Memoir

The human factor

Empathy as a therapeutic tool

I would like to believe in the myth that we grow wiser with age. In a sense my disbelief is wisdom. Those of a middle generation, if charitable or sentimental, subscribe to the wisdom myth, while the callous see us as dispensable objects, like broken furniture or dead flowers. For the young we scarcely exist unless we are unavoidable members of the same family, farting, slobbering, perpetually mislaying teeth and bifocals.

Patrick White, Three Uneasy Pieces (Jonathan Cape, 1988)

IN 2004 I was an intern at a major tertiary hospital. I’d spent six years studying the human body – the miraculous way it worked, the thousands of horrific ways it could fail, the hundreds of invisible microbes that could invade and destroy it. My peers and I were the last cohort to complete what is now referred to as the old medical curriculum – one founded on rote learning, with a heavy emphasis on the basic sciences – before the university switched to a problem-based model.

Perhaps unsurprisingly, when I graduated, I didn’t see patients as people, but as vehicles for diseases. Social histories (the medical fraternity’s collective noun for a patient’s career, relationship status, passions and hobbies) were superfluous tidbits of information, relevant only if they impeded discharge, and then as obstacles to be quickly and cleverly surmounted.

As I emerged from the hospital lift to embark on my first shift as an intern, I did so with the steadfast belief that medicine was an exact science. If I didn’t know the answer, I was not trying hard enough. There was always a solution, and failure to find it was a personal one.

Unlike most of my peers, who were scheduled to begin their first shift in the calm and rational light of day, I began my first rotation in the middle of the night with a skeleton hospital staff. In those days the general medical ward was the hospital equivalent of a bargain bin – a place for miscellaneous patients whose diseases were too common or too undifferentiated or too messy to fit neatly under a specialty unit. Many of these patients were over the age of sixty-five. Quite a few had been transferred from
nursing homes.

This is the context. What follows is a description of an encounter I’ve rarely spoken about, let alone put down in words.

A few weeks into my string of night shifts, a nurse had paged me to insert an intravenous drip into a patient. The message would have read something like: 5E Bed 12 needs new IV for antibiotics. This would have been one of thirty-plus calls to my pager – a mammoth and ever-growing to-do list. Being on night shift, I had no relationship with this patient. I was a stranger. A stranger pulling a curtain wide in the middle of the night.

The patient, whom I’ll call Mrs X – for the purpose of confidentiality but also because I have no memory of her actual name – had been transferred from a nursing home with an infection. Her illness was complicated by delirium – an acute state of confusion, common in the elderly, especially during sepsis.

I’m sure I introduced myself, but I’m also sure that I did so in the bored, perfunctory manner of a supermarket cashier. Mrs X moaned and arched her back. I wheeled the trolley through a gap in the curtains, turned on the lamp. The light revealed that her wrists were shackled to the bed rails. This did not surprise me. I’d spent enough time on the wards to know that this practice, while not common, was certainly not unheard of. I might have even been the one who wrote the order for the restraints on the drug chart, at the request of nursing staff, below paracetamol and temazepam. Shackles, daily, pro re nata – as required.

I swabbed the back of Mrs X’s bony hand with disinfectant. At the touch of the cold liquid she attempted to jerk her hand away. I can’t remember if I cooed or dropped some absurd platitude like ‘it’s okay’ before jabbing her with the needle. All I remember is that the cannula failed, and the blue vein blew up like a miniature balloon beneath her tissue-paper skin. Silently cursing, I pressed a piece of gauze to the wound and searched her atrophied arms for another target. After my second failed attempt, Mrs X was groaning and writhing on the bed.

What would later shock me most about this incident was not Mrs X, or the shackles, or even my behaviour at the bedside, but how I felt in that moment. Because – and I cringe as I write this – in truth, I didn’t feel sadness or compassion or shame. My overwhelming feeling was one of anger – a deep and toxic resentment.

In Quarterly Essay 57: Dear Life: On Caring For The Elderly, Karen Hitchcock writes: ‘Some doctors seem to view old patients as a different species of human, unrelated in any way to their young selves.’ In 2004, I was that doctor. Somehow I’d reached a point in my training where Mrs X was not a fellow human being with needs and dignity and loved ones, but a disembodied task on a ridiculously long to-do list. I may have been familiar with the map of veins on the back of her arthritic hand, but I didn’t know anything else about her. My tired eyes had grown accustomed to skimming across her face, and other faces like hers, without seeing a person at all.

 

AS I WRITE this, we are being drip-fed reports from a Royal Commission into Aged Care Quality and Safety. In the news we are hearing shocking descriptions of maggots in head wounds, patients left for days in soiled clothes, staggering numbers of physical assaults. No doubt many are wondering how such horrific incidents occur, and while it’s the difficult task of the Royal Commission to unpack this extremely complex issue, as I reflect on my time as a junior doctor I can’t help but wonder if one of the first and most crucial events in this tragic chain reaction is the dehumanising of aged-care residents.

