22 The Empathy Exams by Leslie Jamison

My job title is Medical Actor, which means I play sick. I get paid by the hour. Medical students guess my maladies. I’m called a Standardized Patient, which means I act toward the norms of my disorders. I’m standardized-lingo SP for short. I’m fluent in the symptoms of preeclampsia and asthma and appendicitis. I play a mom whose baby has blue lips.

Medical acting works like this: you get a script and a paper gown. You get $13.50 an hour. Our scripts are ten to twelve pages long. They outline what’s wrong with us—not just what hurts but how to express it. They tell us how much to give away, and when. We are supposed to unfurl the answers according to specific protocols. The scripts dig deep into our fictive lives: the ages of our children and the diseases of our parents, the names of our husbands’ real-estate and graphic-design firms, the amount of weight we’ve lost in the past year, the amount of alcohol we drink each week.

My specialty case is Stephanie Phillips, a twenty-three-year-old who suffers from something called conversion disorder. She is grieving the death of her brother, and her grief has sublimated into seizures. Her disorder is news to me. I didn’t know you could have a seizure from sadness. She’s not supposed to know either. She’s not supposed to think the seizures have anything to do with what she’s lost.

STEPHANIE PHILLIPS

Psychiatry

SP Training Materials

CASE SUMMARY: You are a twenty-three-year-old female patient experiencing seizures with no identifiable neurological origin. You can’t remember your seizures but are told you froth at the mouth and yell obscenities. You can usually feel a seizure coming before it arrives. The seizures began two years ago, shortly after your older brother drowned in the river just south of the Bennington Avenue Bridge. He was swimming drunk after a football tailgate. You and he worked at the same mini-golf course. These days you don’t work at all. These days you don’t do much. You’re afraid of having a seizure in public. No doctor has been able to help you. Your brother’s name was Will.

MEDICATION HISTORY: You are not taking any medications. You’ve never taken antidepressants. You’ve never thought you needed them.

MEDICAL HISTORY: Your health has never caused you any trouble. You’ve never had anything worse than a broken arm. Will was there when it was broken. He was the one who called for the paramedics and kept you calm until they came.

Our simulated exams take place in three suites of purpose-built rooms. Each room is fitted with an examination table and a surveillance camera. We test second- and third-year medical students in topical rotations: pediatrics, surgery, psychiatry. On any given day of exams, each student must go through “encounters”—their technical title—with three or four actors playing different cases.

A student might have to palpate a woman’s ten-on-a-scale-of-ten pain in her lower abdomen, then sit across from a delusional young lawyer and tell him that when he feels a writhing mass of worms in his small intestine, the feeling is probably coming from somewhere else. Then this med student might arrive in my room, stay straight-faced and tell me that I might go into premature labor to deliver the pillow strapped to my belly, or nod solemnly as I express concern about my ailing plastic baby: “He’s just so quiet.”

Once the fifteen-minute encounter has finished, the medical student leaves the room and I fill out an evaluation of his/her performance. The first part is a checklist: which crucial pieces of information did he/she manage to elicit? Which ones did he/she leave uncovered? The second part of the evaluation covers affect. Checklist item 31 is generally acknowledged as the most important category: “Voiced empathy for my situation/problem.” We are instructed about the importance of this first word, voiced. It’s not enough for someone to have a sympathetic manner or use a caring tone of voice. The students have to say the right words to get credit for compassion.

We SPs are given our own suite for preparation and decompression. We gather in clusters: old men in crinkling blue robes, MFA graduates in boots too cool for our paper gowns, local teenagers in ponchos and sweatpants. We help each other strap pillows around our waists. We hand off infant dolls. Little pneumatic Baby Doug, swaddled in a cheap cotton blanket, is passed from girl to girl like a relay baton. Our ranks are full of community-theater actors and undergrad drama majors seeking stages, high-school kids earning booze money, retired folks with spare time. I am a writer, which is to say: I’m trying not to be broke.

We play a demographic menagerie: young jocks with ACL injuries and business executives nursing coke habits. STD Grandma has just cheated on her husband of forty years and has a case of gonorrhea to show for it. She hides behind her shame like a veil, and her med student is supposed to part the curtain. If he’s asking the right questions, she’ll have a simulated crying breakdown halfway through the encounter.

Blackout Buddy gets makeup: a gash on his chin, a black eye, and bruises smudged in green eye shadow along his cheekbone. He’s been in a minor car crash he can’t remember. Before the encounter, the actor splashes booze on his body like cologne. He’s supposed to let the particulars of his alcoholism glimmer through, very “unplanned,” bits of a secret he’s done his best to keep guarded.

Our scripts are studded with moments of flourish: Pregnant Lila’s husband is a yacht captain sailing overseas in Croatia. Appendicitis Angela has a dead guitarist uncle whose tour bus was hit by a tornado. Many of our extended family members have died violent, Midwestern deaths: mauled in tractor or grain-elevator accidents, hit by drunk drivers on the way home from Hy-Vee grocery stores, felled by a Big Ten tailgate—or, like my brother Will, by the aftermath of its debauchery.

Between encounters, we are given water, fruit, granola bars, and an endless supply of mints. We aren’t supposed to exhaust the students with our bad breath and growling stomachs, the side effects of our actual bodies.

Some med students get nervous during our encounters. It’s like an awkward date, except half of them are wearing platinum wedding bands. I want to tell them I’m more than just an unmarried woman faking seizures for pocket money. I do things! I want to tell them. I’m probably going to write about this in a book someday! We make small talk about the rural Iowa farm town I’m supposed to be from. We each understand the other is inventing this small talk and we agree to respond to each other’s inventions as genuine exposures of personality. We’re holding the fiction between us like a jump rope.

