One of the most helpful parts of a person’s medical history is the catalogue of illnesses that affected their family members. It provides a context for present complaints and worries. It helps the clinician estimate risks. Knowing what troubles befell genetically related individuals provides a lantern in the darkness of diagnostic uncertainty. The family history is also the most cost-effective “genetic testing” we have, still dwarfing the promise of the Human Genome Project that mapped some 25,000 genes.
But the taking of the family history, if you were to let it, can bring you to tears that spill like a salty blot upon an otherwise austere medical chart.
“So… Your mother died at 53 of breast cancer, and your father died at 72 of colon cancer. I’m sorry. That must have been really hard for you. But with this information we should pay particular attention to breast and colon cancer screening, and talk about preventative strategies.”
That’s what the suspension of full empathy while taking a family history allows. A level-headed, composed and somewhat thoughtful response that is mostly appreciated by the patient, who is also suspending joyful and painful memories of the past.
My copy of Bate’s Guide to Physical Examination and History Taking states:
The family history helps you to assess the patient’s risks of developing certain diseases and may also suggest family experiences relevant to the patient’s concerns… Note the age and health, or age and cause of death, of each immediate family member (i.e., parents, siblings, spouse, and children). Data on grandparents or grandchildren may also be useful…
But what if we were to let slip the velvet curtain for moment? What if we let loose the true spirits of the silent actors who once graced the stage?
The suffering of your poor mother, unthinkable, the woman who dreamed you up, whose very womb cherished you into being, whose selfless love and surrender of freedom achieved your present stature as she set you free like a paper boat upon a great stream; her thoughts, prayers, and counsel guiding and protecting you like an unseen wind. That she suffered the indignity, the absurd pain and torture of a slow death from withering cancer… It’s almost too much to bear. That your proud father, a man who, like your mother, had imperfections, but who loved you with fervent hope for your happiness, who tried his best to be a hero for his family, who fought wars and sleeplessness to console your infant cries, and who thought of you every night of your life as he lay his head down upon a pillow to rest, even as a rotting colostomy, obstructed bowels, and incessant pain rendered him ridiculous.
It’s enough to make you cry, every day. There’s an epic poem within each trivial office visit.
To let just the right amount of empathy through in conversation is an art form all of us practice in daily life, sloppily at times, with too much paint, clashing colors, and mistaken strokes that cannot be taken back.
Too much empathy is not good. To lapse into maudlin imaginations of another’s experience can be presumptive, invasive, and uncomfortable. The exposing of vulnerability might be constructive or destructive to health, relationships, and wellbeing. To step too far into another’s shoes can sap the very resourcefulness needed by both parties. Perhaps empathy is best displayed when it acknowledges suffering, with merely one foot in the shoe of another.
But sometimes, even if it’s just a single breath, I allow myself a silent, meditative, and empathetic pause. Great literature, tragedy, and the very bones of our pitifully glorious existence are forever one question, and one perilously considered answer, away.
Driving home for a visit, looking through old photos, sitting with family and old friends who are now ill… I suspect you know how to take a family history, too.
The healthy detachment vs. empathy reminds me of a song…
A billion people died on the news tonight
But not so many cried at the terrible sight
Well mama said
It’s just make believe
You can’t believe everything you see
So baby close your eyes to the lullabies
On the news tonight
Who’s the one to decide that it would be alright
To put the music behind the news tonight
Well mama said
You can’t believe everything you hear
The diegetic world is so unclear
So baby close your ears
On the news tonight
On the news tonight
The unobtrusive tones on the news tonight
And mama said
Mmm
Why don’t the newscasters cry when they read about people who die
At least they could be decent enough to put just a tear in their eyes
Mama said
It’s just make believe
You cant believe everything you see
So baby close your eyes to the lullabies
On the news tonight
Jack Johnson – The News lyrics
What a lovely way of expressing how to thread that needle. Thank you.
I have always – if in retrospect – appreciated the effort of the doctors who have both the empathy and the willpower to control the influence it has on their displayed emotions. When announcing the worst news to my mother – first about her husband’s, our father’s, untimely and sudden death, then three years later about her mother’s departure, our family doctor who was also a friend to us all did it in a very straightforward way, using as few words as possible to convey the message. She was there for us to lean on, she did feel the pain, but she did not show it.
I think you can immerse yourself in the experience of the grieving family without outwardly grieving. After my patient is gone, I see the family has now become my patient, collectively. Most of the good you can do is to remain, to not leave the room after you recount the science and offer some trite, terse phrase about how sorry you are. You’re not there for a condensed version of the grieving process that you can spit out to tell everyone the stages they’re going to go through.
You can look for those who are not handling it well, and try to offer some heloful interaction, let them ventilate, let them sob like they’re not going to stop, and just let them.
Eventually, you can tell when it’s Ok to leave, not because you have something more important to do, but because your presence is no longer needed.
Stalin is reputed to have said that one death is a tragedy, a million deaths, a statistic.
Well said, Greg.
I’ve heard that the impact of anything you say before the word “but” is lost. The statement could be even better if worded this way:
“So… Your mother died at 53 of breast cancer, and your father died at 72 of colon cancer. I’m sorry. That must have been really hard for you. With this information we should pay particular attention to breast and colon cancer screening, and talk about preventative strategies.”
I’ve not a pithy thing to add except “welcome back.”
Until it was recently revealed, I never knew that my grandfather was an orphan. He gifted me with his glaucoma and love of gardening. He also, it turns out, beat his children.
Mom and Pop divorced when I was four, and we, oddly, stayed with Dad. I know little of her.
And so, I have always invented my Family Medical History, choosing lovelier fictions.