The Doctor-Patient Relationship: Illness and Empathy in David Flichtentrei’s La verdad y otras mentiras: historias de hospital 

My name is Sarah Downey. I have a rare advanced-stage cancer; yet, this is not who I am. I am a complex being with fears, intentions, and ambitions. I am a patient because I have to be. As Susan Sontag reminds us, “Illness is the night-side of life, a more onerous citizenship. Everyone who is born holds a dual citizenship.” Patient is a secondary label imposed on us by the inevitability of illness and mortality; however, before, during, and after we are patients, we are an immeasurable medley of life experiences, intense emotions, and intricate relationships.

A 2012 study (“Cardiac angiosarcoma management and outcomes: 20-year single-institution experience”) suggests that the median overall survival rate of Cardiac Angiosarcoma is 19.5 months for patients presenting with locally advanced AS (Hong et al.). It is easy to spend hours fixating on and predicting biological timelines and outcomes. It is much harder to live with and accept the uncertainty that no research study can resolve. If anything, sitting with a set of numbers that suggest I have already lived the majority of my life at twenty-two years should hypothetically horrify me; however, oftentimes, it is more difficult to live with the uncertainty than to feign a sense of superior knowledge on the basis of a set of data. The doctor-patient relationship often rocks on the waves of this uncertainty, where both parties must confront their own internalized fears of uncertainty and mortality and where one’s confrontation of such fears influences the others. My medical oncologist at Dana Farber Cancer Institute in Boston, Massachusetts gained my trust and respect early on into my treatment when I forced him to address the question of my impending death. His white coat could not hide the natural discomfort and fear that we, as humans, face in the midst of such conversations. However, he quickly settled into the conversation and accepted uncertainty:

 
“If you hadn’t gone to the ER when you did, you would have survived a few more weeks” and “Before we had evidence that the first line of chemo was working, I would have given you around three months. Now, I just don’t know.”

 

As a patient, I view the practice of admitting that one does not have all of the answers as a fundamental pillar of the medical practitioner’s relationship with their patient. Through admitting that scientific data is not enough in itself, the practitioner accepts the immutable role that their personhood has in their professional practice and demonstrates this duality to their patient.

 
“La relación doctor-paciente: La enfermedad y la empatía en La verdad y otras mentiras: historias de hospital de Daniel Flichtentrei” (“The Doctor-Patient Relationship: Illness and Empathy in David Flichtentrei’s La verdad y otras mentiras: historias de hospital”) is a reflection of my diverse research pursuits that originated during my sophomore year at Providence College, where I received a grant to study female sexual repression under the Castroist regime in Cuba. This work, that brings “narrative medicine” into the context of the Latin American hospital, exemplifies a convergence of my long-held interests in both medicine and the humanities. Furthermore, it demonstrates one of the many ways I navigate the human experience and struggle to cultivate purpose, connection, and ‘normalcy’ in the face of biological threats. The following paper is not a grand work of merit. It is a mere final paper I wrote in a one-day frenzy for a literary investigation class I enrolled in last fall as part of a Master’s program in Hispanic Literatures and Modern Languages. However, despite its many gaps and shortcomings that beg for my attention, I believe the paper contributes to one of the most crucial aspects of modern medicine. It addresses the need for intentional practices of human connection and empathy, confronting the detachment brought on by a greater focus on scientific human experimentation and unbridled life-extending measures that challenge a patient’s quality of life.

In his collection of personal-professional accounts, Argentine cardiologist Daniel Flichtentrei articulates the controlled yet unpredictable chaos of the hospital setting, establishing a contradiction between the rigidity and scientific certainties of traditional medical education and the naturality and inconsistencies of human life. Flichtentrei chronicles the often concealed aspects of medicine, including his own internal conflicts as a practitioner in the face of the illness and death of his patients. His work encompasses the profundity of interpersonal relationships, demonstrating human depth through focusing on the diverse and complex dynamics between medical personnel and patients. The first of two prologues in his collection integrates classic Latin American literary references into the study and practice of medicine. Argentine neurologist Facundo Manes, author of the book’s initial prologue, cites the renowned Argentine author Jorge Luis Borges, noting: “Yo aconsejaría esta hipótesis: la imprecisión es tolerable o verosímil en la literatura, porque a ella propendemos siempre en la realidad.” (9) The postmodern author’s consideration of literature, not as a tool that searches for mathematical exactitudes, but a force that captures the human experience in all of its ambiguities and contradictions, becomes useful in the distinguishment between the objectivity of the scientific method and the subjective authenticity of “narrative medicine” throughout the work.

