Empathy: House of the Russian Doll (part 1)

 

“It can be very dangerous to see things from somebody else's point of view without the proper training.”― Douglas Adams, The Ultimate Hitchhiker's Guide

Great. Just great. I rolled up my oxford sleeves, tucked my tie in between second and third buttons, and took a deep breath. It was 11 am on another steamy summer Friday in my island clinic and I was already an hour behind. I pulled the chart off the door and scanned the finely-gridded super-bill. Barry X, DOB 11/14/1953, Chief Complaint: “Pain”. Cracking the door open, I rapped on the wall. 

“Morning, B.  How’s the knee doing?” The deli paper on the worn blue vinyl exam table crinkled as he shifted his hips. “Guess, OK”, he said, looking down at the floor. “That’s not why I’m here.” A newly-retired attorney from DC, Barry was one of my resort regulars. Brilliant but troubled, he was a complicated guy. He turned to marathon running after his wife died from a brutal struggle with cancer, but had to stop because of knee problems. It took an arthroscopic surgery and nearly three tortuous months of rehab just to get him sorted. I hadn’t heard from him in over a year and figured he was doing fine. I was wrong.

 “OK, what’s bugging you?” I said. The sharp aroma of ethanol drifted up as I washed my hands with a squirt of foam. I sat down on the exam stool and spun around to face him. 

He looked up at me and said, “I need you to do something for me, Ray.” I couldn’t help smiling as I leaned in closer. Damn, I hate when people call me Ray. Most call me Rocco; I’m cool with that. Only my crazy mother ever called me Ray, and that was when she was pissed. Probably should let that go.

“Sure, Barry, what do you need? Go on.” He watched me quietly beneath his rimless glasses, then turned away and looked out through the half-closed venetian blinds.  Blue. They’re pale blue. Funny, I never noticed the color of his eyes before. After a moment, he looked back at me and continued, “I want you to stop being a surgeon for just a minute. Just for a minute- and listen to me. Just be like a real doctor. You know, a real doctor. Like when you got out of medical school.  I know you’re a surgeon, but I need somebody to really listen. Can you do that for me?” 

My smile was gone. The low hum of the fluorescent lights seemed to fill the room. “Fair enough, you got my attention.” I said, “Fire away.”

“It’s like this, Ray, you know I love to travel and I’m kind of a foodie. I like my wine. I enjoy a good meal. After Martha passed, it took me a long time to get back to it...but eventually, I was, you know, doing OK. But over the past few months, I just don’t enjoy anything anymore. The food doesn’t taste the same. Wine’s lost its appeal. I’m tired all the time. I don’t have the energy to run and I feel bloated when I eat. Something’s just not right.  I tried telling my primary care, but he just thinks I’m depressed. I’m telling you, I’m not that depressed. Something’s really wrong with me.”

You have to understand that like most orthopedic surgeons, I’m a denier. It’s my preferred coping style. I do dangerous things in a dangerous world.  It works for me. I guess I’m a little jaded but I tend to take the long view and most problems seem to work themselves out. But this was different. I could sense Barry’s anxiety. Feel his distress. Frankly, I was getting a little anxious myself. The fragile truce he had reached with life after his wife’s death was failing and he knew his body was at fault. The whole thing was unsettling. I questioned him about his medications, habits, weight, regularity, even his love life. All the stuff a real doctor’s supposed to ask. His vital signs were fine. No fever. Nada. Everything checked out. 

On paper, Barry looked pretty god-damned good. But I could see it. I could feel it. Something was off. Barry was a vain guy and usually an impeccable dresser, but not today. His hair was unruly, his beard stubble untrimmed. Fingerprint smudges spotted his eyeglasses. A bead of sweat slowly ran down his forehead as he reached for a tissue. “Anything else feeling off to you?” I asked. 

“You know, I get this really weird back pain.” He pointed to his right flank. “I’ve had it for a couple months. Kind of comes and goes. Everything aches, but that’s normal, right?” I stood up and said, “Mind, if I take a look?”

I examined him carefully but found nothing out of the ordinary (I even used a stethoscope- which officially makes me the last orthopedist in the United States to actually use one). I ordered routine blood tests and x-rays. They all came back normal, but I kept digging. A CT scan of his abdomen finally detected the problem. Barry had a solid mass invading his pancreas. Follow up labs and a biopsy by a specialist in the Capital confirmed the worst. He had advanced metastatic pancreatic cancer. Barry was dying and there was no way back.

Making the correct diagnosis did not save his life. It didn’t even extend it. Still, I think he was satisfied. He visited me a few weeks later and thanked me. He said that finally knowing what he was up against had pressed him to organize his life, pay for his grandchildren’s education, resolve lingering family disputes, fulfill a few life-long dreams and, most importantly, come to terms with his wife’s death and his own mortality. The key here was that Barry’s call for help tapped the most critical reservoir shared by doctors and patients. Empathy.

Empathy has become the central focus of a new battlefield in medicine.  Patients seek it, researchers analyze it, doctors debate it, and some companies are even trying to sell it. In a field where technical prowess is presumed, emotional content has become the new currency. Despite all this attention, the nature of empathy remains controversial.   

NEXT WEEK: Empathy: House of the Russian Doll (part two)