Silent Empathy

Benjamin W. Frush, M.A.

September 19, 2017

“I’m dead as hell, man,” Mr. Smith ¹ whispered as he gazed up at me with doleful brown eyes ensconced in purple and yellow contused orbits – damage wrought after banging his head on the hard wall of the inpatient psychiatry unit common room yesterday. Mr. Smith had Cotard’s syndrome, a rare delusional condition in which patients believe that they are dead, as well as a severe intellectual disability. Seated stolidly in his customary blue chair with the plangent shrill of the common room television in the background, Mr. Smith could have been easily confused with the corpse he maintained that he was. He had been in the psychotic unit for several months and was awaiting a transfer to a different psychiatric facility where he would likely mire in his death delusion for the remainder of his life, as I learned from his medical record.

“Well Mr. Smith, as we discussed, you’re not dead, but I understand that must be a scary feeling.  Is there anything I can do for you today?” I offered my customary hackneyed response and glanced down, preparing to move on to my next patient. Instead, I was halted in my tracks, frozen by the look of unmistakable, intractable pain so clearly inscribed on Mr. Smith’s face. Although I had not been able to carry a conversation in the five days I had known him, in the stark agony canvassing his countenance I sensed a primal familiarity, one that transcended words. “See me!’’ it screamed mutely, “Don’t leave me for dead!”  

Familiar with my role as a feckless medical student by this point, my strategy in situations where I could do little was to sit and listen to patients’ stories, to try to identify with them – my empathic offering in lieu of the clinical expertise and authority I sorely lacked. But I knew Mr. Smith would not offer any stories or sensible verbal common ground upon which I could stand in solidarity; indeed his intellectual capacity and delusion precluded this. How, exactly, was I to empathize with a dead man?

The importance of empathy has received newfound emphasis in contemporary medical education, which seeks to mold physicians who are not only technically competent but also humanistic.¹ This focus is especially exigent in light of recent findings indicating that empathy decreases during the course of medical school._² Indeed, five of the AAMC’s fifteen “core competencies” for incoming medical students deal with interpersonal skills focused on forging connections with others,¹ with the implicit goal of cultivating empathic relationships in the future. Many patients and practitioners alike view this as a welcome change from the erstwhile era in which patients were viewed as objects, or at best recipients of paternalistic directives.³ Conversely, contemporary training that emphasizes empathy encourages students and practitioners to pursue commonality and compassion instead of demarcating difference.  

Predictably, there are barriers we encounter as practitioners to seeing ourselves in our patients’ shoes. For one, medical education and training can lead to a detached, objective, analytical view of disease—the famed “medical gaze” so named by Michel Foucault⁴— that makes it difficult to appreciate the experiential component of suffering we witness. Secondly, we frequently encounter those patients who arrive at their moment of illness with backgrounds, worldviews, cultural norms, and assumptions markedly different from our own, challenging our ability to imagine ourselves in their stead in the hospital bed or exam table before us.

Given these common challenges to cultivating and conveying empathy, where can we as students, residents, and attending physicians turn for common ground with patients with whom we struggle to identify?

Confronted by Mr. Smith’s convicting silence that morning, I now realize that an inchoate form of this very question was rattling around in my head as I looked down helplessly at his pained expression. In the midst of this seemingly unbridgeable chasm of silence, I furiously groped for words I might offer, while also holding out hope that he might verbally invite me to share in his plight. As I consider the discomfort and helplessness I felt that day, I realize that I was disoriented because I found alarmingly empty that well of empathy from which I had learned to draw in medicine: that of language.

This idea of language as both the source of and conduit for empathy is reinforced early and often during medical school. The emphasis on listening to and, when appropriate, speaking with others to garner a more empathic understanding of their experiences is reflected in the “Tell Me More” project funded by the Gold Humanism Honor society, in which medical students listen to and help create visual images depicting patients’ stories⁵; in the burgeoning field of narrative medicine which seeks to give voice to patients who often feel silenced in the midst of illness⁶; and in various medical school initiatives that encourage students to interview and form relationships with elderly people, those living with chronic illnesses, or members of other marginalized groups, predicated on shared stories. Such initiatives can be powerful empathy-generating experiences, but also implicitly convey the idea that such empathy must be sought primarily, if not exclusively, in dialogue.

