Empathy and the literary imagination.

Once while trying to persuade an adolescent diabetic patient to attend more carefully to her diet and insulin, I heard my voice echo in a strange chamber of my memory. Not the lecture hall with its erudite revelations of glucose and lipid metabolism, hyperglycemic pathologies, and insulin mechanisms of action, but rather the stunted, plaintive, haunted world of J.D. Salinger. Let us first acknowledge that as rapturously complex as diabetes mellitus is to the scientist, the options available to the practitioner for treating this teenager are brutally simple: diet and insulin. The concepts and instructions I imparted were well within her comprehension. Yet it was impossible for me to manage her disease. She was the only one who could do so, a task she sullenly avoided even as her eyes under her matted hair, which she periodically shook into new disorders, avoided mine. As a result, this emotionally windswept young woman was in and out of hypoglycemia and coma and, of course, in and out of the hospital. Her future, I kept trying to remind her, grew dimmer with each lapsewhich, I added encouragingly, could be avoided by the simplest of measures: diet and insulin. I heard myself endlessly repeating: Do you understand me? Tell me what you are thinking. Why are you doing these things to yourself? And then the source of the echo came to me: the scene in The Catcher in the Rye when Holden Caulfield's English teacher in the most kindly, persistent way tries to understand why his young student is failing (1). Tell the truth, boy, his teacher implores. But the teenager is not about to lay truth across the yawning chasm between him and this old man. Rather, he regards his excruciatingly well-intentioned mentor from another world entirely: Well, you can see he felt pretty lousy about flunking me. So I shot the bull for a while. I told him I was a real moron, and all that stuff. I told him how I would have done exactly the same thing if I'd been in his place, and how most people didn't appreciate how tough it is being a teacher. That kind of stuff. The old bull. Meanwhile the dedicated teacher is pursuing the issue with all his heart. How do you feel about all of this boy? I would be very interested to know. Very interested. Holden Caufield never responds to the teacher's entreaties, barely tolerating the sight of that repellent alien objectan old man (I sort of wish he'd cover up his bumpy chest. It wasn't such a beautiful view.) Nor does he even bother to explain his silence. (I didn't feel like going into the whole thing with him. He wouldn't have understood it anyway. It wasn't up his alley at all.) And so, as I sat before this young woman whose eyes listed one way, then another, barely tolerating the sight of me, I realized that I too was experiencing that aching frustration that has no parallelthe adolescent embarked on willful self-destruction. It didn't matter that it was her very life we were talking about. No amount of good will on my part would overcome her stubborn self-imposed deafness to my entreaties. Indeed, nothing could compensate for the crime I had committed, that pre-empted everything else in her hierarchy of values: I was one of theman un-teenager. Totally forget it! How could anything I say be of the slightest interest to her? Indeed, as far as she was concerned, having forfeited my rights by growing old (I was then in my thirties), I was lucky she was deigning to grant me even this much of her time. And yet, though I could do nothing about it, I persuaded myself I could at least feel how she felt, fortified by the imagination of J.D. Salinger. It was not my scientific training or even my medical training that helped me make this emotional connection. Rather it was the experience of literary fiction. But notice I said, imagination. Salinger's skill at imagining the fictional monologue of an alienated teenager had helped me imagine that I had achieved a state of shared feeling. Was this empathy or was it self-delusion? Did it help me heal the young woman? Not really. She continued her difficult ways. In time we both moved on and I lost track of her. So then, what good is empathy? Why seek it? Just to help us overcome [i]solation, long hours of service, chronic lack of sleep, sadness at prolonged human tragedies, and depression at futile and often incomprehensible therapeutic maneuvers . (2)? If that's all empathy is good for, then kindly companionship, soothing drugs, longer hours of sleep, and more frequent vacations would do as well. Do the advocates of empathy in medicine not lead us to expect more? Do they not claim that empathy makes us better physicians? The closer we get to the feelings of our patients, goes the argument, the better we can understand them. The better we understand them, the closer we come to discovering the true state of affairs, and the more likely we will be able to diagnose and treat correctly. This is what novels, stories, and other works of art are