One time a student forgets we are pretending and starts asking detailed questions about my fake hometown—which, as it happens, if he’s being honest, is his real hometown—and his questions lie beyond the purview of my script, beyond what I can answer, because in truth I don’t know much about the person I’m supposed to be or the place I’m supposed to be from. He’s forgotten our contract. I bullshit harder, more heartily. “That park in Muscatine!” I say, slapping my knee like a grandpa. “I used to sled there as a kid.”

Other students are all business. They rattle through the clinical checklist for depression like a list of things they need to get at the grocery store: “sleep disturbances, changes in appetite, decreased concentration.” Some of them get irritated when I obey my script and refuse to make eye contact. I’m supposed to stay swaddled and numb. These irritated students take my averted eyes as a challenge. They never stop seeking my gaze. Wrestling me into eye contact is the way they maintain power, forcing me to acknowledge their requisite display of care.

I grow accustomed to comments that feel aggressive in their formulaic insistence: That must really be hard [to have a dying baby], That must really be hard [to be afraid you’ll have another seizure in the middle of the grocery store], That must really be hard [to carry in your uterus the bacterial evidence of cheating on your husband]. Why not say, I couldn’t even imagine?

Other students seem to understand that empathy is always perched precariously between gift and invasion. They won’t even press the stethoscope to my skin without asking if it’s OK. They need permission. They don’t want to presume. Their stuttering unwittingly honors my privacy: “Can I… could I… would you mind if I—listened to your heart?” “No,” I tell them. “I don’t mind.” Not minding is my job. Their humility is a kind of compassion in its own right. Humility means they ask questions, and questions mean they get answers, and answers mean they get points on the checklist: a point for finding out my mother takes Wellbutrin, a point for getting me to admit I’ve spent the last two years cutting myself, a point for finding out my father died in a grain elevator when I was two—for realizing that a root system of loss stretches radial and rhizomatic under the entire territory of my life.

In this sense, empathy isn’t measured just by Checklist item 31—“Voiced empathy for my situation/problem”—but by every item that gauges how thoroughly my experience has been imagined. Empathy isn’t just remembering to say That must really be hard, it’s figuring out how to bring difficulty into the light so it can be seen at all. Empathy isn’t just listening, it’s asking the questions whose answers need to be listened to. Empathy requires inquiry as much as imagination. Empathy requires knowing you know nothing. Empathy means acknowledging a horizon of context that extends perpetually beyond what you can see: an old woman’s gonorrhea is connected to her guilt is connected to her marriage is connected to her children is connected to the days when she was a child. All this is connected to her domestically stifled mother, in turn, and to her parents’ unbroken marriage; maybe everything traces its roots to her very first period, how it shamed and thrilled her.

Empathy means realizing no trauma has discrete edges. Trauma bleeds. Out of wounds and across boundaries. Sadness becomes a seizure. Empathy demands another kind of porousness in response. My Stephanie script is twelve pages long. I think mainly about what it doesn’t say.

Empathy comes from the Greek empatheia—em (“into”) and pathos (“feeling”)—a penetration, a kind of travel. It suggests you enter another person’s pain as you’d enter another country, through immigration and customs, border-crossing by way of query: What grows where you are? What are the laws? What animals graze there?

I’ve thought about Stephanie Phillips’s seizures in terms of possession and privacy—that converting her sadness away from direct articulation is a way to keep it hers. Her refusal to make eye contact, her unwillingness to explicate her inner life, the very fact that she becomes unconscious during her own expressions of grief, and doesn’t remember them afterward—all of these might be ways of keeping her loss protected and pristine, unviolated by the sympathy of others.

“What do you call out during seizures?” one student asks.

“I don’t know,” I say, and want to add, but I mean all of it.

I know that saying this would be against the rules. I’m playing a girl who keeps her sadness so subterranean she can’t even see it herself. I can’t give it away so easily.

LESLIE JAMISON

Ob-Gyn

SP Training Materials

CASE SUMMARY: You are a twenty-five-year-old female seeking termination of your pregnancy. You have never been pregnant before. You are five and a half weeks but have not experienced any bloating or cramping. You have experienced some fluctuations in mood but have been unable to determine whether these are due to being pregnant or knowing you are pregnant. You are not visibly upset about your pregnancy. Invisibly, you are not sure.

MEDICATION HISTORY: You are not taking any medications. This is why you got pregnant.

MEDICAL HISTORY: You’ve had several surgeries in the past but you don’t mention them to your doctor because they don’t seem relevant. You are about to have another surgery to correct your tachycardia, the excessive and irregular beating of your heart. Your mother has made you promise to mention this upcoming surgery in your termination consultation, even though you don’t feel like discussing it. She wants the doctor to know about your heart condition in case it affects the way he ends your pregnancy, or the way he keeps you sedated while he does it.

*

I could tell you I got an abortion one February or heart surgery that March—like they were separate cases, unrelated scripts—but neither one of these accounts would be complete without the other. A single month knitted them together; two mornings I woke up on an empty stomach and slid into a paper gown. One operation depended on a tiny vacuum, the other on a catheter that would ablate the tissue of my heart. Ablate? I asked the doctors. They explained that meant “burn.”

One procedure made me bleed and the other was nearly bloodless; one was my choice and the other wasn’t; both made me feel—at once—the incredible frailty and capacity of my own body; both came in a bleak winter; both left me prostrate under the hands of men, and dependent on the care of a man I was just beginning to love.

