they carry weight, exert gravitational pull.

  It’s the last cluster, social self-confidence, that I don’t understand as well. I’ve always treasured empathy as the particular privilege of the invisible, the observers who are shy precisely because they sense so much—because it is overwhelming to say even a single word when you’re sensitive to every last flicker of nuance in the room. “The relationship between social self-confidence and empathy is the most difficult to understand,” the study admits. But its explanation makes sense: social confidence is a prerequisite but not a guarantee; it can “give a person the courage to enter the interpersonal world and practice empathetic skills.” We should empathize from courage, is the point—and it makes me think about how much of my empathy comes from fear. I’m afraid other people’s problems will happen to me, or else I’m afraid other people will stop loving me if I don’t adopt their problems as my own.

  Jean Decety, a psychologist at the University of Chicago, uses fMRI scans to measure what happens when someone’s brain responds to another person’s pain. He shows test subjects images of painful situations (hand caught in scissors, foot under door) and compares these scans to what a brain looks like when its body is actually in pain. Decety has found that imagining the pain of others activates the same three areas (prefrontal cortex, anterior insula, anterior cingulate) as experiencing pain itself. I feel heartened by that correspondence. But I also wonder what it’s good for.

  During the months of my brother’s Bell’s palsy, whenever I woke up in the morning and checked my face for a fallen cheek, a drooping eye, a collapsed smile, I wasn’t ministering to anyone. I wasn’t feeling toward my brother so much as I was feeling toward a version of myself—a self that didn’t exist but theoretically shared his misfortune.

  I wonder if my empathy has always been this, in every case: just a bout of hypothetical self-pity projected onto someone else. Is this ultimately just solipsism? Adam Smith confesses in his Theory of Moral Sentiments: “When we see a stroke aimed and just ready to fall upon the leg or arm of another person, we naturally shrink and draw back our own leg or our own arm.”

  We care about ourselves. Of course we do. Maybe some good comes from it. If I imagine myself fiercely into my brother’s pain, I get some sense, perhaps, of what he might want or need, because I think, I would want this. I would need this. But it also seems like a fragile pretext, turning his misfortunes into an opportunity to indulge pet fears of my own devising.

  I wonder which parts of my brain are lighting up when the med students ask me: “How does that make you feel?” Or which parts of their brains are glowing when I say, “The pain in my abdomen is a ten.” My condition isn’t real. I know this. They know this. I’m simply going through the motions. They’re simply going through the motions. But motions can be more than rote. They don’t just express feeling; they can give birth to it.

  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 effort—the labor, the motions, the dance—of getting inside another person’s state of heart or mind.

  This confession of effort chafes against the notion that empathy should always rise unbidden, that genuine means the same thing as unwilled, that intentionality is the enemy of love. But I believe in intention and I believe in work. I believe in waking up in the middle of the night and packing our bags and leaving our worst selves for our better ones.

  LESLIE JAMISON

  Ob-Gyn

  SP Training Materials (Cont.)

  OPENING LINE: You don’t need one. Everyone comes here for the same reason.

  PHYSICAL PRESENTATION AND TONE: Wear loose pants. You have been told to wear loose pants. Keep your voice steady and articulate. You are about to spread your legs for a doctor who won’t ever know your name. You know the drill, sort of. Act like you do.

  ENCOUNTER DYNAMICS: Answer every questio
n like you’re clarifying a coffee order. Be courteous and nod vigorously. Make sure your heart stays on the other side of the white wall behind you. If the nurse asks you whether you are sure about getting the procedure, say yes without missing a beat. Say yes without a trace of doubt. Don’t mention the way you felt when you first saw the pink cross on the stick—that sudden expansive joy at the possibility of a child, at your own capacity to have one. Don’t mention this single moment of joy because it might make it seem as if you aren’t completely sure about what you’re about to do. Don’t mention this single moment of joy because it might hurt. It will feel—more than anything else does—like the measure of what you’re giving up. It maps the edges of your voluntary loss.

  Instead, tell the nurse you weren’t using birth control but wasn’t that silly and now you are going to start.

  If she asks what forms of birth control you have used in the past, say condoms. Suddenly every guy you’ve ever slept with is in the room with you. Ignore them. Ignore the memory of that first time—all that fumbling, and then pain—while Rod Stewart crooned “Broken Arrow” from a boom box on the dresser. Who else is gonna bring you a broken arrow? Who else is gonna bring you a bottle of rain?

  Say you used condoms but don’t think about all the times you didn’t—in an lowan graveyard, in a little car by a dark river—and definitely don’t say why, how the risk made you feel close to those boys, how you courted the incredible gravity of what your bodies could do together.

  If the nurse asks about your current partner, you should say, we are very committed, like you are defending yourself against some legal charge. If the nurse is listening closely, she should hear fear nestled like an egg inside your certainty.