The Difference Between Pity and Empathy

This is an essay I published in the Los Angeles Times on March 28, 2005. I remember being overwhelmed by the hundreds of emails from people around the country who were powerfully moved by it, and the memories of their loved ones it evoked. I wrote the essay about 10 years after I took care of this patient when I had finished my training and was in private practice. I remember feeling at the time that it was ironic that I was getting more meaningful connection with people from writing about patients than from providing care for them in the confines of our modern healthcare system.

Being a medical student is tough for many reasons, but mainly because you always feel clueless and useless while trying to prove your worth to everyone around you. Reading this story now, all these years later, I’m struck by the fact that along with that cluelessness was a newness of experience that made everything so vivid and meaningful. And along with that uselessness came the freedom and time to spend with patients doing “nothing” that I’d never have again. I think it was worth it.

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He was the first patient I cared for in medical school. At first glance, he looked pretty good. He sat on the covers of his hospital bed in a button-down shirt that was tucked neatly into creased khakis. His shoes gleamed from polish. 

But I quickly saw that the fastidious clothes were a disguise. His skin looked like old china: yellowed and glassy with a damp patina. His dyed blond hair was matted down in a wide part and his precisely trimmed mustache was covered by a fine mist of sweat. 

He had AIDS. Pneumocystis pneumonia clogged his lungs, cytomegalovirus retinitis clouded his eyes and Kaposi's sarcoma ulcerated his esophagus. He was dying an agonizing death. And he was only 30. I stumbled through my painfully thorough evaluation, pulling reflex hammers, flashlights and tuning forks out of my lab coat like a bad magician. 

I did a rectal exam to check for internal bleeding and gamely tried to explain the mechanics of the exam -- only to be met with a statement that he was gay, followed by a humorless joke about his sexual practices. 

Despite my inexperience, I knew that men often deflect their embarrassment at this exam with locker room humor. But his comment still caught me off guard. I awkwardly laughed at the joke and pulled gloves onto my shaking hands. 

Apparently this wasn't the response he was looking for, because as he dropped his pants he continued, this time with a comment about romance. 

He wasn't simply deflecting his embarrassment; he was throwing it back at me with as much resentment as he could muster. 

My first instinct was to retaliate. To say "Hey, pal, don't blame me. You got yourself in this mess. I'm just trying to help." Instead, I finished the exam in silence and left the room as quickly as possible. 

We were both so furious and afraid; he at being eaten away by this horrible disease, and me at feeling like an inadequate idiot because I had no idea how to help him. 

I went to visit him the next day, determined that things would go better. His room revealed no signs of a life beyond its walls: not a single get-well card tacked to the bulletin board, not one little fold-up tent card on the bedside table notifying him of a missed call from a friend. I had never seen someone so alone. 

I asked him what he did for a living. He told me that he worked in computer networking and was hoping to finish his design for a new audiovisual coupling technique before he died. 

He said it was his last chance to make a mark on the world. This seemed to sadden him more than his physical suffering; it wasn't that his life was ending, but that he would have so little to show for it. 

I asked him about his family. Unlike many gay AIDS victims, his parents were tolerant of his lifestyle and even offered to care for him during his illness. I offered to call them but he adamantly refused. 

He said it would be too hard on his mom. 

The familiarity with which he said this caught my breath. The outside world flooded into the room, and I suddenly saw this man not as a patient, but as someone's son. I finally got a taste of the anguish he was trying to make me feel the day before. His condition worsened precipitously the next night and I finally convinced him to let me call his parents. They said they would leave as soon as they could but they lived in New Jersey, nine hours away. 

He died during rounds the following morning. As his pupils dilated and his breathing became a rhythmic, mechanical gasp, his nurse reached out and held his hand. I grabbed his other wrist as if to check for a pulse, hoping the gesture appeared sufficiently clinical to my attending physician. 

An hour later, his parents called from a rest stop in Pennsylvania about four hours away. I thought his mother would be more upset, but I got the feeling that she expected things to end this way. He had underestimated her; she had been strong enough to respect his need to spare her suffering, even though she knew it meant that she might never see him again. 

He had underestimated himself too. He never saw the doctor that he helped me become, but every patient I have cared for since has benefited from the lesson he taught me. 

I had leaned into our conversations with all the sympathetic voice inflections and reassuring touches I could muster from my doctor-patient relationship class. But I had looked at him with pity, not empathy, and he saw right through me. 

It wasn't until he made me see him as a person that I was able to effectively treat him as my patient. The mark he made on the world extended further than he'd imagined.