Dave and I first kissed in a Maryland basement at three in the morning on our way to Newport News to canvass for Obama in 2008. We canvassed for an organizing union called Unite Here. Unite Here! Years later, that poster hung above our bed. That first fall we walked along Connecticut beaches strewn with broken clamshells. We held hands against salt winds. We went to a hotel for the weekend and put so much bubble bath in our tub that the bubbles ran all over the floor. We took pictures of that. We took pictures of everything. We walked across Williamsburg in the rain to see a concert. We were writers in love. My boss used to imagine us curling up at night and taking inventories of each other’s hearts. How did it make you feel to see that injured pigeon in the street today?, etc. And it’s true: we once talked about seeing two crippled bunnies trying to mate on a patchy lawn—how sad it was, and moving.

We’d been in love about two months when I got pregnant. I saw the cross on the stick and called Dave and we wandered college quads in the bitter cold and talked about what we were going to do. I thought of the little fetus bundled inside my jacket with me and wondered—honestly wondered—if I felt attached to it yet. I wasn’t sure. I remember not knowing what to say. I remember wanting a drink. I remember wanting Dave to be inside the choice with me but also feeling possessive of what was happening. I needed him to understand he would never live this choice like I was going to live it. This was the double blade of how I felt about anything that hurt: I wanted someone else to feel it with me, and also I wanted it entirely for myself.

We scheduled the abortion for a Friday and I found myself facing a week of ordinary days until it happened. I realized I was supposed to keep doing ordinary things. One afternoon, I holed up in the library and read a pregnancy memoir. The author described a pulsing fist of fear and loneliness inside her—a fist she’d carried her whole life, had numbed with drinking and sex—and explained how her pregnancy had replaced this fist with the tiny bud of her fetus, a moving life.

I sent Dave a text. I wanted to tell him about the fist of fear, the baby heart, how sad it felt to read about a woman changed by pregnancy when I knew I wouldn’t be changed by mine—or, at least, not like she’d been. I didn’t hear anything back for hours. This bothered me. I felt guilt that I didn’t feel more about the abortion; I felt pissed off at Dave for being elsewhere, for choosing not to do the tiniest thing when I was going to do the rest of it.

I felt the weight of expectation on every moment—the sense that the end of this pregnancy was something I should feel sad about, the lurking fear that I never felt sad about what I was supposed to feel sad about, the knowledge that I’d gone through several funerals dry-eyed, the hunch that I had a parched interior life activated only by the need for constant affirmation, nothing more. I wanted Dave to guess what I needed at precisely the same time as I needed it. I wanted him to imagine how much small signals of his presence might mean.

That night we roasted vegetables and ate them at my kitchen table. Weeks before, I’d covered that table with citrus fruits and fed our friends pills made from berries that made everything sweet: grapefruit tasted like candy, beer like chocolate, Shiraz like Manischewitz—everything, actually, tasted a little like Manischewitz. Which is to say: that kitchen held the ghosts of countless days that felt easier than the one we were living now. We drank wine and I think—I know—I drank a lot. It sickened me to think I was doing something harmful to the fetus, because that meant thinking of the fetus as harm-able, which made it feel more alive, which made me feel more selfish, woozy with cheap Cabernet and spoiling for a fight.

Feeling Dave’s distance that day had made me realize how much I needed to feel he was as close to this pregnancy as I was—an impossible asymptote. But I thought he could at least bridge the gap between our days and bodies with a text. I told him so. Actually, I probably sulked, waited for him to ask, and then told him so. Guessing your feelings is like charming a cobra with a stethoscope, a boyfriend told me once. Meaning what? Meaning a couple things, I think—that pain turned me venomous, that diagnosing me required a specialized kind of enchantment, that I flaunted feelings and withheld their origins at once.

Sitting with Dave, in my attic living room, my cobra hood was spread. “I felt lonely today,” I told him. “I wanted to hear from you.”

I’d be lying if I wrote that I remember what he said. I don’t. Which is the sad half-life of arguments—we usually remember our side better. I think he told me he’d been thinking of me all day, and couldn’t I trust that? Why did I need proof?

Voiced empathy for my situation/problem. Why did I need proof? I just did.

He said to me, “I think you’re making this up.”

“This” meaning what? My anger? My anger at him? Memory fumbles.

I didn’t know what I felt, I told him. Couldn’t he just trust that I felt something, and that I’d wanted something from him? I needed his empathy not just to comprehend the emotions I was describing, but to help me discover which emotions were actually there.

We were under a skylight under a moon. It was February beyond the glass. It was almost Valentine’s Day. I was curled into a cheap futon with crumbs in its creases, a piece of furniture that made me feel like I was still in college. This abortion was something adult. I didn’t feel like an adult inside of it.

I heard “making this up” as an accusation that I was inventing emotions I didn’t have, but I think he was suggesting I’d mistranslated emotions that were already there—attaching long-standing feelings of need and insecurity to the particular event of this abortion; exaggerating what I felt in order to manipulate him into feeling bad. This accusation hurt not because it was entirely wrong but because it was partially right, and because it was leveled with such coldness. He was speaking something truthful about me in order to defend himself, not to make me feel better.

But there was truth behind it. He understood my pain as something actual and constructed at once. He got that it was necessarily both—that my feelings were also made of the way I spoke them. When he told me I was making things up, he didn’t mean I wasn’t feeling anything. He meant that feeling something was never simply a state of submission but always, also, a process of construction. I see all this, looking back.

I also see that he could have been gentler with me. We could have been gentler with each other.