In this brief paper, I reflect on the multifaceted nature of the doctor-patient relationship presented in Flichtentrei’s book through the theoretical lens of “narrative medicine” and “narrative competence.” Through an understanding of “narrative medicine,” medical competence is established, defined by Rita Charlton as: “the capacity to recognize, absorb, metabolize, interpret, and be moved by stories of illness” (“What to do with stories: The sciences of narrative medicine”). It is by way of “narrative medicine” and “narrative competence” that I analyze the relationships between medical personnel and patients, biographical descriptions of patients, and Flinchtentrei’s internal conflict, with the objective of demonstrating the psychological and relational dimensions of illness and death within the clinical context. I address the institutional fragmentation and shortcomings in traditional practitioner formation that contribute to gaps in empathetic and holistic care, while also considering the need for self-reflection, relationality, and awareness in medical practice. I propose, within this analysis of literature as a diagnostic tool, that medical professionals read their patients’ narratives just as they read literary works: intensely, analytically, and carefully. In this way, the patient maintains their personhood and dignity in the face of a force that attempts to rob them of this dignity.

Human connection does not have the capacity to heal on the biological level; however, medical treatment does not guarantee healing either. Therefore, when healing is no longer possible, which tools is the doctor left with to care for their patient? The doctor is left with nothing more than their ‘being’ or their ‘self’: the capacity to accept imperfections and loose ends, to value the patient’s narrative and to take their patient by the hand, aiming to maintain the dignity of the person until the end. North American neurosurgeon Paul Kalanithi, the late medical professional and stage four lung cancer patient, described a doctor’s role as a “mortal responsibility,” saying: “Our patients’ lives and identities may be in our hands, yet death always wins.” Despite unfavorable odds, Kalanithi describes this responsibility as one in which the medical professional does not cease to fight for their patient, “believ[ing] in an asymptote toward which [the doctor is] ceaselessly striving” (When Breath Becomes Air 114-115). In his testimonial, La verdad y otras mentiras: historias de hospital, Daniel Flichtentrei assumes this “mortal responsibility” by means of employing medical practice that takes into account the profound duality of the patient as an incarnate being. Flinchtentrei contributes to the ‘narrative competence,’ that Charon establishes within the field of “narrative medicine,” exemplifying the analytic and literary attention of patient narratives and the essentiality of this narrative focus in comprehensive medical care.

 
My exploration of Daniel Flichtentrei’s La verdad y otras mentiras: historias de hospital, as a work of literary merit and a valuable object of study in “narrative medicine,” but brushes the surface of the work that needs to be done toward a more universal “narrative competence”. I, as a scholar and a patient, view this paper as a small foundational piece of my advocacy and research, through which I aim to cultivate and partake in open dialogues between academics, medical professionals, and patients. In the face of my own mortality, I am in pursuit of a future in which quality medical care is synonymous to holistic and personalized attention that maintains and honors the dignity of both the patient and the medical professional. 

 

II. ​The Foundation of Narrative Medicine

From the first pages of his testimonial book, La verdad y otras mentiras: historias de hospital, Flichtentrei emphasizes the psychological and relational dimensions of illness, establishing a connection between the skills needed to analyze literature and to interview a patient. This diagnostic and comprehensive approach, where the patient's narrative informs clinic, research, and education, is referred to as ‘narrative medicine’, where the patient's narrative resembles a literary work with a plot, characters, metaphors, etc.
Building upon an understanding of narrative medicine, ‘narrative competence’ is established, defined by Charon as: "the capacity to recognize, absorb, metabolize, interpret, and be moved by stories of illness." (“What to do with stories: the sciences of narrative medicine”) The development of narrative competence leads to greater empathy and a closer, more human relationship between patient and doctor, working to validate the patient's experiences and promote the doctor's creativity and self-reflection.

