In a nightmarish story called A Country Doctor, Kafka writes about a night when the titular character has to ride miles away to a patient dying from a terrible wound. The doctor’s horses have suddenly died, and he must borrow someone else’s. A groomsman offers to lend the doctor his own. As the doctor prepares to leave, the groomsman bites the doctor’s maidservant, Rosa, on the face and chases her into the doctor’s house. Time is running out. The doctor, momentarily conflicted, leaves with the horses and is haunted by his choice.
He arrives at his patient’s home and finds the source of illness: a bright red gash on the boy’s side that blooms like a rose, full of tiny white worms that wriggle and spread. The doctor is unable to help. The horses huddle around the windows, poking their heads in and reminding him of what he gave up and of what the groomsman will do to Rosa. He is unable to focus. Bystanders appear, strip the doctor naked, and throw him into the bed with the patient, who openly questions the doctor’s ability to do anything.
Lying next to him, the doctor replies that the patient’s wound is not so bad. The doctor has seen far worse. “My young friend,” he says to his patient, who is probably dying, “your mistake is this: you lack perspective.”
I stand bleary-eyed in the narrow hallway of the ward, heart beating fast from adrenaline and the iced coffee I’d downed before leaving for the overnight shift. There is a constant hum of keyboards and groans from the overcrowded triage area, where patients wait on stretchers to be assigned to rooms as needed. The sliding doors to the ambulance bay open and shut as new patients are wheeled in, sometimes heralded by an overhead announcement if the incoming patient is in severe danger and will need a medical team’s attention as soon as possible.
My partner—another student in my class—and I were told to wear street clothes so no one would mistake us in the chaos of the E.R. for a nurse or doctor.
That was all the instruction we were given before showing up at the hospital. When we arrived, we tried to explain ourselves in our best professional voices—here were our names, here was the information about the course we were taking; maybe we were on some sort of list? The nurse at the reception desk stared at us for a few seconds as if we were selling magazine subscriptions, then waved us through into the ward. There, we were stopped and questioned again by an attending physician who gave us blank nametags. The shift begins, the patients enter, and we watch. I take on small tasks when offered, grateful for the chance to do something. I hold a patient’s hand to keep her arm still while a nurse finds a vein for an IV and fold the sheets of a woman with dementia who’d been left, fallen out of bed, for hours. I clean the dried blood off the faces of two men whose motorcycles sent them flying into a ravine.
They had been drinking. I ask, perhaps too eagerly, if there was anything I could do to help once the two have been stabilized. I talk with them about the music video for Rihanna’s “Pour it Up” as I wipe their foreheads with hydrogen peroxide. They seem nonplussed and somehow sober. I ask, as my hands move around eyes and noses, if I’m hurting them.
Otherwise my partner and I hover in the background, grabbing gloves and gauze and gauges when asked. But mostly, we spend the night behind the glass partition with the emergency room scribes, or flush against a wall, trying to take up as little space as possible, watching the orchestral response of finding and fixing wounds.
There are norms and rituals. A surprising and necessary lack of fanfare for the patient who is brought in already dead. That’s how we’ve been told to think of those who need CPR—already dead. If a patient needs CPR, they have no pulse, are considered clinically dead, and are unlikely to survive. For a caregiver, people with a chance need the attention more now.
The chest compressions must have started soon after the man collapsed, then continued in the ambulance and into the hospital room until the resident directing the code says gently, “If it’s alright with everyone, I’m going to pronounce.” No one protests, and the room empties as quickly as it filled.
I do not look at the man’s face. I have the time, and I’m not forced by necessity to keep tending to patients. But I don’t enter his room. Maybe that would have affected me more. I don’t want to look at him as an object or a curiosity, but from this perspective, that’s how I am looking at them all.
I remember speaking to a classmate who’d observed the weekend before. “It was awesome,” she said the next day. “I saw, like, two cardiac arrests and a femur fracture.”
In speech, patients become their ailments. That’s what we are there to learn about, and in theory fix to the limited degree that we can. As students, this is supposed to be our focus—taking in the information of these pains, naming them, and turning them into solvable problems. And in care that sometimes calls for a degree of detachment, it makes more sense to think like the doctor who kills the worm and sutures the side than the one who fixates on the patient’s lack of perspective. Sitting and stewing with a notebook doesn’t fix fractures.
“Did anyone die?” I had no idea how I’d react if I saw it happen, and I wanted to know. Some part of me thought her answer would prepare me.
“Yeah,” she said. “We lost this kid who OD’d. Fifteen years old. It was really sad.”
After going over this anecdote with my shift partner she told me this detail was wrong—there was no one who died of an overdose that night. “But that’s part of it, and so understandable even if it’s unsettling,” she said. “There are so many of them and it’s so hard to keep it straight.” I keep moving. I ask if there are warm blankets I can fetch, a patient’s cellphone I can set aside for safekeeping, some small detail I can look after.
A few hours in, one of the nurses calls us over and asks us to wait with a patient while she finds rooms for new arrivals. Smiling, she thanks us and says to come get her if anything happens.
Inside there’s a man lying silent on a hospital bed. Sitting next to him is a woman in a gray coat, hands folded on her lap.
It is just the four of us in the room.