*

We went to Planned Parenthood on a freezing morning. We rummaged through a bin of free kids’ books while I waited for my name to get called. Who knows why these children’s books were there? Meant for kids waiting during their mothers’ appointments, maybe. But it felt like perversity that Friday morning, during the weekly time-slot for abortions. We found a book called Alexander, about a boy who confesses all his misdeeds to his father by blaming them on an imaginary red-and-green-striped horse. “Alexander was a pretty bad horse today.” Whatever we can’t hold, we hang on a hook that will hold it. The book belonged to a guy named Michael from Branford. I wondered why Michael had come to Planned Parenthood, and why he’d left that book behind.

There are things I’d like to tell the version of myself who sat in the Planned Parenthood counseling room, the woman who studiously practiced cheerful unconcern. I would tell her she is going through something large and she shouldn’t be afraid to confess its size, shouldn’t be afraid she’s “making too big a deal of it.” She shouldn’t be afraid of not feeling enough, because the feelings will keep coming—different ones—for years. I would tell her that commonality doesn’t inoculate against hurt. The fact of all those women in the waiting room, doing the same thing I was doing, didn’t make it any easier.

I would tell myself: Maybe your prior surgeries don’t matter here, but maybe they do. Your broken jaw and your broken nose don’t have anything to do with your pregnancy except that they were both times you got broken into. Getting each one fixed meant getting broken into again. Getting your heart fixed will be another burglary, nothing taken except everything that gets burned away. Maybe every time you get into a paper gown you summon the ghosts of all the other times you got into a paper gown; maybe every time you slip down into that anesthetized dark it’s the same dark you slipped into before. Maybe it’s been waiting for you the whole time.

STEPHANIE PHILLIPS

Psychiatry

SP Training Materials (Cont.)

OPENING LINE: “I’m having these seizures and no one knows why.”

PHYSICAL PRESENTATION AND TONE: You are wearing jeans and a sweatshirt, preferably stained or rumpled. You aren’t someone who puts much effort into your personal appearance. At some point during the encounter, you might mention that you don’t bother dressing nicely anymore, because you rarely leave the house. It is essential that you avoid eye contact and keep your voice free of emotion during the encounter.

*

One of the hardest parts of playing Stephanie Phillips is nailing her affect—la belle indifference, a manner defined as the “air of unconcern displayed by some patients toward their physical symptoms.” It is a common sign of conversion disorder, a front of indifference hiding “physical symptoms [that] may relieve anxiety and result in secondary gains in the form of sympathy and attention given by others.” La belle indifference—outsourcing emotional content to physical expression—is a way of inviting empathy without asking for it. In this way, encounters with Stephanie present a sort of empathy limit case: the clinician must excavate a sadness the patient hasn’t identified, must imagine deeply into a pain Stephanie can’t fully experience herself.

For other cases, we are supposed to wear our anguish more openly—like a terrible, seething garment. My first time playing Appendicitis Angela, I’m told I manage “just the right amount of pain.” I’m moaning in a fetal position and apparently doing it right. The doctors know how to respond. I am sorry to hear that you are experiencing an excruciating pain in your abdomen, one says. It must be uncomfortable.

Part of me has always craved a pain so visible—so irrefutable and physically inescapable—that everyone would have to notice. But my sadness about the abortion was never a convulsion. There was never a scene. No frothing at the mouth. I was almost relieved, three days after the procedure, when I started to hurt. It was worst at night, the cramping. But at least I knew what I felt. I wouldn’t have to figure out how to explain. Like Stephanie, who didn’t talk about her grief because her seizures were already pronouncing it—slantwise, in a private language, but still—granting it substance and choreography.

STEPHANIE PHILLIPS

Psychiatry

SP Training Materials (Cont.)

ENCOUNTER DYNAMICS: You don’t reveal personal details until prompted. You say you wouldn’t call yourself happy. You say you wouldn’t call yourself unhappy. You get sad some nights about your brother. You don’t say so. You don’t say you have a turtle who might outlive you, and a pair of green sneakers from your gig at the mini-golf course. You don’t say you have a lot of memories of stacking putters. You say you have another brother, if asked, but you don’t say he’s not Will, because that’s obvious—even if the truth of it still strikes you sometimes, hard. You are not sure these things matter. They are just facts. They are facts like the fact of dried spittle on your cheeks when you wake up on the couch and can’t remember telling your mother to fuck herself. Fuck you is also what your arm says when it jerks so hard it might break into pieces. Fuck you fuck you fuck you until your jaw locks and nothing comes.

You live in a world underneath the words you are saying in this clean white room, It’s OK I’m OK I feel sad I guess. You are blind in this other world. It’s dark. Your seizures are how you move through it—thrashing and fumbling—feeling for what its walls are made of.

Your body wasn’t anything special until it rebelled. Maybe you thought your thighs were fat or else you didn’t, yet; maybe you had best friends who whispered secrets to you during sleepovers; maybe you had lots of boyfriends or else you were still waiting for the first one; maybe you liked unicorns when you were young or maybe you preferred regular horses. I imagine you in every possible direction, and then I cover my tracks and imagine you all over again. Sometimes I can’t stand how much of you I don’t know.

I hadn’t planned to get heart surgery right after an abortion. I hadn’t planned to get heart surgery at all. It came as a surprise that there was anything wrong. My pulse had been showing up high at the doctor’s office. I was given a Holter monitor—a small plastic box to wear around my neck for twenty-four hours, attached by sensors to my chest—that showed the doctors my heart wasn’t beating right. The doctors diagnosed me with SVT—superventricular tachycardia—and said they thought there was an extra electrical node sending out extra signals—beat, beat, beat—when it wasn’t supposed to.

