Examining empathy

[Pages:2]Perspectives

Books Examining empathy

The Empathy Exams: Essays Leslie Jamison.

Graywolf Press, 2014. Pp 248. US$15?00.

ISBN 9781555976712

My first encounter with a medical actor playing a standardised patient happened one Tuesday afternoon in 2008. I was taking part in my institution's Teaching Scholars Program and we faculty were getting a taste of a medicine usually prescribed for our students.

Except it was worse than that. Students must contend with only a standardised patient; we were confronted with both an actor-aspatient and a senior medical student playing a more junior student, each following a standardised script. In a perfect simulation of what I did weekly in my real practice, I was to be evaluated on my ability to teach and provide patient care simultaneously, making sure the needs of both student and patient were met.

I had often heard from students that the greatest challenge of standardised patient exercises was the suspension of disbelief. The most vociferous complained that circumstances so contrived couldn't possibly test them on actual practice skills. As my own encounter began, I could see their point. Yet soon thereafter, with patient and student fully immersed in their roles, I couldn't help but behave--and respond--much as I would in socalled real life. There was artifice but also familiar work to be done.

We made it through the history and much of the physical without event. Then the student seemed challenged by part of the physical exam. It wasn't normal. He tried again. Still abnormal. This guy's a hell of an actor, I thought of our standardised patient--until, stepping in to help my student, I elicited the same findings myself.

In the same quick moment the medical student and I realised that the actor playing our patient was in fact also a real patient, albeit not our real patient, and I knew that I

would have to manage not only the needs of the standardised patient and standardised student but also those of a real student playing a fake student who needed help managing the reality of a real patient playing a fake patient. Most surprising, however, was how little difference there was between these two tasks; both required reaching across the divide between human beings to consider the experiences, needs, and suffering of another person.

"Jamison examines empathy not just across life choices and illness states but also across cultures, geographical borders, gender, and socioeconomic status."

It is this reaching across coexisting layers of truth and pain in human experience that is the subject of The Empathy Exams, the powerful new essay collection by Leslie Jamison, a young American writer whose previous book, The Gin Closet, was a critically acclaimed novel. The structure and remarkable insight of the title essay, the first in the collection, announce Jamison's style, subject, and skill. It describes her experience playing a standardised patient for medical students who are being tested on, among other things, their ability to display empathy for the patient she portrays, while also telling of her own actual experiences as a patient seeking an abortion and undergoing ablation for a cardiac dysrhythmia.

We learn about Leslie the real patient not only directly but also in a mock case write-up that mimics the form and language of the standardised patient script she uses when playing the fake patient. In this way Jamison at once considers pain and our responses to pain: the things

we do to understand it, bring it close and hold it at a distance in ourselves and others.

Although some of the eleven essays in the collection relate to medicine, the book considers empathy more broadly. "Another person's pain", Jamison writes, "registers as an experience in the perceiver: empathy as forced symmetry, a bodily echo". Jamison examines empathy not just across life choices and illness states but also across cultures, geographical borders, gender, and socioeconomic status. She travels, among other places, to Nicaragua where she's hit in the face during a robbery; to Bolivia where a larva emerges from her ankle after a botfly bite; to West Virginia for a visit to an acquaintance in a prison; and to the wilds of Tennessee to watch a particularly sadistic ultramarathon. Jamison considers all forms of pain--physical, emotional, and psychological; her own and that of others--and often explores topics both literally and metaphorically.

Among the great joys of literary writing are the beauty of language and the skilful manipulation of form in service of content. In this volume, Jamison writes in muscular, often rhythmic sentences and shows that she not only appreciates the potential of form in literature, she knows how to use it to advantage. In "Devil's Bait", for example, she adopts the subheadings of a research paper-- introduction, methods, results, discussion, acknowledgments--to explore the world of people with Morgellons disease, an unexplained internet age condition perched at the intersection of the physical and the psychiatric in which people feel infested and become disfigured. The acknowledgments section begins: "I've left the kingdom of the ill. Dawn and Kendra and Paul and Rita remain. Now I get the sunlight and they

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don't. They feed themselves horse dewormers and I don't. But I still feel the ache of an uncanny proximity...I kept telling them, I can't imagine, and every once in a while, softer, I can." In "Pain Tours (I)" she writes in the second person, using literary point of view to reinforce the experiential gulf between herself and the former gang members leading the tour she's taking of her native Los Angeles. Her commentary here and elsewhere, while not about medicine, will strike home for some health professionals: "You feel uncomfortable. Your discomfort is the point. Friction rises from an asymmetry this tour makes plain: the material of your diverting morning is the material of other people's lives, and their deaths."

