Too close: from empathy to over-identification

I know what to do. Make sure I know exactly what the diagnosis is, speak confidently about the possible treatments, have an onward plan prepared to allow some positive focus, a constructive approach. He’s bound to ask about prognosis but I’ll have to deflect that…it’s too early to get into numbers. He’s going to need to see an oncologist. This is just the first hurdle – breaking the bad news. He has an inkling, I know, but we haven’t talked about it openly. I know how to do this.

There will be a quiet, private room. There will be two seats, for him and his wife. I’m going to switch off my phone. The diary is clear for an hour, we can talk for as long as necessary. I’ve done it before, I’ve seen worse. It’s not exactly routine but it’s part of the job.

He’s not much older than me. He shouldn’t have something this serious. I think he’s got young children. Last time I saw him he was on his own, on the ward. We drew some fluid and sent it off for analysis. This is a follow up appointment, arranged urgently after the report landed on my desk. I did mention some possibilities at the time, as I was suspicious even at that early stage. I’ve no idea if he shared his fears with his wife or partner. She’s coming with him though.

What does he need from me? He’s a fairly matter of fact man, he just wants to get to the facts. And that’s how I’m going to be. I’ve got the facts, but I haven’t got the whole story. I can’t tell him how long he’s got. But I can provide a clear interpretation of the facts that I do have. I’ve done it many times.

That I’m thinking so much about this means something. I tell people every week that they have potentially lethal diseases, but this one is bugging me. I think it’s because he and I are similar. We’re at similar stages in our different careers, we both have young families. Am I nervous because I fear for myself when I see him? Am I worried that his misfortune will contaminate me? What is going on if my response to his illness is concern for my own future? If bad luck was contagious I’d be dead by now.

It’s different with the elderly; serious illness is an almost inevitable part of aging. And they tend to take it with little expressed emotion. What was it I read the other day? ‘He had reached an age where death no longer has the quality of ghastly surprise…’ The Great Gatsby. A book about young people. This man is being halted in his prime. I find myself thinking about how I would react if it was me. I’m thinking about it too much, that’s the problem.

I am walking to the clinic. It’s pretty quiet in the department as I arranged to use a room over the lunch hour. They haven’t arrived yet. I go through the notes, but there is no new information. A nurse opens the door and tells me he has arrived. He enters with his partner, they take their seats.

How are you? It’s an irrelevant question, a needless pleasantry.
Okay. Have you got the results?
Yes. There are abnormal cells in the fluid. Cancer cells.
His partner juts forward. You mean it’s cancer?
Yes.
I look at him. He is sweating. He is no longer receptive to my words.

His phone vibrates. In a matter of fact way, as is his manner, he pulls it out of his jacket pocket to read the text. I think he’s consciously carrying on as normal. I glance at the lighted screen of his phone, and see the image that he has saved to his home screen. Two children. I am rocked by the sudden realisation that he is not going to see them grow up. I stutter. I am very uncomfortable. The professionalism, the experience, the constructive momentum that I hoped would facilitate this consultation, have faded to nothing. I lose my way repeatedly, failing to find a secure path between his need for information and her evolving horror.

10 minutes later they leave. I have laid out the short-term plan, forced it onto the table, and I have avoided the big question about prognosis. But it didn’t go well. I know it didn’t go well. How could it, really? But my ‘performance’ was not right. For a few moments I was swimming in the murky waters of that couple’s emotional pain, and I was not doing my job. Perhaps they noticed. She did, I’m pretty sure.

Empathy is vital in the practise of medicine. It involves understanding a patient’s condition from their perspective. But it lies on a spectrum, with ‘detached concern’ at one end, and over-identification at the other. In this instance I over-identified. Next time I will play it cool. Think less. Feel less. Stay professional.

 

(This fictional episode was inspired by several clinical encounters.)

 

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4 comments

  1. I think there is a middle road between over-identification and between being cool; being a “professional.” Chaplains refer to that middle road as “being a non-anxious presence.” The non-anxious part is the detachment we need to do our job and take in and analyze patient behavior; the “presence” part implies the caring, being there and above all connecting with another human being by how we respond to them as authentically as possible.

  2. Wow, how godlike you are. Definitely, stay professional next time. Limit your empathy least you be rattled driving home in your Mercedes.

    1. All opinions welcome. Comments like this act as a reminder that this is a blog written by a doctor and that there is a risk that the emotions expressed seem overly doctor-centric. The importance of emotions bring experienced by the patient are not under-estimated, but I can’t pretend to represent them. When I do try to imagine what patients are feeling I make it very clear that it is a work of the imagination.

      When I manage to trade in the Ford Focus for something better I will let you know.

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