They explained how to fix it: they’d make two slits in my skin, above my hips, and thread catheter wires all the way up to my heart. They would ablate bits of tissue until they managed to get rid of my tiny rogue beatbox.

My primary cardiologist was a small woman who moved quickly through the offices and hallways of her world. Let’s call her Dr. M. She spoke in a curt voice, always. The problem was never that her curtness meant anything—never that I took it personally—but rather that it meant nothing, that it wasn’t personal at all.

My mother insisted I call Dr. M to tell her I was having an abortion. What if there was something I needed to tell the doctors before they performed it? That was the reasoning. I put off the call until I couldn’t put it off any longer. The thought of telling a near stranger that I was having an abortion—over the phone, without being asked—seemed mortifying. It was like I’d be peeling off the bandage on a wound she hadn’t asked to see.

When I finally got her on the phone, she sounded harried and impatient. I told her quickly. Her voice was cold: “And what do you want to know from me?”

I went blank. I hadn’t known I’d wanted her to say, I’m sorry to hear that, until she didn’t say it. But I had. I’d wanted her to say something. I started crying. I felt like a child. I felt like an idiot. Why was I crying now, when I hadn’t cried before—not when I found out, not when I told Dave, not when I made the appointment or went to it?

“Well?” she asked.

I finally remembered my question: did the abortion doctor need to know anything about my tachycardia?

“No,” she said. “Is that it?” Her voice was so incredibly blunt. I could hear only one thing in it: Why are you making a fuss? That was it. I felt simultaneously like I didn’t feel enough and like I was making a big deal out of nothing—that maybe I was making a big deal out of nothing because I didn’t feel enough, that my tears with Dr. M were runoff from the other parts of the abortion I wasn’t crying about. I had an insecurity that didn’t know how to express itself, that could attach itself to tears or else to their absence. Alexander was a pretty bad horse today. When of course the horse wasn’t the problem. Dr. M became a villain because my story didn’t have one. Mine was the kind of pain that comes without a perpetrator. Everything was happening because of my body or because of a choice I’d made. I needed something from the world I didn’t know how to ask for. I needed people—Dave, a doctor, anyone—to deliver my feelings back to me in a form that was legible. Which is a superlative kind of empathy to seek, or to supply: an empathy that rearticulates more clearly what it’s shown.

*

A month later, Dr. M bent over the operating table and apologized. “I’m sorry for my tone on the phone,” she said. “I didn’t understand what you were asking.” It was an apology whose logic I didn’t entirely understand. It had been prompted. At some point my mother had called her to discuss my upcoming procedure—and had mentioned how upset I’d been by our phone conversation.

Now I was lying on my back in a hospital gown. I was woozy from the early stages of my anesthesia. I felt like crying all over again, at the memory of how powerless I’d been on the phone—powerless because I had needed so much from her, a stranger—and how powerless I was now, lying flat on my back and waiting for a team of doctors to burn away the tissue of my heart. I wanted to tell her I didn’t accept her apology. I wanted to tell her she didn’t have the right to apologize—not here, not while I was lying naked under a paper gown, not when I was about to get cut open again. I wanted to deny her the right to feel better because she’d said she was sorry.

Mainly, I wanted the anesthesia to carry me away from everything I felt and everything my body was about to feel. In a moment, it did.

*

I always fight the impulse to ask the med students for pills during our encounters. It seems natural. Wouldn’t Baby Doug’s mom want an Ativan? Wouldn’t Appendicitis Amy want some Vicodin, or whatever they give you for a ten on the pain scale? Wouldn’t Stephanie Phillips be a little more excited about a new diet of Valium? I keep thinking I’ll communicate my pain most effectively by expressing my desire for the things that might dissolve it. Which is to say, if I were Stephanie Phillips, I’d be excited about my Ativan. But I’m not. And being an SP isn’t about projection; it’s about inhabitance. I can’t go off-script. These encounters aren’t about dissolving pain, anyway, but rather seeing it more clearly. The healing part is always a hypothetical horizon we never reach.

*

During my winter of ministrations, I found myself constantly in the hands of doctors. It began with that first nameless man who gave me an abortion the same morning he gave twenty other women their abortions. Gave. It’s a funny word we use, as if it were a present. Once the procedure was done, I was wheeled into a dim room where a man with a long white beard gave me a cup of orange juice. He was like a kid’s drawing of God. I remember resenting how he wouldn’t give me any pain pills until I’d eaten a handful of crackers, but he was kind. His resistance was a kind of care. I felt that. He was looking out for me.

*

Dr. G was the doctor who performed my heart operation. He controlled the catheters from a remote computer. It looked like a spaceship flight cabin. He had a nimble voice and lanky arms and bushy white hair. I liked him. He was a straight talker. He came into my hospital room the day after my operation and explained why the procedure hadn’t worked: they’d burned and burned, but they hadn’t burned the right patch. They’d even cut through my arterial wall to keep looking. But then they’d stopped. Ablating more tissue risked dismantling my circuitry entirely.

Dr. G said I could get the procedure again. I could authorize them to ablate more aggressively. The risk was that I’d come out of surgery with a pacemaker. He was very calm when he said this. He pointed at my chest: “On someone thin,” he said, “you’d be able to see the outlines of the box quite clearly.”