Moreover, locating empathy in language is constantly realized and reinforced in everyday clinical interactions with patients. Students, residents, and attending physicians alike recognize the familiar yet powerful “me too!” moment in the course of a discussion with a patient with whom we previously thought we shared little in common. The joy of discovering a connection in the form of a shared birthday, favorite college basketball team, or even a familiar accent forges a bridge born of words that traverses the professional, cultural, or experiential distance previously described.  

Once we recognize the extent to which our idea of empathy traffics in the currency of language, however, we must consider the implications for those whom this economy of words renders poor; that is, the silent patients we serve. If language and the ability to speak articulately and think rationally is the entrée into this world of empathy, where does that leave those bereft of these linguistic abilities, such as individuals with intellectual disability or persistent delusional disorders like Mr. Smith, or countless others with autism spectrum disorder, dementia, or diseases such as cerebral palsy, which can render patients non-verbal even when their cognition is intact?  

When we are formed as practitioners to associate empathy with language, both by our training and our daily clinical experiences, we can come to find it difficult, if not impossible, to fully empathize with those bereft of such language. In a culture in which the vivifying sense of shared experience is born primarily through language, it makes sense how those like Mr. Smith, even the absence of such a delusion, might therefore feel “dead as hell.”  

I’ve been challenged since this encounter with Mr. Smith to consider what it might look like to expand our idea of empathy beyond its heavy reliance on dialogue. Perhaps we would be best served by a renewed attention to the original meaning of “empathy” found in the word’s historical etymology. “Empathy,” is derived originally from the Greek words “en” (in) and “pathos” (feeling or suffering) to most closely approximate the term “in suffering.”^7,8 At its core, then, empathy signifies being present to, or being “in” the suffering of another. Such an understanding of empathy thus necessitates presence before, and sometimes instead of, mere words.  

This primacy of presence points to the universal desire of those suffering to be seen, remembered, and ensured that they will not be abandoned, a desire that each of us has likely felt at some point, regardless of our communicative abilities. This presence-mediated empathy therefore represents a more inclusive way of considering how we might see some of ourselves in those patients lacking the intellectual, cognitive, or linguistic abilities to speak or comprehend, as people who share this fundamental need of company in the presence of pain.  

By resolving to stand or sit in silence, even if only briefly, with those patients who lack the ability to speak or understand, might we as practitioners be able to affirm both the plight, and the existence, of those who frequently go unseen because they are unheard? And might we remind ourselves that we share with these patients a humanity that at once precedes and supersedes the ability to speak and be heard?   

As I look back on the pained expression on Mr. Smith’s face that morning, I now recognize that it was this hunger for presence, this yearning to be attended to, affirmed, and reassured that he was not alone, that beseeched me with a silent but incisive clarity. Finally heeding his patient urge for me to see instead of merely speak, I pulled up my own blue chair and reluctantly joined him. I can’t pretend to know whether my presence that morning fully assuaged the pain that his face silently bespoke; perhaps it is impossible to ever know this, even in suffering patients who verbally reassure us that we have helped. Yet as I reflect on the gift of Mr. Smith’s gentle didactic silence in that moment, I am grateful for the important lesson on empathy that he wordlessly shared with me, which I carry to this day. That is, if we as practitioners are to see a part of ourselves in the silent patients we serve, we must indeed first see, even, and perhaps especially, when words fail.

View Editor's Comments

REFERENCES

1. Core Competencies for Entering Medical Students. AAMC.org. https://www.staging.aamc.org/initiatives/admissionsinitiative/competencies/. Accessed: 1 June 2017.

2. Chen DC, Kirshenbaum DS, Yan J, Kirshenbaum E, Aseltine RH. Characterizing changes in student empathy throughout medical school. Med Teach. 2012;34(4): 305-311.

3. Kaba R, Sooriakumaran P. The evolution of the doctor-patient relationship.  Int J Surg. 2007;5(1): 57-65.

4. Foucault M.  The Birth of the Clinic: An Archeology of Medical Perception.  New York, NY:  Vintage Books, 1963.

5. Tell Me More.  Gold Humanism Honor Society. http://www.goldfoundation.org/programs/tell-me-more/. Accessed June 1, 2017.

6. Charon R.  Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust. JAMA. 2001; 286(15): 1897-1902.

7. Lanzoni S.  The Atlantic. A Short History of Empathy. Oct 15, 2015. https://www.theatlantic.com/health/archive/2015/10/a-short-history-of-empathy/409912/. Published October 15, 2015.  Accessed June 2 2017.

8. Harper D.  Empathy. Online Etymological Dictionary. http://www.etymonline.com/index.php?term=empathy.  Accessed June 1 2017.