We have spent so much of the night trying to stay out of the way as patients are sped through on stretchers and crash teams fill up the rooms that the largeness of our presence now feels strange and unjustified.
“You guys are students,” she says, smiling as if she’s guessed right at charades.
I try to find something to do with my hands. The person in the bed groans now and again, moving his hand to his forehead, feeling over the bruise where he must have landed.
By now it’s around 5:00 in the morning. The woman in the coat will have to be at work in a couple of hours, she says, as if it’s almost time to buy another carton of milk.
Maybe this has happened before. Maybe she wasn’t as calm the first time. The patient groans again. The blanket heaves and billows with the squirming of his legs. I notice for the first time he’s slurring his words.
My next memory is of him sitting bolt upright, wide awake.
“Don’t tell her anything,” he says, his voice just below a yell, “don’t tell her a thing.”
The woman in the coat promises that she won’t.
I find a chair and sit down across from her. We have been taught that getting on the same level as a patient is good practice. She speaks softly and holds my gaze. She talks about her daughter. She will have to drive her to school in the morning on her way to work.
I don’t ask what happened because I have no reason for doing so. I cannot judge what help they need and I can’t provide them with it.
I ask if there’s someone she can call to take her daughter instead, hoping the answer is yes and that the thought just hasn’t occurred to her.
“No, that’s alright,” she says, looking over at her husband—they’re married, aren’t they?—who is now dozing again under the covers. “I’ll take her myself.”
I picture the two men thrown off their motorcycles as I imagine this woman driving her daughter down the highway after a sleepless night. But to have someone drive her daughter she would have to tell someone what happened. Tell them something, which she said she won’t do. At some point the nurse comes back in and we slink back into the hallway, floating from room to room like ghosts, waiting for someone’s pain to teach us something.
After I leave in the morning, I wonder about the man in the bed and the woman in the chair. No one ever told us why they were there. In my mind their story is a sketch—an outline to be filled in. There are many narratives that could fit, and the one I’m drawn to suggests the two are a couple and they’ve been through this before. He’ll be back in the hospital, and she’ll continue to bring him in, and then drive herself to work and their daughter to school on not enough sleep.
I read a lot that year about empathy—it’s a word that continues to come up again and again when it comes to medicine. As psychologist Paul Bloom wrote, it’s a value sometimes seen as beyond justification, an idea that is obvious in its goodness. It has sparked books like Leslie Jamison’s The Empathy Exams. It pops up in think pieces and debates (the Boston Review published a 13-piece spread on Paul Bloom’s claims about empathy in 2014) and is lauded by some as a moral gift, one of the main benefits of literature in the classroom. It’s one of the ideals of narrative medicine, a movement in medical education that encourages caregivers to develop narrative competence and engage with the stories of their patients in order to deliver better care.
As someone predisposed to value story and empathy (or the set of values it’s sometimes used to describe) I’ve found myself playing devil’s advocate after my night of shadowing. I want to interrogate the value in being able to identify with someone else, and that means breaking open a more specific, literal definition of empathy: to share and imagine the feelings of another. To recognize one’s pain in another verges on projecting more than understanding or sharing. To empathize, we recall our own experiences and stories as reference. Past pain teaches us that the stove is hot, the knife is sharp, and rejection stings, and we trust it is the same for everyone.
This raises the question of how to understand someone else’s pain, how to empathize with another without having felt the same thing, or fear of the same emotion. If it’s possible to successfully imagine someone’s pain, the only way seems to be to imagine our pain as theirs.
The outline of this empathy becomes a Rorschach blot.
A Country Doctor is sometimes taught to medical students. I’ve been told this is to try to teach the feeling of vulnerability of being a patient. The same professor who introduced the story to me said most doctors he taught were horrified by the thought of being in the position of Kafka’s doctor. Underneath that initial horror, Kafka’s doctor shows something of this dark side of empathy. The doctor is laid low and put in the same sickbed; he understands on some level how the patient feels. He too is injured. The roseate wound on the boy’s side is a double, a surrogate for Rosa’s rape. The doctor’s own wound bleeds out its edges, coloring his world and obscuring the need and means to help his patient. Too much of a good thing renders him helpless.
As expected, I was of no use to the people I saw that night. But weeks and years after these charades I find myself returning to my own ghosts. To those I’ve loved and continue to love who became ill, went to the hospital, and died or came close to it. To those I’ve loved who drank themselves into harm’s way—sometimes in grand, terrifying, one-off acts (still none that rival flipping off road on a motorcycle), sometimes in ways more chronic, invisible, and insidious. It might be hyperbole to say those experiences left me wounded. And yet these are the ones that braid themselves into these memories and encounters. These are the ones that color my vision, that bend and fill in the outlines, transforming a man in a bed and a woman in a chair into a saga that I may have very well invented. My position that night as a privileged kind of spectator was a safeguard: calling on these memories would not keep me from delivering the kind of care that requires a healthy distance—something empathy’s greatest advocates in medicine repeatedly name as a necessity. I do believe empathy offers good, though I don’t claim to understand it fully. But I do know that, like Kafka’s doctor, my empathy is shaped by what I can draw from my own ghosts.
JOSEPH FRANKEL ’16 changed and omitted identifying information in this piece.