Empathy Exams

While contemplating compassion

I used to teach in a three year professional midwifery school in Mexico. I taught obstetrics, administration, counseling, and ethics, which meant I would see the same group of students over the years in different classes. Since I didnt do clinical rounds with them, when we’d meet I would always ask how the week had gone, what they had seen in the clinic that stood out for them, or what they had doubts about.

I could feel the tension one day in class, when I posed the usual greeting. Students looked at each other nervously. I said “ Well, what? Anybody want to tell me what happened this week? ” One student mumbled that Rosy, a fellow student, had hit someone in labor, and was in big trouble . The students were mostly under age 21, recruited from small communities around Mexico. Most ( but not all) had completed high school but had little else in terms of educational or emotional preparation. Many had come to the school because they were offered full scholarships. Many barely knew what midwifery was, explaining to me originally they had hoped to become nurses, or vetrinarians but then the recruiter had come to their town and it seemed close enough.

I asked Rosy to tell us what happened, doubting that she would. She was generally sullen and non communicative in class. After a pause she shifted in the heavy wooden chair, stared at her pencil on the huge wooden table we all sat around, she said, without lifting her gaze: “ Well, this idiot was in labor and she just kept yelling and screaming. She wouldnt let me do a tacto ( internal exam) or listen to the baby’s heartbeat . She just kept screaming. She was getting on my nerves. So finally, I slapped her.”

You slapped her? I echoed in disbelief. Well, maybe I punched her, Rosy conceeded . I asked what words, exactly, was the woman screaming.

“ She kept saying she wanted to die. She couldnt go on, the pain was killing her, that she was dying. Obviously she wasnt, or she wouldnt have been able to be yelling and rolling around.” Rosy shook her head in disgust while the rest of us glanced at each other, eyebrows raised. This seemed an important window to teach about empathy and counseling techniques, so I tread carefully.

I asked Rosy to give us more context; Who was this woman? How old was she? What was her story? Was it her first baby? Had something terible happened to her or someone in her family around childbirth?

Rosy shrugged. “Some idiot. Barely sixteen years old. First baby. Dont know her name.” I turned to the class, all eight of us. “Okay everyone, this is a perfect example of why we need to develop empathy. We need to be able to put ourselves in another’s shoes, to understand how they are feeling and why. Lets just explore a bit: what must a person be feeling who is sixteen years old, in heavy labor, and screaming Im dying, I want to die. What would possibly make you want to die in labor?” The students began lifting a hand or a pencil shyly in the air, Fear? Desperation? Pain? they ventured.

Good, I nodded. Lets close our eyes and try to imagine just how incredibly desperate you must be feeling to actually think dying is any kind of option…

Rosy?..I asked softly, can you step into her shoes for a minute here?

Rosy heaved a big sigh. “ Its not going to work, maestra. I would never put on her stupid shoes because Im not that big an idiot!”

Part of me just wanted to skip over to the part where I ask the class other ways they could have helped this 16 year old, but I needed Rosy to understand this first.

“I dont mean “you” in her shoes, I mean try to imagine if “you” werent you, but were her, not her situation, I pressed, though Rosy had her arms folded over her chest and it looked like I may be the next recipient of a punch.

“That jerk reminded me of my kid sister. She’s knocked up with her second baby and she’s only sixteen, like this one. It makes me so mad. My sister could have had a life, a career, like me and my big sister are getting. She knew better. We taught her all about birth control. We are midwives, for Christsake. She knew. And now shes whining and crying all the time about being pregnant. The stupid jerk. Just like this one. So when she went on and on- I couldn’t take it- I hit her.”

For a long time after, I used Rosy’s story of an example of how not having empathy can look, the angry defiance in her when she said; Im not going to step in her shoes because Id never be that stupid”, and the students and I would chuckle and roll our eyes at her insensitivity. Until one day I realized how my own empathy had stopped short of understanding Rosy’s rage. One of the students that semester had heard my example and asked: Why was the student like that? And I reflected:

She came from a small indigenous community in the mountains where choices are few and young women, to this day, are still sometimes traded or sold by thier fathers to pay off debts. The traditional midwives there are older women who are hours, even days away from any medical services, facing life threatening complications with their wits, traditions,and plants. In the elder midwive’s time, it wasnt uncommon for a midwife to slap or berate a woman in labor. Not because they were cruel, but because something had to happen to bring the mother and baby through it alive- it was like tough love to get the baby out when no other options were available. Rosy was frustrated. She and her elder sister had a way out now, by becoming professional midwives. They were active politically, advocating changes in both laws and customs of how to care for the women in their community, and educating them about their bodies and their rights. They wanted to be part of the change, part of what breaks the cycles of hopelessness and abuse that Rosy and her sister were finding themselves still in.

Deepak Chopra once described empathy on a sort of spectrum like this:

Sympathy- you understand what a person is feeling; possibly pity them, as in: I feel sorry for you.

Empathy- You feel what a person is feeling. as in: I feel you.

Compassion- You may or may not understand and feel what a person is feeling, but you are willing to be there with them. Compassion is an emotional response to empathy which awakens the desire to help, to relieve suffering in general and in specific. Compassion says: I see you, and I honor and seek our mutual healing.