I pictured waking up from general anesthesia to find a metal box above my ribs. I remember being struck by how the doctor had anticipated a question about the pacemaker I hadn’t yet discovered in myself: how easily would I be able to forget it was there? I remember feeling grateful for the calmness in his voice and not offended by it. It didn’t register as callousness. Why? Maybe it was just because he was a man. I didn’t need him to be my mother—even for a day—I only needed him to know what he was doing. But I think it was something more.

Instead of identifying with my panic—inhabiting my horror at the prospect of a pacemaker—he was helping me understand that even this, the barnacle of a false heart, would be OK. His calmness didn’t make me feel abandoned, it made me feel secure. It offered assurance rather than empathy, or maybe assurance was evidence of empathy, insofar as he understood that assurance, not identification, was what I needed most.

Empathy is a kind of care but it’s not the only kind of care, and it’s not always enough. I want to think that’s what Dr. G was thinking. I needed to look at him and see the opposite of my fear, not its echo.

*

Every time I met with Dr. M, she began our encounters with a few perfunctory questions about my life—“What are you working on these days?”—and when she left the room to let me dress, I could hear her voice speaking into a tape recorder in the hallway: “Patient is a graduate student in English at Yale. Patient is writing a dissertation on addiction. Patient spent two years living in Iowa. Patient is working on a collection of essays.” And then, without fail, at the next appointment, fresh from listening to her old tape, she bulleted a few questions: “How were those two years in Iowa? How’s that collection of essays?”

It was a strange intimacy, almost embarrassing, to feel the mechanics of her method so palpably between us: “Engage the patient, record the details, repeat.” I was sketched into CliffsNotes. I hated seeing the puppet strings; they felt unseemly—and without kindness in her voice, the mechanics meant nothing. They pretended we knew each other rather than acknowledging that we didn’t. It’s a tension intrinsic to the surgeon-patient relationship: it’s more invasive than anything but not intimate at all.

Now I can imagine another kind of tape—a more-naked, stuttering tape; a tape that keeps correcting itself, that messes up its dance steps:

Patient is here for an abortion for a surgery to burn the bad parts of her heart for a medication to fix her heart because the surgery failed. Patient is staying in the hospital for one night three nights five nights until we get this medication right. Patient wonders if people can bring her booze in the hospital likes to eat graham crackers from the nurses’ station. Patient cannot be released until she runs on a treadmill and her heart prints a clean rhythm. Patient recently got an abortion but we don’t understand why she wanted us to know that. Patient didn’t think she hurt at first but then she did. Patient failed to use protection and failed to provide an adequate account of why she didn’t use protection. Patient had a lot of feelings. Partner of patient had the feeling she was making up a lot of feelings. Partner of patient is supportive. Partner of patient is spotted in patient’s hospital bed, repeatedly. Partner of patient is caught kissing patient. Partner of patient is charming.

Patient is angry disappointed angry her procedure failed. Patient does not want to be on medication. Patient wants to know if she can drink alcohol on this medication. She wants to know how much. She wants to know if two bottles of wine a night is too many if she can get away with a couple glasses. Patient does not want to get another procedure if it means risking a pacemaker. Patient wants everyone to understand that this surgery is isn’t a big deal; wants everyone to understand she is stupid for crying when everyone else on the ward is sicker than she is; wants everyone to understand her abortion is also about definitely not about the children her ex-boyfriends have had since she broke up with them. Patient wants everyone to understand it wasn’t a choice it would have been easier if it hadn’t been a choice. Patient understands it was her choice to drink while she was pregnant. She understands it was her choice to go to a bar with a little plastic box hanging from her neck, and get so drunk she messed up her heart graph. Patient is patients, plural, which is to say she is multiple—mostly grateful but sometimes surly, sometimes full of self-pity. Patient already understands is trying hard to understand she needs to listen up if she wants to hear how everyone is caring for her.

Three men waited for me in the hospital during my surgery: my brother and my father and Dave. They sat in the lounge making awkward conversation, and then in the cafeteria making awkward conversation, and then—I’m not sure where they sat, actually, or in what order, because I wasn’t there. But I do know that while they were sitting in the cafeteria a doctor came to find them and told them that the surgeons were going to tear through part of my arterial wall—these were the words they used, Dave said, tear through—and try burning some patches of tissue on the other side. At this point, Dave told me later, he went to the hospital chapel and prayed I wouldn’t die. He prayed in the nook made by the propped-open door, because he didn’t want to be seen.

It wasn’t likely I would die. He didn’t know that then. Prayer isn’t about likelihood, anyway, it’s about desire—loving someone enough to get on your knees and ask for her to be saved. When he cried in that chapel, it wasn’t empathy—it was something else. His kneeling wasn’t a way to feel my pain but to request that it end.

I learned to rate Dave on how well he empathized with me. I was constantly poised above an invisible checklist item 31. I wanted him to hurt whenever I hurt, to feel as much as I felt. But it’s exhausting to keep tabs on how much someone is feeling for you. It can make you forget that they feel, too.

I used to believe that hurting would make you more alive to the hurting of others. I used to believe in feeling bad because somebody else did. Now I’m not so sure of either. I know that being in the hospital made me selfish. Getting surgeries made me think mainly about whether I’d have to get another one. When bad things happened to other people, I imagined them happening to me. I didn’t know if this was empathy or theft.

For example: one September, my brother woke up in a hotel room in Sweden and couldn’t move half his face. He was diagnosed with something called Bell’s palsy. No one really understands why it happens or how to make it better. The doctors gave him a steroid called prednisone that made him sick. He threw up most days around twilight. He sent us a photo. It was grainy. He looked lonely. His face slumped. His pupil glistened in the flash, bright with the gel he had to put on his eye to keep it from drying out. He couldn’t blink.

