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Other Features: Teaching and Learning Moments

Rationing Empathy

Donato, Anthony A. MD

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doi: 10.1097/01.ACM.0000345399.47940.8b
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“I lost a 35-year-old woman today.” My listener, a middle-aged mother, stops what she is doing and meets my eyes.

“Kids?” she asks. “Two,” I answer. My listener looks aghast, looking down momentarily at a child darting past.

“Car accident?” “No—infectious complications of HIV.” The bond that tied her to the story loosens its grip. My listener goes a little further to detangle with a common defense. “How'd she get HIV?” “Not sure, but she was an IV drug user.” “Kinda did it to herself, huh?”

The last of the bonds fall away.

If there was any connection left, I could have told her that the patient had a dependent personality disorder, and had on more than one occasion blamed her worsening illness on the fact that her family wasn't forcing her to take her antiretroviral therapy. She took no personal responsibility for her condition, and in fact escaped it to the very end through her drug use. Furthermore, she was a difficult person to deal with on many levels—she was frequently not truthful with her doctors, and was often manipulative to her physicians and her family.

My listener moves on, returning to the task that my story had interrupted and leaves me to mourn her passing alone.

I wonder—was she ever valued? Was she loved? Was there a time—even a brief one—where things could have gone differently for her? I will never know. The sadness of her unfulfilled life casts a shadow over me. My listener, now noting my distance, reconnects.

“I don't know how you do what you do,” she notes with some pity in her tone.

I know there is great sadness in the world, and my job is in many ways an immersion experience in that sadness. Much like my listener, as a physician I must balance the depth to which I engage that sadness. I see my housestaff attempting this balance as they present a readmission of a patient with acute alcoholic pancreatitis. When I point out that he was a war veteran with depression that he treated with alcohol, my assertion is met with a mix of receptive contemplation and downcast glances; some acknowledge the teaching point, and others choose to observe at a distance. I know I have my limits too. At 3 am on my third night in a row on call, my sleep interests me far more than the anxiety and poor coping skills of my patient who is nursing the wounds of a recent divorce, and I struggle to remind myself of the lessons I teach my housestaff.

Reflecting on the sadness in others' lives can give us perspective about our own lives, a frame of reference for our struggles, or the joy of sharing in the triumph of the human spirit. It can also, at high doses or inadequate titrations, paralyze us with grief or numb us entirely.

As a physician, I walk that fine line. Connect. Find meaning in the human struggle. Pull out before that struggle paralyzes me. Pull out too early and I become callous; stay in too long and I feel the flames of burnout.

I take another step forward, not sure on which side of the line my foot will land.

© 2009 Association of American Medical Colleges