supposed to help us with. As a physician and writer I both believe and doubt this. More recently, while taking an interval history from a 70-year-old man with progressive congestive heart failure, I did what every good clinician doestried to get things down in precise numbers. I sought exact quantities. Not only weight, pulse, blood pressure, and vital capacity but also measures of activity: How many blocks could he walk, how many stairs could he climb? I inserted these questions as deftly as I could into his charming, meandering discourse on life's occasions, plucking the numbers out of his rambling commentary. A brief passage of words almost slipped by me; indeed I do not recall how long it took me to notice them after they were uttered. Something about apricots. Every year at this time, he was murmuring, he likes to putter in his garden. Lately, he could no longer capture the apricots at the very top of the trees and that's when the words appeared, mildly rueful, with a self-effacing cough and smileThe story of my life. He paused, and it was the pause that allowed me to spot the words in the underbrush of all the others, made me realize how central was this aside. The story of his lifeand the most important measure of his deteriorating healthwas not the stairs he could no longer climb, nor the blocks he could no longer walk. It was the fruits at the tops of trees this modern-day Tantalus could no longer reach. My ballpoint pen circled in a holding pattern over my notes. Where among my numbers could I put this remark, this most revealing utterance, this line of poetry, this statement both specific and profound that went utterly to the heart of his existence? I finally honored it with a line all its own to ensure it would not be overlooked. Patient states: I can no longer reach the apricots at the tops of the trees. The story of my life. It was my bow to Literature. Indeed, pro-empathicists would be pleased to hear that this stirring of empathy diverted me to ask more about his garden, his trees, his apricots. I learned that he produced them by the bushel. What do you do with them all, I asked. His eyes lit up proudly. Make pies for my friends, he said. I used to make dozens of pies. Immediately, though, I felt the impatient flick of Medicine's riding crop, and resumed collecting my numbershow else would I know whether my treatments were helping him? And how many pies can you make now, I heard myself gurgle. My stories often begin when something unsettling occurs, some word, some gesture, some image that remains nettlesome and restless long after the event. An awkward silence, a clumsy half-ashamed and hastily retracted complaint, eyes that avoided minedisturbing signs that I missed something, a meaning, a connection, a vital, now irretrievable secret. Whenever this happens, naturally I try to figure out what went wrong. But if I fail to correct my oversight or make up for my failure, I still have my imagination. My imagination is wonderfully tolerant. It allows me to retract and remake history by infusing into the present my own memories from the past. How did the other person feel when this happened? How is that feeling similar to feelings I have had? What can I do to make up for what happened? What would I have wanted for myself? This process, we are told, is empathy. It is also the workings of the literary imagination. One, we are told, brings us closer to the truth. The other is conspicuously false. What is one to believe? Like many writers I keep a notebook in which I write down snatches of overheard conversations; descriptions of gestures, events, words, and phrases I suddenly fall in love with, moments I observe in the everyday life around me. When I began to do this many years ago I assumed that the notebooks would provide me with a sumptuous smorgasbord for my writing. But I rarely make use of them. Except for an odd note here and there, these observations hardly ever coincide with what I'm making up at the moment. It should have been self-evident, of course, but it wasn't to me: Fiction is not reality. A work of fiction has its own impulse, its own momentum, its own boundaries. In writing my stories I mix things together, pounding and stretching, even twisting off and throwing away parts that don't fit some personal esthetic command. Fiction, that is, the literary imagination, is not about what happened, but about a whole cosmos of happeningwhat might have happened, or could have happened, or if you delve into the psyche of the author, what should have happened. Fiction, unlike science, cannot be validated by experimental confirmation. Like any art form, fiction can be good only if it creates something unique, something no other artist created, whereas the whole point of science is to discover something common, something other scientists would inevitably discover. Mozart did not have to race against other composers to be the first to produce his Requiem. He raced against death. Without him the work would never exist.