Jamison's own life and pain are woven throughout these essays, an important thread in a book that isn't primarily memoir. Sometimes that narrative verges on the overly self-referential. More often, it helps make real and personal the ideas she's exploring with her keen intellect.

Jamison is in conversation with musicians from Tori Amos to Verdi, movies you will and might not have heard of (Brian De Palma's Carrie and Joe Berlinger and Bruce Sinofsky's Paradise Lost trilogy), television shows like HBO's Girls, artists, and especially with certain writers whose work has clearly informed her own, including Susan Sontag, Lucy Grealy, Joan Didion, and James Agee. Although the collection has flaws, the strength of the prose and Jamison's acute cognitive and metacognitive skills are such that she might legitimately be considered a budding heir to writers of that stature.

In recent decades, we in medicine increasingly have divorced empathy from its imaginative and emotive origins. It is now most commonly defined as a cognitive skill, one that can be taught and feigned and measured. While there is truth to this competency-based approach--studies have shown that certain words and gestures can make patients feel better understood and more cared

for, even in the absence of real human connection--we shortchange not only our patients but ourselves by reducing empathy to a set of rote behaviours.

In last year's The Faraway Nearby, Rebecca Solnit described empathy as "first of all an act of imagination, a storyteller's art, and then a way of traveling from here to there". In medicine, the here and there are the health professional and the patient or caregiver, the land of the well and the world of the ill. Empathy doesn't require a clinician to feel vicariously what his or her patient feels; rather, as Jamison so effectively shows in this collection, it represents an emotional resonance and effort to understand that deepen one person's engagement with the experiences and suffering of another.

Louise Aronson

Department of Medicine, Division of Geriatrics, University of California, San Francisco, San Francisco, CA 94118, USA aronsonl@medicine.ucsf.edu

Politics and public health--the role of the US Surgeon General

On Feb 27, 2014, a Senate committee approved the nomination of Vivek Murthy, President Barack Obama's choice for Surgeon General of the United States. The next day, the National Rifle Association (NRA) stepped up its lobbying against the nominee, citing Murthy's prior writings against gun violence, such as his statement that "Guns are a health care issue". The NRA mobilised opposition despite Murthy's public testimony that his intended focus would be on obesity, tobacco use, mental health, and immunisations. 2 weeks later, the White House announced it would delay a confirmation vote by the full Senate, prompting an uproar from the medical and public health community.

To Mike Stobbe, a journalist and author of Surgeon General's Warning, these events were just the latest in

a series of setbacks for the nation's doctor. With the rare blend of a reporter's nose for a story and a scholar's fastidiousness, Stobbe chronicles the past century and a half of Surgeons General. The result is a stimulating perspective on the history of American public health. But the book also drives unequivocally towards the conclusion of its subtitle: How Politics Crippled the Nation's Doctor.

Stobbe traces the evolution of the Office of the Surgeon General from its origins supervising Marine Hospitals for injured and sick merchant seamen, and later as a federal agency responsible for responding to outbreaks of yellow fever, cholera, and plague. We learn of major advances rooted in the leadership of a Surgeon General: the beginnings of a health-care system dedicated to war veterans' needs;

growth of biomedical research funding through the National Institutes of Health; and racial desegregation of hospitals.

Throughout, Stobbe weaves threads of fascinating public health arcana into the narrative. Take the release of Surgeon General Luther Terry's landmark 1964 report on smoking and health. 2 years earlier, the UK's Royal College of Physicians had synthesised epidemiological evidence against smoking, likely inspiring a reporter's question on the issue to President John F Kennedy. Kennedy tasked Terry with studying the issue. A committee was assembled, although cigarette manufacturers were permitted to influence its composition. Despite this, and the fact that half the committee members smoked, the report delivered the clear-eyed message that smoking

Surgeon General's Warning: How Politics Crippled the Nation's Doctor Mike Stobbe. University of California Press, 2014. Pp 394. US$34?95. ISBN 9780520272293

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