Having worked in Russia recently I have become very interested in the wealth of Russian literature about medicine. In one of Chekhov’s medical tales, called ‘A Nervous breakdown’, he describes an intense experience by a young law student with his friends. They observe and feel a situation of depravity, poverty and in particular poverty of spirit with vulnerable people being abused. He is so affected by this unexpectedly heart-rending experience that he empathises very strongly with the situation and has a personal and spiritual crisis, which showed itself in abject physical distress.
Chekhov writes, “It was clear to him that everything that is called human dignity, personal rights, the Divine Image and semblance, were defiled to their very foundations …”. He encouraged his imagination to picture himself as part of the scene he had witnessed, and it moved him to horror. Vassilyev, the hero of our story, writes that he could reflect in his soul the suffering of others. “When he saw tears, he wept; beside a sick man he felt sick himself and moaned; if he saw an act of violence, he felt as though he himself were the victim of it, he was frightened as a child and in his fright ran to help. The pain of others worked on his nerves, excited him, roused to a state of frenzy and so on.” These are the writings of an intense and sensitive young man developing his views of the world and in many ways are similar to those of a medical student progressing through medical training. They see all sorts of desperate situations, and their response and feelings are not necessarily discussed after the event.
We know that medical students tend to lose compassion as they progress through their training. The Dean in the ‘Patch Adams’ film speaks to his new students in American medical school, “We’re going to drill the humanity out of you and make you into something better … We’re gonna make doctors out of you.”
So how is the healthcare professional to accommodate these two extremes of empathy and hardness? Is there a middle road where we can take on the sufferings and tragedy of the patients we serve and yet cope with them personally? Can we continue to set our face again for each new contact? How can healthcare professionals develop the robustness of emotion that allows them to be themselves compassionate, truly understand the feelings and distress of those they see and yet give a dispassionate medical opinion taking all these factors into account?
Returning to Vassilyev. In our story, he describes in detail the depth of his empathy: “His whole attention was turned upon the spiritual agony which was torturing him. It was a dull, vague, undefined anguish akin to misery, to an extreme form of terror, and to despair. He could point to the place where the pain was, in his breast under his heart, but he could not compare it with anything. In the past he had had acute toothache, he had had pleurisy and neuralgia, but all that was insignificant compared with this spiritual anguish. In the presence of that pain life seemed loathsome… But he also knew by experience that this agony would not last more than three days.“
However, when his friends came to visit and saw him in this state of spiritual distress they took him to see a mental doctor. One of his friends, a medical student, almost shed tears, but considering that doctors ought to be cool and composed in every emergency said coldly, “It’s a nervous breakdown. But it’s nothing. Let us go at once to the doctor.”
The medical student recommends the doctor he has chosen to see his friend, “He is a very nice man and thoroughly good at his work. He took his degree in 1882 and he has an immense practice already. He treats students as though he were one himself.”
This is very high praise and the way we as healthcare practitioners would like to be described.
The ensuing encounter is, however, very interesting…
“The stout fair-haired doctor received the friends with politeness and frigid dignity and smiled only on one side of his face.” The doctor addressed many questions to the medical student for twenty minutes – but not to the patient. “Vassilyev was annoyed by the way the doctor kept stroking his knees and talking of the same thing… Half the questions usually asked by doctors of their patients can be left unanswered without the slightest ill effect on the health, but it seemed that if he failed to answer one question all will be lost. As he received the answers the doctor for some reason noted them down on a slip of paper.” The doctor did not want to be interrupted, “‘Don’t interrupt me, you prevent me from concentrating,’ said the doctor.” And he smiled on one side of his face.
Vassilyev becomes quite indignant about the lack of compassion from the doctor and his colleagues for the intense experience that he has just experienced. He says, ‘”It seems marvellous to me that I should have taken my degree in two faculties and you look upon that as a great achievement, that I have written a work which in three years will be thrown aside and forgotten. I am praised up to the skies for this, but because I cannot speak of this situation as unconcernedly as of these chairs, I am being examined by a doctor, I’m called mad. I am pitied!” Vassilyev felt unutterably sorry for himself, burst into tears and sank into a chair. The doctor, with the air of completely comprehending the tears and the despair, feeling himself a specialist in that line, went to the patient and without a word, gave some medicine to drink and then when he was calm, he undressed him and began to investigate the degree of sensibility of the skin, the reflex action of the knees and so on.’
Interestingly, our hero’s distress melted away and his heart grew lighter. He began to feel ashamed and he forced himself to continue his life. The problem was resolved for now, but the patient was not understood nor heard, and seeing the doctor was not a healing process.
As you can probably tell, this story written in Russia by a doctor a hundred years ago, made a great impression on me and it remains for me one of the most emotional descriptions of empathy I have read. It says a lot about understanding vulnerability and understanding darkness, man’s position in the cause of this and his reaction to it.
There is a song I know which describes a healing relationship as “deep cries out to deep” and it is this level of spiritual intelligence that I hope one day to reach. I pray I never lose my empathy and compassion for people, but that I may be given strength to cope with the heaviness of it and that those I contact in my life as a healthcare practitioner may experience this compassion and empathy.
So when I go into work today, I will be smiling on both sides of my face.
Dr Ros Simpson, PRIME Senior Tutor