During the entire year of my internship I only read one novel – a cult classic called The House of God (Penguin Putnam). First published in 1978, it details the experiences of the author, Samuel Shem (a pseudonym), during his residency at a Boston hospital. At the time it seemed like all my peers were reading it, and all my consultants had already read it. It was, I came to understand, something of an unofficial manual for medical residents. But while intended as satire, my colleagues and I appropriated the book’s vocabulary without a hint of irony. One term we adopted with particular gusto was the acronym gomer, best explained in Shem’s own words:

Gomer is an acronym: Get Out of My Emergency Room – it’s what you say when one’s sent in from the nursing home at three am…

But gomers are not just dear old people… Gomers are human beings who have lost what goes into being human beings. We’re cruel to the gomers, by saving them, and they’re cruel to us, by fighting tooth and nail against our trying to save them. They hurt us, we hurt them.

After six years of training in which I’d learnt to view a human being as both the sum total of hundreds of chemical reactions and a machine of moving mechanical parts, this portrayal of old, immobilised and nonverbal patients as not quite human didn’t seem all that far-fetched. Quite literally stripped of everything that made them individuals – their clothes, make-up, accessories – only to be re-dressed in shapeless white gowns, the patients had become almost indistinguishable from one another. I think my peers and I sensed that if we were to survive in the job, we couldn’t possibly devote time to imagining that every patient we chemically or physically restrained was a real person with a real life. It was them or us, and we chose us.

In 2017, This is Going to Hurt by Adam Kay was published by Picador in the UK to great acclaim. Like The House of God, it chronicles the life of a junior doctor in a tertiary hospital. Early on in the book, Kay writes briefly about the discipline of geriatrics:

Geriatrics is now known as ‘care of the elderly’. Presumably they want it to sound less clinical – less like a place where someone might actually expire, and more like a luxury spa where you can get a mani-pedi while drinking something bright green from a smoothie-maker. Some hospitals have rebranded the speciality ‘care of the older patient’ or ‘care of the older person’ – I would suggest the more appropriate ‘care of the inevitable’.

For junior doctors who, for years, have been sold a career of saving lives, geriatric medicine doesn’t offer bang for buck. In scientific trials, quantity of life rather than quality of life is the outcome used to measure success. Indeed, nursing-home patients find themselves in a tragic catch-22 situation where nothing is being done to improve their quality of life, and that poor quality of life is then used to justify further reductions in interventions.

Of course, such views are not limited to the medical community. Public discourse around aged care and the ageing population is frequently riddled with loaded words like ‘drain’ and ‘burden’. This is having a significant impact on elderly people’s perception of what they’re entitled to from their healthcare system. Karen Hitchcock observes how ‘almost every day an elderly patient will tell me – with shame – that they are a burden or a nuisance, that they’re taking up a hospital bed someone else needs’.

But mine is not a story of despair. Quite the contrary. I want to insist that empathy, once lost, is not lost forever. And I’m delighted to report that while the erosion of mine was an insidious, almost decade-long process, its rediscovery was surprisingly swift.

For me, this watershed moment occurred in the dimly lit room of an inner-city nursing home. I was a general practice registrar and it was my job to do a weekly round of the residents. Every Thursday afternoon I would update the drug charts and check in on any patients the staff had concerns about. On this particular afternoon I was freezing an early-stage skin cancer off one of the resident’s hands. Like Mrs X, the patient was nonverbal and bed bound. But unlike Mrs X, who’d been dwarfed, indeed almost engulfed, by the blank white walls of the hospital, this patient was surrounded by a selection of his own belongings – handmade blankets, old trinkets, faded photos. A couple of these were mounted on a shelf behind his head. One was a framed pharmacy degree. The other was a photo of him in happier times, flanked by the smiling faces of his large, extended family. It was hard to believe the man in the bed was the same bright-eyed pharmacist in the photo, but if I peered hard enough I could just make out the same high-arched cheekbones, the same aquiline nose.

As absurd as it sounds, it suddenly occurred to me that the person in the bed was also a man with accomplishments and a family – a person whose death would be a loss to someone, perhaps everyone who knew him. I’d call it a revelation if it hadn’t been so goddamn obvious. Of course intellectually I’d always known that nursing-home residents were people with pasts and careers and loved ones, but it’s one thing to know something intellectually; it’s an entirely different thing to understand something emotionally. For the first time in my medical career, in that musty nursing-home room, my emotional and intellectual experiences of the elderly aligned.

From that day on I took greater care during my nursing-home visits. Rather than running away once my tasks were finished, I hung around and chatted with the residents. I made the effort to speak to family members over the phone to get a sense of how they felt their loved ones were doing. Within two years, my own grandfather – a stoic and fiercely independent man – suffered a stroke that left him immobile and incontinent. It became easier to see my grandparents in the elderly patients I cared for.