The two prologues of Flichtentrei's book introduce his humanist vision, influenced by literature, and how this multifaceted perspective plays a significant role in the practice and interpersonal relationships he vividly portrays in the following pages. The first prologue, written by Argentine neurologist Facundo Manes, begins with a quote from the renowned Argentine author Jorge Luis Borges, stating: “I would advise this hypothesis: imprecision is tolerable or plausible in literature, because we always tend toward it in reality” (9). The postmodern author considers the power of literature not in seeking mathematical exactitudes or an absolute truth, but in capturing the human experience in all its complexity, characterized by ambiguities and contradictions. Borges thus relates human perception and narration of reality to literature, as they too are subjective, dynamic, and imprecise perspectives.

Through multiple references to Borges throughout the prologue, Manes distinguishes the objectivity of the scientific method from the subjective authenticity of narrative medicine. Manes describes: “Just as the scientific discourse has as its premise achieving the unambiguous certainty of what is true and what is not, the artistic one, rather, promotes doubt, ambiguity, multiple meanings” (9). In this way, Manes sets the stage for his colleague Flichtentrei’s evocative short stories, in which Flichtentrei narrates experiences of illness and death, reflecting the importance of giving voice to the multiplicity of the patient's self against the demands of "scientific evidence-based medicine and transparent rationalized treatment programs that progressively eliminate enigmas and uncertainties.” (“Narrative Medicine: What Discourse adds to Listening” by Cabral et. al). Manes criticizes the inability of modern medicine to accept uncertainty, proposing a reading of La verdad y otras mentiras: historias de hospital that recognizes Flichtentrei's humanistic outlook. This perspective is developed "through memories, fears, premonitions," which, according to Borges, are the ways we see and hear the world (17). Argentine author and doctor Francisco Magli, in the book's second prologue, also proposes an active and attentive reading, suggesting that: “Daniel does more than write, he dialogues with the reader, he makes them a participant in the story, he makes them feel like another protagonist” (17). Magli demonstrates the relational and descriptive style of Flichtentrei's writing, setting the stage for us to read the doctor's accounts with attention to human relationships, emotions, and, above all, the duality of the patient's and the doctor's personhood.

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III. Conflict, Dehumanization, and the Physician's 'Self'

In his first story, “Hospital,” Flichtentrei characterizes the hospital environment as a controlled yet unpredictable chaos, establishing a contradiction between the rigidity and scientific certainties of traditional medical training and the naturalness and inconsistencies of human life. He describes the hospital's "night landscape" as "a zoo of fantastic animals barking at the night, Cyborgs, half machine, half human. Things floating in a battlefield atmosphere" (21). In addition to the unknown, which the author alludes to through the description of "fantastic animals," Flichtentrei introduces for the first time the patient's duality and the implied contradiction between the mechanical and the human. The antagonism between the mechanical and the human represents a theme developed deeply throughout the book through intrapersonal and interpersonal conflicts, where the doctor is forced to reformulate what it means to be a physician on his own terms, unlearning the objective coldness instilled during professional training.

In the story “El Sargento Kirk y yo” (“Sergeant Kirk and I”), Flichtentrei not only recounts his first experience with a patient's death during his internship but also the pressure and inhumanity of the superior physician he worked under at the time, revealing the weight of relationships between interns and their superiors on patient care and the future of medical humanity. Flichtentrei addresses the superior physician in the narrative, calling him "Sergeant Kirk" to criticize the abruptness of his teaching style. When a man near death enters the unit, "Sergeant Kirk" leaves Flichtentrei to handle the case alone, knowing it will result in the patient's death. Although Flichtentrei does everything he can to keep the patient alive, the patient ultimately dies under his care. The doctor recalls his superior's words: “Quite good for the first time—you told me—although it could have been better if you made the effort to revive a living person and not a corpse.” I couldn't answer you” (29).