I found myself obsessed with his condition. I tried to imagine what it was like to move through the world with an unfamiliar face. I thought about what it would be like to wake up in the morning, in the groggy space where you’ve managed to forget things, to forget your whole life, and then snapping to, realizing: “Yes, this is how things are.” Checking the mirror: still there. I tried to imagine how you’d feel a little crushed, each time, coming out of dreams to another day of being awake with a face not quite your own.

I spent large portions of each day—pointless, fruitless spans of time—imagining how I would feel if my face was paralyzed, too. I stole my brother’s trauma and projected it onto myself like a magic-lantern pattern of light. I obsessed, and told myself this obsession was empathy. But it wasn’t, quite. It was more like inpathy. I wasn’t expatriating myself into another life so much as importing its problems into my own.

*

Dave doesn’t believe in feeling bad just because someone else does. This isn’t his notion of support. He believes in listening, and asking questions, and steering clear of assumptions. He thinks imagining someone else’s pain with too much surety can be as damaging as failing to imagine it. He believes in humility. He believes in staying strong enough to stick around. He stayed with me in the hospital, five nights in those crisp white beds, and he lay down with my monitor wires, colored strands carrying the electrical signature of my heart to a small box I held in my hands. I remember lying tangled with him, how much it meant—that he was willing to lie down in the mess of wires, to stay there with me.

*

In order to help the med students empathize better with us, we have to empathize with them. I try to think about what makes them fall short of what they’re asked to do—what nervousness or squeamishness or callousness—and how to speak to their sore spots without bruising them: the one so stiff he shook my hand like we’d just made a business deal; the chipper one so eager to befriend me she hadn’t washed her hands at all.

One day we have a sheet cake delivered for my supervisor’s birthday—dry white cake with ripples of strawberry jelly between its layers—and we sit around our conference table eating her cake with plastic forks while she doesn’t eat anything at all. She tells us what kind of syntax we should use when we tell the students about bettering their empathy. We’re supposed to use the “When you… I felt” frame. When you forgot to wash your hands, I felt protective of my body. When you told me eleven wasn’t on the pain scale, I felt dismissed. For the good parts also: When you asked me questions about Will, I felt like you really cared about my loss.

A 1983 study titled “The Structure of Empathy” found a correlation between empathy and four major personality clusters: sensitivity, nonconformity, even-temperedness, and social self-confidence. I like the word structure. It suggests empathy is an edifice we build like a home or office—with architecture and design, scaffolding and electricity. The Chinese character for listen is built of many parts: the characters for ear and eye, the horizontal line that signifies undivided attention, the swoop and teardrops of heart.

Rating high for the study’s “sensitivity” cluster feels intuitive. It means agreeing with statements like “I have at one time or another tried my hand at writing poetry,” or “I have seen some things so sad they almost made me feel like crying,” and disagreeing with statements like “I really don’t care whether people like me or dislike me.” This last one seems to suggest that empathy might be, at root, a barter, a bid for others’ affection: I care about your pain is another way to say I care if you like me. We care in order to be cared for. We care because we are porous. The feelings of others matter, they are like matter: they carry weight, exert gravitational pull.

It’s the last cluster, social self-confidence, that I don’t understand as well. I’ve always treasured empathy as the particular privilege of the invisible, the observers who are shy precisely because they sense so much—because it is overwhelming to say even a single word when you’re sensitive to every last flicker of nuance in the room. “The relationship between social self-confidence and empathy is the most difficult to understand,” the study admits. But its explanation makes sense: social confidence is a prerequisite but not a guarantee; it can “give a person the courage to enter the interpersonal world and practice empathetic skills.” We should empathize from courage, is the point—and it makes me think about how much of my empathy comes from fear. I’m afraid other people’s problems will happen to me, or else I’m afraid other people will stop loving me if I don’t adopt their problems as my own.

Jean Decety, a psychologist at the University of Chicago, uses fMRI scans to measure what happens when someone’s brain responds to another person’s pain. He shows test subjects images of painful situations (hand caught in scissors, foot under door) and compares these scans to what a brain looks like when its body is actually in pain. Decety has found that imagining the pain of others activates the same three areas (prefrontal cortex, anterior insula, anterior cingulate cortex) activated in the experience of pain itself. I feel heartened by that correspondence. But I also wonder what it’s good for.

During the months of my brother’s Bell’s palsy, whenever I woke up in the morning and checked my face for a fallen cheek, a drooping eye, a collapsed smile, I wasn’t ministering to anyone. I wasn’t feeling toward my brother so much as I was feeling toward a version of myself—a self that didn’t exist but theoretically shared his misfortune.

I wonder if my empathy has always been this, in every case: just a bout of hypothetical self-pity projected onto someone else. Is this ultimately just solipsism? Adam Smith confesses in his Theory of Moral Sentiments: “When we see a stroke aimed and just ready to fall upon the leg or arm of another person, we naturally shrink and draw back our own leg or our own arm.”

We care about ourselves. Of course we do. Maybe some good comes from it. If I imagine myself fiercely into my brother’s pain, I get some sense, perhaps, of what he might want or need, because I think, I would want this. I would need this. But it also seems like a fragile pretext, turning his misfortunes into an opportunity to indulge pet fears of my own devising.

I wonder which parts of my brain are lighting up when the med students ask me: “How does that make you feel?” Or which parts of their brains are glowing when I say, “The pain in my abdomen is a ten.” My condition isn’t real. I know this. They know this. I’m simply going through the motions. They’re simply going through the motions. But motions can be more than rote. They don’t just express feeling; they can give birth to it.

