Read an Excerpt
The Empathy Exams
By Leslie Jamison GRAYWOLF PRESS
Copyright © 2014 Leslie Jamison
All rights reserved.
ISBN: 978-1-55597-671-2
CHAPTER 1
THE EMPATHY EXAMS
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 set for 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 protocol. 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 convulse 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 miniature-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 you broke it. He was the one who called 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 exam day, 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-scale-of-ten abdominal pain, 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'm about to 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 ended, the medical student leaves the room, and I fill out an evaluuation 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. 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, MFAs in boots too cool for our paper gowns, local teenagers in hospital ponchos and sweatpants. We help each other strap pillows around our waists. We hand off infant dolls. Little pneumonic 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 means 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 asks 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 fender bender he can't even 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 off 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 mid-western deaths: mauled in tractor or grain-elevator accidents, hit by drunk drivers on the way home from Hy-Vee grocery stores, felled by big weather or Big-Ten tailgates (firearm accident)—or, like my brother Will, by the quieter aftermath of 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, 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 okay. 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 rhyzomatic under the entire territory of my life.
In this sense, empathy isn't just measured 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. 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 way she becomes unconscious during her own expressions of grief and doesn't remember them afterward—all of these might be a way to keep 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; each one a morning I woke up on an empty stomach and slid into a paper gown. One 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 burning.
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 were with 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 her 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 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 harmable, which made it feel more alive, which made me feel more selfish, woozy with cheap Cabernet and spoiling for a fight.
(Continues...)
Excerpted from The Empathy Exams by Leslie Jamison. Copyright © 2014 Leslie Jamison. Excerpted by permission of GRAYWOLF PRESS.
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