The position of an M0.5 is a very paradoxical one. We’ve gone through five months of class, amazed that our brains can fit in so much material and even more amazed that we have to make room for more. We’ve gotten our white coats and try to ask patients smart questions while having no idea what solution we can provide for the ailments being enumerated. Our goal at this point is not to diagnose — it’s to learn as much information as we can so that somewhere down the long, long line, we’ll be able to utilize what we know and make something of it.
The majority of medical school so far has been learning about the science of living. It’s the physiology, biochemistry, anatomy; the material that you pray that if you stare at the lectures long enough or watch enough Khan Academy videos, you’ll eventually get. And — fingers crossed — you probably will. The science is learnable because at the end of the day, it’s the stuff you feel that you’ve just got to know, whether it’s for the test in three weeks or for a diagnosis ten years down the line.
But in this age of patient-centered care, medical education cannot merely focus on the sciences. Knowing how to build rapport with patients is extremely important to a successful physician-patient relationship. Thus, another major component of this first year has been practicing how to talk with patients. In the past five months, I’ve thankfully practiced with standardized patients who’ve kindly understood why I’ve asked them if they had a fever three times in a row. When it comes to clinical applications, learning comes from the patient interactions themselves.
One of the most common feedbacks I’ve heard standardized patients give to first-years is something along the lines of, “I can really feel your empathy, that you care, and that’s great.” In the vein of learning how to interact with patients, this concept of empathy is something that crops up often — after all, a good doctor is an empathetic one. We are told that there are certain ways you can show empathy: a consoling hand on the shoulder, a softer tone of voice, steady eye contact, the occasional nod. All these convey one message: I understand and I care.
Yet, as much as I appreciate and strongly believe we do need the classes focusing on clinical skills, I can’t help but wonder — exactly how effective are these classes? Sure, you can teach students how to appear empathetic, but can you ever teach anyone to actually empathize? Essentially, it’s the question that doctors have asked for decades already — can we actually be taught to care?
In Margaret Edson’s Pulitzer Prize-winning play “W;t,” Professor Vivian Bearing is a college English professor diagnosed with stage IV ovarian cancer. She agrees to be part of a clinical study, where she meets Jason Posner, a clinical fellow who had taken her 17th-century poetry class during his undergraduate years. Jason is the archetypal research-oriented physician who cares too deeply about the science of the disease but lacks insight into how the science manifests in patients’ lives. After one morning’s grand rounds, where Jason expertly presents Vivian’s case to the team, he is prepared to leave when his attending prompts, “Clinical.” Reminded, Jason turns to Vivian and says, “Thank you, Professor Bearing. You’ve been very cooperative.”
It’s easy to distance ourselves from Jason, a character who seems offensively stereotypical as the socially clueless doctor who clearly still has not “mastered” the “bedside manner.” When reading this line, I typically picture Jason saying this statement in a rehearsed, mechanical way. But “W;t” is a play, meant to be spoken aloud, and without any stage direction, Jason’s phrase could manifest in multiple manners: perhaps mechanically, perhaps coldly, but also perhaps kindly, warmly, empathetically. If the latter were true, what would change if Jason had mastered the bedside manner — just its presentation, and not its entity?
Empathy is often likened to understanding. Unlike sympathy or pity, which imply a hierarchy (“I feel sad for you, let me help you.”), empathy connotes feeling for someone else because we understand them. Empathy is the feeling that results from understanding that we could be them, and therefore we care. Supposedly by understanding the experiences of patients or anyone around us, we can empathize because we can imagine ourselves in their positions.
Yet, this logic is faulty. To assume that we could be them, that only by possibly being them can we understand why we should care is not only flawed, but also self-imposing and hugely self-important. It is the same logic employed by many to convince others why rape culture exists — “imagine if it were your mother, your sister, your daughter.” By this argument, we care only when we imagine how rape culture directly impacts us or someone we love, not because it is fundamentally terrible and damaging to others and to society as a whole. In the context of medicine, this process defeats the purpose of patient-centered care. Not only does this place our personal feelings at the forefront, it also invalidates the actual patient experience.
Furthermore, to “walk in the shoes” of patients is a grand assumption. In “W;t,” Jason assumes he understands Vivian as the strict, imposing professor he had and therefore assumes that he understands Vivian’s condition. As such, he assumes that Vivian is capable of pushing forward with rounds of chemotherapy without difficulty. By holding her to a standard created from his own projection of understanding, he completely silences Vivian’s pain and her wishes. This culminates at the end of the play in his attempt to forcibly resuscitate Vivian despite her DNR.
More damaging than lack of understanding is the invalidation of a patient or any marginalized individual’s experience by assuming that we do understand. Can Jason, a healthy, young man truly imagine the experiences of a woman with stage IV ovarian cancer? Similarly, can I, a young, healthy student, truly “understand” the experiences of a patient three times my age? The answer is undoubtedly, “No.” We cannot empathize with all our patients. I highly doubt we can actually empathize with any of our patients, unless we’ve been in the same exact conditions.
This leaves us with a conundrum: why teach clinical skills when we can’t fully understand? Are these classes useless then?
Of course not. Clinical skills are crucial and important; being able to care for patients is both an innate characteristic and a skill that can be honed. But caring for a patient does not necessarily require understanding their experiences in the sense that we can imagine ourselves in them. Rather than learning these skills in the context of empathy, we should be learning them in the context of acknowledgment. Instead of caring for patients because we understand them, we should be caring for patients in spite of understanding them, for only then do we practice actual patient-centered care: care for the patient’s emotions, experiences, and understanding, not our own.