Written by Clay Smith.
This Is Water
A few years ago, I watched a video called This Is Water, based on a full commencement speech by David Foster Wallace (now deceased). This speech has some strong language some may find offensive, and the author had some serious personal flaws. But skimming the beauty from this speech, it made me think about empathy, specifically empathy for our patients.
Patients can be weird. Patients can be unreasonable. Children can be annoying. Their parents can be helicopters. Shifts can be long. Fatigue is real. The trauma of what we see almost every shift is disturbing. Sometimes we have nightmares. Sometimes we wake up in a sweat because we dreamed it happened to our kids, our spouse, our loved one. Who else hears of a possible mass shooting and thinks, "I'd better text my wife and tell her I may have to stay late at work."? That happened to me last week. This is a weird job, friends.
A Sea of Self
Wallace began the speech with a parable.
There are these two young fish swimming along, and they happen to meet an older fish swimming the other way, who nods at them and says, “Morning, boys, how's the water?” And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes, “What the hell is water?
His point is that our default condition is self-centeredness. We are immersed in ourselves and don’t even realize it. Like a fish unable to conceive of anything but water, we are swimming in a sea of self. The prerequisite to empathy is to realize our default setting - we tend to be self-centered. One purpose of education is to help us get outside the prison of self and realize that we can choose to think differently. Confession time - the notification of a possible mass casualty incident last week happened near the end of my shift. My first thought was, "Oh great... now I am going to have to stay late." I'm not proud of that. How could I be so self-centered? Thankfully, I didn't articulate that stupid thought (until now) and was able to stop and see how selfish it was. Mercifully, I was able to choose to think of the victims, the worried families, the law enforcement officers risking their lives, and how proud I was of all my colleagues around me who were ready to spring into action. I'm not sure self-centered thoughts will ever stop coming to mind first. That seems to be the default human condition. But thankfully we can choose to think differently as a glorious second impulse.
One way I want to think differently is about my patients. My default, maybe our default, is to think about how a patient impacts us first. They are so demanding. They are so stinky. They are so rude. They are so needy. They are such a poor historian. To be sure, those things may be true. But is there a reason - can I think about this differently?
There is a lot of talk about empathy these days. It's a good thing. Empathy is the ability to understand and share the feelings of others. We can't begin to have empathy though until we can get outside our own selves long enough to think differently about the patient in front of us.
A Mile In Their Shoes
For every patient I want to take just a minute and think what it's like to be in their shoes.
Fears - I had a mother demand testing for her child, which was inappropriate for the situation. I was really frustrated that I couldn't convince her that her chubby, smiling infant was perfectly fine. It didn't make sense until I learned her other child had died of SIDS. Many patients come to the ED because they are scared out of their minds. They do their best to suppress this and present themselves in a way that feels less vulnerable, less embarrassing, such as being demanding or angry. Learn to spot fear. Facts don't address fear. Comfort addresses fear. Comfort first - then facts have a place to land.
Pain - Very recently, a cancer patient snapped at me. What he said was very hurtful and rude. He had unrelenting pain from bony metastases. His demeanor changed after treatment, when he saw a little hope that his pain would ease. Then he was sheepish and apologized. I felt choked up - he didn't need to apologize. How would I have acted if it were me? If you've ever had serious pain, you know a little about what gnawing, constant pain can do to your psyche. We may become irritable, angry, withdrawn, rude, hopeless, or depressed. Pain can masquerade as despair or bluster.
Addiction - I was caring for an alcoholic with serious medical issues who needed more workup but refused to stay and left against medical advice. I just couldn't convince him to stay for the CT. It didn't dawn on me then, but it was probably nearing 8 hours since he'd had a drink. Most of us don't know what severe alcohol withdrawal feels like, but the patient did. Erratic behavior, bad choices, irrational decision making, exacerbation of psychiatric illness - all are fueled by addiction.
Past trauma - A teenage girl was uncooperative as I tried to interview her, do a basic exam, and listen to heart and lungs. I thought she was just being a punk. Then I learned she had a history of awful physical and sexual abuse in her past. Turns out, I was the one being a punk. Self-loathing, depression, self-harm, risky behavior, intense fear, and irritability can all spring from prior emotional, sexual, or physical trauma. Sometimes this is overtly self-destructive. Sometimes is it carefully veiled. All of us have "baggage" and emotional scars. All of us have a backstory. For some, it is truly horrifying. Think of your scars and how they affect you. Could past trauma be affecting your patient? Current abuse, such as domestic violence, may have a different look, such as minimizing or covering up external signs of trauma or having exaggerated pain symptoms.
Educational barriers/ Language barriers - I happened into a patient's room and saw an illiterate patient become surly toward the registration staff about signing forms, etc. He was covering up embarrassment that he couldn't read the forms or write. One in six Americans has low literacy, reading below a fourth grade level. Regarding language barriers, one of my dear friends became sick while we were traveling overseas, and we didn't speak Spanish well. It is really scary to need medical care and not speak the language. It means a lot to patients when we communicate with them in a way they can understand.
Mental illness - I recently had a young man who had trouble articulating why he was in the ED - pain "all over," needing opiates, etc. When I reviewed the chart, I saw a prior psychiatric admission that noted he minimized symptoms of paranoia and hallucinations. When I had a chance to talk to family, I learned that he had been destroying the home (literally) and threatening his mother with harm, none of which was apparent at first. This was scary, and I almost missed it. Mental illness is highly prevalent, and it may take a little more time to sift through the vague complaints to learn that the patient's thinking is disorganized, overtly psychotic, or they are harboring suicidal or homicidal thoughts. Maybe the "poor historian" is actually me.
Poverty/ Hunger/ Homelessness - A young mother would not stay with her 10 year old boy while we were waiting for labs to return. She was belligerent and said she had to pick up her other child from school or she, "would be in trouble." She had no one else to help her with childcare. Clearly, there was a backstory here. The nurse rightly expressed concern about her behavior and seeming neglect of the child in the ED. But another way of thinking about it made her decision completely rational. Her 10 year old was in a safe place with us. Her other child was not in a safe place. Her failure to pick him up may have resulted in foster care placement, which she perceived as even more dangerous. In that light, her decision, even her strident tone, was perfectly rational. In a similar vein, we have all had homeless patients ask us for a sandwich or manufacture symptoms to stay a little longer in the ED out of the cold. Poverty, hunger, and homelessness can make patients act in ways that may seem irrational, but when we put ourselves in their shoes and understand their desperation, it explains a lot.
Power of Empathy
To be clear, we can't tolerate unruly or violent behavior from patients. Realistically, some patients will need be escorted from the premises or have agitated delirium treated. These are not the ones I am talking about. Sometimes we can get beneath the surface-level irritability or anger and address the fear, pain, hurt, sorrow, embarrassment, hunger, despondency, or desperation that is driving it. Many patients just need to see a glimpse that we understand what they are facing, to hear a kind, comforting word that we "get it," and bluster will often dissolve into tears. Often the truth will pour out about what's really going on. Empathy is powerful. It not only changes us, it meets a need for the patient as well - to be heard and comforted.
How's the Water?
Genuinely trying to empathize with patients can make our job sweeter. It's not as simple as this, but developing empathy has certainly helped me in my personal struggles with burnout. Empathy can help patients feel cared for, because it's true. It can defuse angry crises by simply getting close and trying to understand the situation from the patient's perspective. But a key first step is to realize what we're swimming in; self-centeredness will steal the benefits of empathy from us. Next time you see me acting selfishly, you have full permission to say, "Hey, Clay. How's the water?"