Empathy isn’t just something that happens to us—a meteor shower of synapses firing across the brain—it’s also a choice we make: to pay attention, to extend ourselves. It’s made of exertion, that dowdier cousin of impulse. Sometimes we care for another because we know we should, or because it’s asked for, but this doesn’t make our caring hollow. The act of choosing simply means we’ve committed ourselves to a set of behaviors greater than the sum of our individual inclinations: I will listen to his sadness, even when I’m deep in my own. To say “going through the motions”—this isn’t reduction so much as acknowledgment of the effort—the labor, the motions, the dance—of getting inside another person’s state of heart or mind.

This confession of effort chafes against the notion that empathy should always arise unbidden, that genuine means the same thing as unwilled, that intentionality is the enemy of love. But I believe in intention and I believe in work. I believe in waking up in the middle of the night and packing our bags and leaving our worst selves for our better ones.

LESLIE JAMISON

Ob-Gyn

SP Training Materials (Cont.)

OPENING LINE: You don’t need one. Everyone comes here for the same reason.

PHYSICAL PRESENTATION AND TONE: Wear loose pants. You have been told to wear loose pants. Keep your voice steady and articulate. You are about to spread your legs for a doctor who won’t ever know your name. You know the drill, sort of. Act like you do.

ENCOUNTER DYNAMICS: Answer every question like you’re clarifying a coffee order. Be courteous and nod vigorously. Make sure your heart stays on the other side of the white wall behind you. If the nurse asks you whether you are sure about getting the procedure, say yes without missing a beat. Say yes without a trace of doubt. Don’t mention the way you felt when you first saw the pink cross on the stick—that sudden expansive joy at the possibility of a child, at your own capacity to have one. Don’t mention this single moment of joy, because it might make it seem as if you aren’t completely sure about what you’re about to do. Don’t mention this single moment of joy, because it might hurt. It will feel—more than anything else does—like the measure of what you’re giving up. It maps the edges of your voluntary loss.

Instead, tell the nurse you weren’t using birth control but wasn’t that silly and now you are going to start.

If she asks what forms of birth control you have used in the past, say condoms. Suddenly every guy you’ve ever slept with is in the room with you. Ignore them. Ignore the memory of that first time—all that fumbling, and then pain—while Rod Stewart crooned “Broken Arrow” from a boombox on the dresser. “Who else is gonna bring you a broken arrow? Who else is gonna bring you a bottle of rain?”

Say you used condoms but don’t think about all the times you didn’t—in an Iowan graveyard, in a little car by a dark river—and definitely don’t say why, how the risk made you feel close to those boys, how you courted the incredible gravity of what your bodies could do together.

If the nurse asks about your current partner, you should say, We are very committed, like you are defending yourself against some legal charge. If the nurse is listening closely, she should hear fear nestled like an egg inside your certainty.

If the nurse asks whether you drink, say yes to that, too. Of course you do. Like it’s no big deal. Your lifestyle habits include drinking to excess. You do this even when you know there is a fetus inside you. You do it to forget there is a fetus inside you; or to feel like maybe this is just a movie about a fetus being inside you.

The nurse will eventually ask, How do you feel about getting the procedure? Tell her you feel sad but you know it’s the right choice, because this seems like the right thing to say, even though it’s a lie. You feel mainly numb. You feel numb until your legs are in the stirrups. Then you hurt. Whatever anesthesia comes through the needle in your arm only sedates you. Days later you feel your body cramping in the night—a deep, hot, twisting pain—and you can only lie still and hope it passes, beg for sleep, drink for sleep, resent Dave for sleeping next to you. You can only watch your body bleed like an inscrutable, stubborn object—something harmed and cumbersome and not entirely yours. You leave your body and don’t come back for a month. You come back angry.

You wake up from another round of anesthesia and they tell you all their burning didn’t burn away the part of your heart that was broken. You come back and find you aren’t alone. You weren’t alone when you were cramping through the night and you’re not alone now. Dave spends every night in the hospital. You want to tell him how disgusting your body feels: your unwashed skin and greasy hair. You want him to listen, for hours if necessary, and feel everything exactly as you feel it—your pair of hearts in such synchronized rhythm any monitor would show it; your pair of hearts playing two crippled bunnies doing whatever they can. There is no end to this fantasy of closeness. Who else is gonna bring you a broken arrow? You want him to break with you. You want him to hurt in a womb he doesn’t have; you want him to admit he can’t hurt that way. You want him to know how it feels in every one of your nerve endings: lying prone on the detergent sheets, lifting your shirt for one more cardiac resident, one more stranger, letting him attach his clips to the line of hooks under your breast, letting him print out your heart, once more, to see if its rhythm has calmed.

It all returns to this: you want him close to your damage. You want humility and presumption and whatever lies between, you want that, too. You’re tired of begging for it. You’re tired of grading him on how well he gives it. You want to learn how to stop feeling sorry for yourself. You want to write an essay about the lesson. You throw away the checklist and let him climb into your hospital bed. You let him part the heart wires. You sleep. He sleeps. You wake, pulse feeling for another pulse, and there he is again.

About the Author:

Leslie Jamison’s most recent book, The Recovering, was released in 2014. She’s also written a novel, The Gin Closet, and a collection of essays, The Empathy Exams. Her work has appeared in places including The New York Times Magazine, Harper’s, Oxford American, A Public Space, Virginia Quarterly Review, and The Believer. For several years she was also a columnist for the New York Times Book Review. She lives in Brooklyn, with her family.