And yet, my greatest revelation was still to come.

 

THERE ARE MANY elderly patients who stick in my memory – the widow with wild hair and a contagious laugh who liked to play pranks on telemarketers; the pensioner with severe emphysema who knitted brightly coloured cardigans for my babies when they were born; the keen golfer and artist whose watercolour landscape I hung proudly in my consulting room. But there is one patient, a widower in his late seventies, who stands out from them all. Because doctors, like teachers – in spite of protests to the contrary – have their favourites.

It was 2009. I was a general-practice trainee. I’d been working in the community, under supervision, for more than twelve months. My fear had abated, but I was still far from comfortable in my new role as the family doctor.

I can’t remember what Eric’s presenting complaint was when he arrived at the clinic that morning – no doubt something trivial, like a blood-pressure check or a prescription – but when we got talking, it became very clear, very quickly, that Eric was severely depressed. Having recently completed a rotation in acute psychiatry at The Alfred Hospital in Melbourne, I launched a risk assessment. But no amount of training could have prepared me for Eric’s candid replies. In a calm and steady voice he relayed his plan to kill himself on the anniversary of his wife’s death in six months time. In spite of his cool demeanour, I knew the disclosure had been extraordinarily distressing for him.

Suicide is often perceived as a problem affecting young people. In fact data from the World Health Organization and the Australian Bureau of Statistics suggest that rates are also alarmingly high in elderly men. For Eric, a proud man whose favourite parting words were ‘she’ll be right’, there was great stigma attached to a mental-health diagnosis. Not surprisingly, he refused to see a psychologist and was deadset against antidepressant medication. What he would agree to were weekly appointments with me, and verbal guarantees that he would not harm himself between our visits. Terrified at the enormity of the responsibility, I sought advice from my supervisor.

General practice is best described as an art rather than a science. Give twenty GPs the same patient and you will get twenty different approaches. I told my supervisor that while my head was saying that Eric might need more intensive care in a hospital setting, my gut was saying that a forced admission would jeopardise the one thing he’d demonstrated responsiveness to thus far – our fragile but constructive rapport. My supervisor agreed. She offered to support me through the process of regular and intense follow-up. She also pointed out that Eric’s plan, with a scheduled date in six months’ time, suggested he might be giving life one last chance to change his mind.

I was surprised when Eric returned a week later, reporting a subtle but undeniable improvement in his mood. This perplexed me. I didn’t feel like I’d done anything particularly helpful during our last meeting. I hadn’t cut out a cancer or given him lifesaving antibiotics. From memory, much of my energy during that consultation had actually been devoted to suppressing my own anxiety about his shocking plan. But I was junior then – I had not yet come to appreciate the power of turning away from the computer, making eye contact, listening with kindness.

I continued to meet Eric weekly for my remaining time at the clinic. There were highs and lows but the trend, mercifully, was up. As the anniversary date grew closer, he lost passion for his plan. And as the cloud of his depression dispersed, he saw things he hadn’t seen before, like the concern in his daughter’s eyes during her weekly visits to the family home, and the tenderness in his favourite granddaughter’s voice when she made a spontaneous and unexpected phone call. He grew to understand that when he finally died, he would, in fact, be missed – and not just missed but truly grieved for, in the same way he had grieved for his late and beloved wife.

Ever self-deprecating and deferential, Eric liked to credit me with his recovery, but the truth is ours was a shared revelation. Because as I watched Eric rediscover his love for life and his purpose for living, he taught me life’s most essential lesson: the fundamental importance of human connection, of feeling loved unconditionally.

No doubt this is why the moment with Mrs X in the hospital still haunts me so. Because there’s no getting away from the fact that I, while occupying a position of power and privilege, neglected to show a fellow human being – a person who was alone and distressed on a medical ward in her final weeks – some kindness. I failed her, and in doing so I failed myself.

I’ve spent my medical career trying to make up for the lack of compassion I felt for patients during my internship year. If there’s any silver lining, perhaps it can be found in the writing of this cautionary tale.

It takes mental energy to imagine oneself in another person’s position, but I would argue that it’s time well spent – an investment if you will – if we’re going to avoid incidents like those currently being chronicled by the Royal Commission into Aged Care. Nobody deserves to be treated like ‘broken furniture and dead flowers’, no matter how overworked or sleep deprived we may be. Yes, such conditions need to be addressed, and it’s up to all of us to call them out, but we cannot and must not lose our compassion in the process. And not just for the benefit of the elderly person in front of us, but for the benefit of ourselves. Because it’s a terrifying thing to look at a fellow human and feel nothing – no connection, no empathy, no recognition of a shared humanity.

Eric taught me that true meaning can be found in the smallest of gestures – an unexpected phone call, a smile, a leisurely cup of tea. Such acts can seem trivial in a world obsessed with material success, but they just may be the difference between a life forsaken and a life deemed worth living.

Some names and details have been changed.

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