Questions Doctors Can't Bill For

Oh, yes there is something intriguing in the medical puzzle, as there is in any good mystery. Collecting clues and dismissing the red herrings, watching the story inexorably unfold. The medical mystery often hinges on arriving at a diagnosis, a genre that has catapulted the television show "House M.D." to fame, that runs in the headlines of Lisa Sanders "Think Like A Doctor" in The New York Times, that made the journalist Berton Roueche wildly successful in his carefully researched epidemiology-noir published throughout the 1960s in The New Yorker. 

Even we doctors, perhaps necessarily so, find time to stop each other in the halls, peddling a tale to a group of bug-eyed residents, "I have a 28 year old male who keeps losing weight," and they lean in saying, "Yes? And then what?" 

But these mysteries, however intriguing, are only the first layer, a facade of the whole story. The mystery moves beyond diagnosis. 

Yes, as a physician, I want to know the details of his cough. But I want to know how he's been dealing with the cold this winter. Whether he lives alone or whether his children come home to see him on Christmas Eve. 

I don't want to know only about the swelling in her hands. But what she has trouble doing because of that swelling. That she can no longer open jars. And what it is that she keeps inside jars - what kind of jams, where exactly she goes, every June, to gather the fruit, and how it is to gather them. 

Yes, I want to know your travel history. But I want to know what you saw before you fell sick. Tell me about this city that you love, where your parents live, the balcony where you sat with your father and looked out at the water. 

Why should we care about the answers to these questions? What information do I extract from the details peripheral to your illness? 

What hides in the periphery is the start of empathy. This is a soft word tossed around in medical school curriculums in danger of being ignored because of its softness, usually practiced by the touching of shoulders and the whispering of buzz phrases like "I know that must be difficult." But those gestures are only a shadow of empathy; they are the customary pleasantries of the profession, the "yes, please" and "no, thank you," of medicine. 

I am of the camp that true empathy cannot be taught but must be cultivated. Empathy is not soft at all but a difficult exercise in communication. On closer examination, empathy is an intense curiosity for the human condition in all forms of its expression, whether that expression is produced as suffering, lassitude, fear, nostalgia, humor, sadness. 

Therefore cultivation of empathy is only achieved when the physician opens himself to this spectrum of emotion, a curriculum that moves beyond the science texts into literature, fine art, music, theater, spirituality, and the insights found in both meaningful relationships and solitude. Only then do we truly understand the clues found in the periphery beyond illness, the life into which illness comes. 

And in that periphery is a far more wondrous mystery than simply solving a case. It is in this periphery where we teach the other what it means to fall ill, to lose faith, to feel stuck, to feel pain, to feel crazy, to grow old, to find grace, to stand up, to forgive yourself, to find peace. And in such an exchange, we open doors, for a moment, into each other's lives. 

The empathic exchange is the basis for placebo, that strange phenomenon only recently under study in Western medicine, but omnipresent throughout the world in healing. There is no substitute for good doctoring, for possessing knowledge or technical skill. And there is no easy way to code for these peripheral questions on those pink billing slips or allocate the appropriate amount of time for them. But without empathy, we are only treating the patient without healing them. Without empathy, the door into the patient remains locked, behind which may hide the crucial answer that brings a patient's illness to light. 

This is an art that I am only beginning to learn, that I've witnessed within all kinds of people, not only doctors, not only in those who carry a long list of degrees after their name or produced a great body of research, but in those who have the patience and interest to truly listen. 

It can be, in some ways, a painful way to practice medicine and live life, to open yourself in this way, but alongside this pain comes an honest understanding of the other's circumstances. 

So yes, these are puzzles, in the way medical cases are. But step back and see what shapes these puzzles make. They take the myriad forms, however mundane or astonishing, of the lives of real people.