The student doctor-superior doctor relationship is characterized by the dehumanization of both the doctor and the patient, as it lacks any effort to help the beginner doctor and the critically ill patient, and any empathy toward the death of a human being. The superior's response after the patient's death leaves no room for the intern to feel the natural emotions that accompany witnessing death for the first time, reflecting failures in the superior's own medical training and leaving the intern to process not only his own feelings but also those of the patient's wife. Flichtentrei breaks with the sterile norms of traditional medical training when he embraces the wife, consoling her while trying to console himself. The wife expresses: “Thank you for staying with me”...“And now what?” And that question stays with me to this day. Sometimes I think there is no question more transcendent. Facing the finality of death, what now? But you didn't ask those kinds of questions” (30). This final question reflects the ambiguity of illness and death that is not taught in any textbook, drawing attention to the superior doctor's failures in interpersonal relationships and how the superiors' own deficiencies influence the professional experiences of the interns.

However, the trust Flichtentrei fosters with the deceased patient's wife reveals the essential nature of the doctor's 'self' in practice. In her critical work, “Giving Pain a Voice: Narrative Medicine and the Doctor-Patient Relationship,” Mary T. Shannon concludes: “The self is the physician’s most important therapeutic tool, for the healing that comes from sitting by a patient, leaning forward and listening fully without interruption or ready judgment, often goes beyond any cure.” (6) This “self” of the doctor also forms an essential aspect of his relationships with the patient's family, as the humanity of a hug and a listening ear represents a dedication to medical care even after all measures to save the patient have been exhausted. The doctor's self navigates the deep terrain of human emotion better than any ship of didactic knowledge.

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IV. Institutional Failures and Patient Autonomy

Dehumanization and the denial of the mind-body dualism are side effects not only of indifferent superior doctors but also of a policy system responsible for the fractures in the humanity of the medical profession. The deep failures of the health system are increasingly characterized by the corporatization of medicine, where medicine is operated by health insurance companies that demand health personnel see a high volume of patients daily. This institutionalized requirement prevents doctors from spending more time listening to their patients' stories, resulting in conflicts between the practice of narrative competence and the systemic structure of healthcare.

While interactions between doctors reveal personal failures in care, Flichtentrei acknowledges failures at the institutional level when he articulates:

Many of the tacit rules governing relationships in the hospital were gestures confirming a hierarchical order and the principle of authority based on the time each person had spent in that place. The novice, by definition, should not know, could not opine, did not have to do anything unless someone enabled them to do so. (71)

In the story, “Cama 460” (“Bed 460”), Flichtentrei outlines a hierarchical system in which interns are at the mercy of their superiors, stripped of the ability to question them, resulting in an atmosphere of excessive control and a power dynamic that impacts patients. Flichtentrei prompts us to formulate the question: If doctors themselves are trained without the power to ask questions and advocate for themselves, how will doctors be able to give their patients the autonomy to make decisions about their own bodies?
However, in “Cama 460,” Flichtentrei narrates the opposition of intern Florencia against the hierarchical order, asking for more hours of teaching experience against the Faculty's norms. Although Florencia manages to get more teaching opportunities, this results in the punishment of having to work duty every Sunday for six months, without supervisors or colleagues. We observe another instance where the power dynamics of the medical system result in disorienting conditions for both interns and patients and their families.

One of these Sunday duties, Florencia is in charge of a patient known as “the boy in bed 460,” where the novice doctor is forced to confront death alongside the patient and his family. Despite the father's pleas to save his son, the young patient with advanced terminal cancer communicates with Florencia through touch and the whisper of speech, saying: “—Please, stop, stop… I’m tired, I don’t want any more… —he told her with a whisper broken by breathing, but with the firmness and determination that, despite everything, he transmitted when speaking” (77). Florencia finds a conflict between the family's wishes and the patient's wishes, reflecting the ambiguities and contradictions she has not learned in the university context.