That day long ago in class with Rosy, I had compassion for the young girl in labor,but I did not extend this to Rosy. I judged her as cruel, when really she was overly identifying with her own life situation, feeling the feels too personally as though the young woman were her own sister. I did not offer her any understanding.

This all happened many years ago. Later, being an empath became a thing, often conflated with being a highly sensitive individual, which, on social media, became almost a badge of lofty suffering, how much one felt every nuance of whats wrong in the world, how much it hurt , creating a narrative of akin to victimhood and martyrdom and a host of workshops and remedies to ease the affliction. Like Rosy, I felt mostly annoyed rather than softened by this.

Not because I dont believe in the phenomenon of highly sensitive individuals. Rather, I think by nature we are all deeply empathetic , that it is a survival mechanism we share with all other creatures yet in humans is so often shut down. We are all biologically set up from birth to deploy our mirror neurons that detect how others around us are feeling, and to learn and modify our feelings accordingly. To survive. Other mammals, insects, even plants, also have these feeling detectors to indicate if an approaching animal or person means them harm or help, whether it is safe to interact or to flee. Like Rosy, we may become caught in our own personal engagement of suffering and our response to it. In modern times, the voices, the criticisms, the idealisms, the social exigencies, are so many and so loud we have to filter out so much just to get through the day. We tend to numb out. When we recognize and awaken the desire to not only help ourselves but agree to be present with others in thier suffering in order to help, not judge them, we move towards what the Buddhists refer to as the way of the Boddisattva, the Compassionate ones. Rather than caring too much, or only caring selectivly, compassion asks us to acknowledge on a bigger scale, that everyone wants to live, everthing wants to grow and express itself in safety and feel they have fulfilled their purpose. Compassion allows that this will be an imperfect world, and we can choose to see it from as many angles as we are able with a modicum of empathy for each being. Compassion says not “can I stand in your shoes” but “ perhaps we can slip them off for a while”.

There is a collection of short stories by Leslie Jamison called “The Empathy Exams”. The title refers to one of the stories in which a medical student is doing a role play exercise in order to measure thier empathy responses in various medical situations. Since the 1980s, medical school admissions tests include a segment that measures one’s emotional quotient ( EQ) and also helps to clarify the difference between emotional empathy and cognitive empathy. Emotional empathy, the medical schools agree, is not objective and thus not productive for medical personelle. Cognitive empathy emphasizes one main element, which is good listening; and objective acknowledgment of another’s feelings. I suppose its a logical segue to why AI makes some of us uneasy. Maybe empathy, however personal or misguided, is still the compass that directs us via first feeling our feelings and then steers us towards compassionate reasoning. AI may have the cognitive ability to understand people in pain, but not the irrational ways we interpret things in our lives. It will never have the feeling place of how uncomfortable one’s shoes are or why .

Back to Rosy. What if this whole empathy/compassion thing depends on who is telling the story? In other places and times, the midwife who slapped a birthing woman induced a rush of fear based adrenaline that may have rallied a woman in trouble to rapidly push a struggling baby out, when time was of the essence. Maybe it was secretly an act of compassion when no other plan was available. Maybe not. Maybe it was an act of insensitivity perpetuating obstetric violence passed down through generations. I dont know.

.

Why was it so easy for me to feel empathy for the sixteen year old in labor and yet with Rosy I barely registered her own feelings and circumstances until years later ? What of the young mother Rosy slugged? How come none of the midwifery students in the clinic that day even knew her name? Did Rosy go and apologize later ? Unlikely. Did anyone help her postpartum? What happens to young women after situations like this? Did anyone help Rosy navigate her feelings about her sister?

Once, a couple we knew lost thier sixteen year old daughter in a car crash. The husband was a good freind of my husband, and the wife I only knew peripherally. I had three daughters myself, all under age sixteen, and I felt very deeply for this mother. I could not comprehend the pain, the horror, the deep greif she must be feeling. Or maybe I imagined I could. I dont know. I began sending her a dozen red roses every year on the anniversary of her daughter’s death, with a note saying something like we will never forget her or thinking of you on this day. or sending my love. Initially, she would call me on the telephone and thank me, very formally yet warmly, then hang up. We weren’t really freinds. We didn’t then continue to chat, or meet for coffee. Just that. The flowers. The phone call. One year, I ran into her in a restaurant where both of us were respectivly, a bit tipsy, and we got to talking. She thanked me again for the detail of the roses each year, and suddenly I realized how wrong that had been.

I can’t describe how I knew,but seeing her that day, I did. I said: I need to apologize. I have been sending those roses each year on the day the worst thing happened. I should have been sending them on the day the best thing happened: her birthday. I dont even know her birthday. Can you tell me when it is?

Sympathy sent the flowers commiserating on the worst day. Perhaps it was compassion that apologized and vowed to mark the joy of her having been in thier lives. I may have sent flowers one more time, on the birthday now, and then dropped the whole thing.

He didnt stay with me long enough for anyone else to have known him, the baby son I lost. He died before he was born, at 6 months gestation. So there were no milestones or shared experiences of him for anyone but my family to even know. It has been almost 26 years since he came and went, but sometimes my daughters will still write me on his birthday/deathday a little note acknowledging he had existed and sending me a hug. I dont know if any of them do this out of pity, or empathy or compassion. I just call it love.