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Personal views: The body tells a story

2003; BMJ; Volume: 326; Issue: 7390 Linguagem: Inglês

0959-8138

Paquita de Zulueta,

Empathy and Medical Education

There were two that morning. The first, a young Algerian man, a refugee from Kuwait. It was the eyes I first noticed: the eyes of the traumatised—dead, empty, yet somehow haunted, as if living a perpetual horror. Headache. Pitiless, there all day. His brow furrowed. He described it like a weight on his forehead, crushing him. I asked a question, and then came the story. The beatings to the head, savage, relentless. He was only 18 then. His brothers killed. His body thrown in a heap, like rubbish, among the corpses. For a flash moment, I was there—I could hear the screams, smell the sickening stench, feel the terror. And then back in the haven of my chair. “And have you told anyone your story?” I asked. “No.” “So . . . why now?” He shrugged his shoulders. “Parce que vous etes la,” he said simply. The revelation did not arise from speaking his (second) language; he had been in France for a while after his escape from Kuwait, and described it as a brutalising experience. The second one came in—the same dead eyes. From Iraq. Backache. Again constant, relentless. When I examined him he winced at the slightest touch—all movement was painful. A poor fit with the biomedical model. I asked the same question: “And why do you think you have this?” And the same sickening story emerged: beatings, torture, loss, degradation. I could hear the screams, smell the sickening stench, feel the terror They say that painful memories can become organified, structuralised: neuronal pathways fixing trauma into recurrent circuits of pain. My question released the story, gave meaning to the pain, and bypassed a number of useless investigations. And yet by itself, it was not enough. A number of medical students, during communication skills sessions, while seeking out “the hidden agenda,” have complained in exasperation, “But I asked the question and nothing happened.” (Is communication really only a “skill,” or is it something more intrinsic, a reflection of self?) Perhaps it is not simply asking the question, the revelatory trick, but the timing, the how. Perhaps that is the art. The reply was also revelatory. “Because you are there,” he said. Being there, a simple state, yet so hard to sustain. The silence of empathy drowned by all the noise in our heads, the competing agendas. General practitioners work constantly at the messy hinterland of body and mind—we know that both have to be attended to, validated. Our gaze is not the one described by the French philosopher Michel Foucault, the gaze of Medusa—petrifying, turning the patient into stone, and suffering into several hard pieces of biomedical explanation—always incomplete. No, our gaze dances between two worlds, the inner and the outer, the self and the other, the biomedical and the existential. Doctors bear witness time and time again to people's suffering Doctors bear witness time and time again to people's suffering. Maybe telling a story does relieve suffering. I like to believe that it does. But I also hope that sometimes we can do more than that—we can help people start a new story, as Howard Brody, director of the Center for Ethics and Humanities in the Life Sciences at Michigan State University and author of Stories of Sickness, would endorse. The headache and the backache are now better (not entirely gone of course), but referrals to Arabic speaking counsellors and other therapeutic endeavours have taken place, so I would not presume to take all the credit. But something singular did happen in that encounter—could one quantify it, use it as a performance indicator? The last time the Algerian and I met, his eyes were alive. We laughed together as we compared notes of our 5 year old sons, and their predilection for toy gizmos. That laughter began to tell a new story. There is a way between voice and presence where information flows. In disciplined silence it opens. With wandering talk it closes. (From Only Breath, by Rumi (1207-73))