By describing the patient's manner of speech—a “whisper broken by breathing” that reveals the patient's tiredness, and “firmness and determination” that mark the dignity of his person—Flichtentrei describes the sensory focus of narrative medicine that informs patient care. Florencia responds to him: “—It is necessary that you yourself tell your parents this before making a decision” (79). Her response recognizes the seriousness of end-of-life decisions and takes into account the multifaceted aspects of the patient's life, including the relationship between the patient and his loved ones. By facilitating communication between the son and his parents, Florencia opens the door to a difficult conversation about death that perhaps would not have occurred as calmly without the doctor's facilitation.

Based on the doctor's role in preparing the family for death, Flichtentrei demonstrates that the doctor's role is not only to save the body but to care for the being, posing a bioethical dilemma. After the patient's death, the patient's narrative does not end but lives on in the young man's relatives, reflecting the doctor's responsibility to care for both the patient and their family. The young man's father approaches Florencia, saying: “—. Ariel is finally resting in peace. Thank you very much for everything you did, doctor. —The man caressed her black hair and Florencia felt it was absurd for him to be consoling her” (82). The exchange between the doctor and the father, characterized by physical contact and both internalized and visible emotion, represents the duality of the people who form the patient care team, making visible the human connection rooted in shared loss. While the doctor feels the patient's loss differently from the family, the consolation the father gives the doctor, who is the same age as his recently deceased son, reveals a humanism and a level of holistic and mutual care that medical technology is incapable of achieving.

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V. Self-Reflection and Mutual Impact

The doctor is not only affected by the patient's death itself but also by her own experiences and identity as they relate to death and illness. The doctor and the patient are the same age. Florencia, upon touching Ariel, thinks: “‘It could be me…it is me’” (77). The relationality Florencia establishes with the patient's narrative challenges the division between body and being, demanded by the medical institution to promote bodily care based on efficiency and capital.

Urday-Fernandez and Cuba-Fuentes, in their critical article “Medicina narrativa” (“Narrative Medicine”), urge doctors not only to value the importance of narrative in medicine to "understand the patient in his condition as a text… of an open and multivocal reality," but also to self-reflect in order to improve their professional practice. Both authors state: “Reflective professionals can identify and interpret their own emotional responses to patients, they can make sense of their own life journeys” (111). In the context of patient Ariel, Florencia recognizes the weight of the patient's loss for loved ones, but she also recognizes her own pain caused by relating to the patient on a personal level and by understanding the universality of death and illness, which makes her see herself in the patient's place.

While good practice requires this kind of reflection and relationality, it does not imply that compassionate practice in medicine is an easy task; quite the opposite. Urday-Fernandez and Cuba-Fuentes highlight the importance of self-reflection, taking into account the emotional toll that constant and prolonged proximity to illness and death results in. The doctor's self-reflection indirectly benefits the patient, as a doctor with good emotional intellect and self-awareness will be able to serve their patients better. However, in the same way that we reflect on a literary text and relate it to the context of our own history, the doctor must care for themself by reflecting not only on the impact the doctor has on their patients' narratives but also on the impact these narratives have on them.

Flichtentrei demonstrates the mutual impact of the doctor-patient relationship in his story, “La bufanda roja” (“The Red Scarf”), where he meticulously describes his patient Rocío, who has terminal metastatic cancer. He recounts his last conversation with her before her imminent death. The careful manner in which Flichtentrei describes Rocío's character demonstrates a doctor-patient relationship that, over the years, has become a cherished friendship for both. He describes Rocío not only as a woman with cancer but as a teacher, a school principal, and an avid reader who takes great care of her physical appearance despite the side effects of cancer and treatment. The relationship between Flichtentrei and Rocío is based on reading and conversations about the latest books. In this relationship, cancer seems like a secondary topic. Flichtentrei's role as a human being and a friend seems to weigh significantly more than his role as a medical specialist.

