Empathy.

Can you tell me, Socrates, whether virtue is acquired by teaching or by practice; or if neither by teaching nor practice, then whether it comes to man by nature, or in what other way?(1)

I had barely finished telling her that her colon cancer was incurable when she reached out suddenly to snatch my hand. Clasping it tightly, this stern woman begged me, “I do not want to die.” Her voice broke between sobs.

Taking care of people with Stage IV cancer was like being forced to watch the same bad movie over and over again, only with different sets of people every time. You knew the ending—but you were not supposed to ruin the experience for them. After 5 years of doing this kind of work, I still could not think of a better way to describe it.

I squeezed her hand and turned my gaze away. I held myself back from saying that it was going to be okay, because it was not. I could not tell her what I already knew from the many other patients I had cared for before her. It would only break her spirit so close to the beginning of her final journey. Whether she wanted to or not, this was a journey she had to make. But one that she would not have to make alone.

Staring at the table, I hesitated at first then started: “Give the medicines a chance, the rest we leave up to God. There will be good days and bad days, let us pray together for more good days than bad.”

I had the privilege of taking care of her for 6 months. They were difficult months that consisted of shuttling to and from the hospital every 2 weeks. Her chemotherapy sessions lasted 2 straight days, at times longer.

There were good days and there were bad days.

After 3 cycles her cancer got worse.

We talked about changing her treatment to which she agreed, albeit reluctantly.

All life is finite. Its shelf-life is programed in our DNA. It is a matter of fact. But the fact of the matter is that people do not want to be reminded of it, especially by a stranger. Therefore, dealing with death is never easy to do. Some consider it a skill—callous though it may seem—that is refined with time and practice.

Disclosure, treatment, death. It all becomes familiar with time, like a somber ritual that gets repeated with every new cancer patient who comes to the clinic. While the process of disclosure always follows the same formula, the results tend to vary. Sometimes there are tears, often there is sadness, at times anger or unbelief. I will never forget the woman, who upon being told that she had breast cancer, stared blankly at me for a full minute as her face turned pale, got up from her chair, and left my clinic without uttering a word, never to return.

Her disease was not incurable; but it was the prospect of dying that led her to bolt straight out of my clinic. Cancer casts light on human mortality better than any other disease. It is cold, calculating, unsympathetic—ruthless in every way. And its victims always pay a high price, whether they live, or they die.

When caring for those living with cancer, and especially for those dying of it, the necessary element is always truth, while the enabling disposition is empathy. The latter comes from the Greek empatheia (“passion”) (2). While the root is classical, it is to the German Einfühlung (“feeling into”) that the current use of the word traces its origins (3).

An oncologist, if he is to be a good one, needs to possess this one trait in abundance. Empathy gives birth to compassion, and compassion is the tool that empowers one to comfort (4). And comfort, as the aphorism rightly claims: “to cure sometimes, to relieve often, and to comfort always” is the goal of every clinical encounter (5).

The physician needs to be aware that his task is to alleviate pain. By this it is meant not just the patient’s pain but also the pain of those who bear the burden of the patient’s illness with her. Everyone wants to feel cared for. This applies not only to the patient but also to her family because illness inflicts suffering upon all the lives it touches, directly and indirectly. The spirit of this is perhaps best expressed by Maya Angelou:This awareness of the need to ease the suffering of others at first seems innate, no different from other inborn traits. One is therefore led to assume that individuals who are naturally empathetic have the proclivity for the vocation of medicine. Doctors must have empathy in abundance. If so, where does the image of the distant, jargon-speaking, authority-in-a-white coat come from?

I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.

Much like other precious reserves empathy is a finite resource. Studies have shown that empathy declines during medical training, likely due to “down-regulation” arising from the need to protect oneself from emotional trauma and the physician burnout that it eventually produces (4,6). However, some have questioned the epistemology of the burnout-empathy link and propose that instead of leading to burn-out, empathy protects against it by giving sense to the medical practice and generating greater professional satisfaction (7). Nevertheless, it remains that caring for those who are gravely ill can tax the emotions to the breaking-point. As such, it can be argued that apathy is a symptom of a spirit exhausted by so much suffering and burdened by so much death.

This is the crux of matter: if empathy can be lost, can it be regained?

Research in neurobiology has changed the perception of empathy from a soft skill to a firm competency rooted in the human brain (4). It seems that this vital human capability can be instructed. The ability to “enter into” the suffering of the other is so important in the practice of medicine that it is in fact one of the first things that is taught in medical school. Training physicians to communicate with patients is central to imparting empathy. The other necessary skill for the physician to learn in relation to empathy is self-regulation. Introspection and mindfulness bring forth self-awareness that recenters the physician’s humanity—allowing him to realize that suffering and death are both parts of the human condition, yes, but these do not define it (6,8).

After giving her the first cycle of her new chemotherapy regimen, I sat beside her bed. There were a few moments of silence before I finally asked: “what’s on your mind?”

“I am grateful for this time you have given me. Thank you,” she said.

I smiled at her. She held out her hand. I reached for it. We sat there in silence.

“Let’s pray for each other,” I said. She smiled as if to agree.

On the ride home that evening I thought to myself, had she given up?

She missed her next 2 scheduled cycles of chemotherapy.

The next time I saw her, she was in the emergency room. On the day that she died.

I still pray for her, as I know that she prays for me.