Tuesday, September 15, 2009

Empathic intrusions: the art of medical interviewing

Almost every medical school requires that its students take some sort of "interviewing course," usually in their first and second year before they have much significant clinical interaction with patients. These initial encounters with real patients are in some sense the purest ones we will ever have, since our listening to the patient's story is not yet clouded by needing to "make the diagnosis" and impress the attending physician with our ability to recognize pathology. I wrote the following essay-reflection as a first-year student at the New York University School of Medicine in the fall of 1997. "Sean" is a pseudonym.

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As a first-year medical student, I knew or would soon know all about appendicitis, meningitis, Wilms' tumor, Pfeifer’s syndrome, and Tetralogy of Fallot. But what did I know about gangs and gunshots? About having a father in jail? About the depth of faith and courage required to endure a chronic illness, a life-altering injury, or fifteen operations over five years? My greatest apprehension before I began interviewing patients was not the prospect of seeing disease. I didn’t think that I would flinch at jagged sutures, missing digits, or other unsightly scars. Rather, what gave me anxiety was the question of empathy: how I would identify with these patients and put myself in their worlds? Although the diverse lives that our group witnessed in the pediatric wards at Bellevue and Tisch Hospitals often bore only a passing resemblance to my own, I had always heard that good physicians try to place themselves “in the patient’s shoes” before determining the nature of the medical problem. Were my white coat and identification badge, then, substitutes for life experience and understanding?

Perhaps not, but professional attire certainly permitted entry. As another doctor-in-training observed, “There is a frequent sense of surprise, a feeling that you are not entitled to the kind of intrusion you are allowed into patients’ lives. ... You get used to it all, but every so often you find yourself marveling at the access you are allowed, at the way you are learning from the bodies, the stories, the lives and deaths of perfect strangers.”[1] While I soon “got used to it,” no interview made the extent of this privileged access clearer to me than that of a teenager who had been caught in the middle of a gang war and wounded by a bullet in his right leg. The first thing I wanted to know was how it felt - not only being shot, but being seventeen, physically active, a year from graduation and with a promising future career, and for a few moments, facing the possibility of losing everything.

“So how did it feel, Sean, when you were shot? Was it a sharp pain? You know, having never been shot myself...” It was an awkward question, finessed by nervous laughs all around. I half expected him to say that it was impossible to describe unless I’d gone through it myself. He didn’t, though, and instead continued soberly that he knew in an instant that his leg was broken, and remembered lying on the ground unaware of the bleeding or how much time had passed. Once he arrived at the hospital, Sean said, he knew he was going to be all right, even though he would later receive three blood transfusions and suffer repeated clots as a result. I could tell that he believed in the skill of the doctors, and may have transferred this confidence to my uniform as well. His only disappointment seemed to be the delays in going home.

Where was his anger? Where was the question, “why did this have to happen to me?” At the very least, I expected some sadness at his being unable to return to sports, or even to walk normally. That’s how I would feel, I thought. I tried to probe deeper, to unearth these private emotions which surely lay beneath his facade of acceptance and good cheer. Only later, after coming up empty, did I realize that these well-intentioned questions might have constituted an intrusion. One might call it an “empathic intrusion,” for at that moment, I didn’t only feel sympathy for Sean. I wanted to identify with him and his experience the only way I could, by drawing out his feelings.

What else can I do with these and other lives that move me deeply but touch little of my own? In the future, will I be able to heal my patients as I treat their afflictions, by also understanding their emotional discomfort? One physician suggests that “empathy can be strengthened best through stories.”[2] By reading widely, he argues, medical students can obtain acquired, if not direct, experience. While I would agree, patient interviews are more personal and illuminating than the best of literature. Our profession permits us by custom to know things about people that they may not tell close family or friends, producing to the ever-present danger that these intrusions may merely satisfy our own curiosity. For several weeks this fall, I and my fellow students learned how to be intruders, in the interest of gaining empathy. Although interviews do not necessarily bestow life experience, they serve the vital purposes of allowing us to gradually “grow into” our white coats, to feel more comfortable with our empathic intrusions, and ultimately, to serve our patients in practice.

[1] Perri Klass, “Invasions,” in On Doctoring: Stories, Poems, Essays (New York: Simon and Schuster, 1995), eds. Richard Reynolds and John Stone, 407.
[2] Howard Spiro, “What Is Empathy and Can It Be Taught?”

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