However, Flichtentrei's attempts to maintain an easy-going conversation conflict with the reality of Rocío's health status, reflecting the doctor's own discomfort in the face of his beloved patient's inevitable death. When Rocío tries to give him a half-finished scarf, Flichtentrei rejects it, saying he wants it finished. Similarly, when Rocío tells him he will have to read a new book alone, implying she won't be around, the doctor refuses to accept it, saying: “No, Rocío, we'll both read it and then we'll chat” (180). However, Rocío forces Flichtentrei to admit what they both know is going to happen soon. In this way, Rocío inverts the patient's role, imparting realistic knowledge to the doctor and forcing him to confront his own vulnerability. The patient advocates for herself by demanding: “Don’t treat me like a fool. You never did. And, by the way, cut the crap and be happy once and for all. It shows in your eyes. I love you very much” (180). Rocío defends herself against the doctor's delusion while also shifting the doctor's perspective, representing the way effective doctor-patient relationships are not unilateral but involve the emotions of both sides.

At the end of the story, when Flichtentrei tries to "end the episode" by pointing to the next patient, the doctor sees the half-finished scarf Rocío left for him. The red scarf becomes a symbol of the lasting impact this patient has left on Flichtentrei's own narrative, representing the inevitability of death, where even the most advanced treatments and the avoidance/elusion of the topic of death (mortality) are incapable of stopping this universal finality.

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VI. Conclusion: The Mortal Responsibility

Human connection does not have the capacity to heal at a biological level; however, medical treatments do not guarantee healing either. So, when healing is no longer possible, what tools does the doctor have left to care for their patient? Only their self remains: the capacity to accept the unfinished red scarf, to value the patient's narrative, and to take their patient's hand, striving to maintain the person's dignity until the end. Paul Kalanithi, an American neurosurgeon who died of lung cancer in 2015, described the doctor's responsibility as a “mortal responsibility,” saying: “Our patients’ lives and identities may be in our hands, yet death always wins” (114). However, Kalanithi describes this responsibility as one in which the doctor does not stop fighting for their patient, believing in an asymptote they always aspire to reach even though they know the former is not possible.

In his testimonial book La verdad y otras mentiras: historias de hospital, Daniel Flichtentrei fully embraces this “mortal responsibility” by employing a medical practice that takes into account the profound duality of the patient as an embodied being. By describing medicine, not only in professional terms but in intra- and interpersonal terms, Flichtentrei contributes to ‘narrative competence’, which Charon establishes within the field of ‘narrative medicine’, exemplifying the analytical and literary attention to patients' narratives and the essentiality of this narrative approach to comprehensive care.​

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Works cited

Charon, Rita, et al. The Principles and Practice of Narrative Medicine. Oxford University Press, 2017.
de Jesus Cabral, Maria. “« Narrative Medicine : What Discourse Adds to Listening ».” Anglo Saxonica 13 (2017): 169–187. Print.

Flichtentrei, Daniel. La Verdad y Otras Mentiras: Historias de Hospital. 1st ed., Marketing & Research, 2016.

Kalanithi, Paul, y Abraham Verghese. When Breath Becomes Air. Primera edición. New York, Random House, 2016.

Look Hong, Nicole J et al. “Cardiac angiosarcoma management and outcomes: 20-year single-institution experience.” Annals of surgical oncology vol. 19,8 (2012): 2707-15. doi:10.1245/s10434-012-2334-2
Shannon, Mary T. “Giving pain a voice: Narrative medicine and the doctor-patient relationship.” Journal of General Internal Medicine, vol. 26, no. 10, 16 Apr. 2011, pp. 1217–1218, https://doi.org/10.1007/s11606-011-1702-0.

Urday-Fernández, Dayana, y María Sofía Cuba-Fuentes. “Medicina narrativa.” Anales de La Facultad de Medicina, vol. 80, no. 1, 27 Mar. 2019, pp. 109–113, https://doi.org/10.15381/anales.v80i1.15880. ​​​​​​​​​​