Anton Chekhov in the ER
“To whom shall I tell my grief?” sighs Iona Potatov, the main character of Anton Chekhov’s 1886 short story, “Misery.” This question echoes in my head often, particularly during overnight ER shifts when I struggle to make sense of vague patient complaints, stories told in vexing drips and evasive responses.
Iona, a frail, poor, and lonely sleigh driver—a cabman—sits on the box of his horse-drawn sledge, reeling from the death of his son earlier that week. It’s twilight, and big snowflakes whirl around the streetlamps. Chekhov explains, “If a regular snowdrift fell on him it seems as though even then he would not think it necessary to shake it off.”
When Iona raises the subject of his dead son to three separate fares, he finds indifference, insults, and cruelty. “We shall all die,” is one response that chills the bone. He even suffers a thwack on the back of his neck from one passenger intent on rushing them to their destination.
“To whom shall I tell my grief?” is a particularly devastating question when the answer is, “No one.”
The evening crowds that soon fill the streets are heedless of his misery. That he can’t find “among those thousands someone willing to listen to him” tears at his heart.
Eventually, Iona buckles under these harsh and dispiriting experiences and returns to his lodging, a smelly, stuffy flophouse where snoring men fill floors and benches. But his thirst to express his grief remains. At the water-bucket, Iona reaches out one last time to a young cabman, who, instead of listening, covers his head and drifts back to sleep.
But Iona needs to talk about his son’s death “properly, with deliberation.” How his son fell ill. How he suffered. His last words. The trip to the hospital to collect his son’s clothes.
At the end of the story, Iona puts on his coat and visits his mare in the stables. Watching her munch on hay—he hadn’t earned enough that evening to buy her oats—Iona opens his heart.
“Now, suppose you had a little colt, and were mother to that little colt . . . And all at once that same little colt went and died . . . You’d be sorry, wouldn’t you? . . . ”
I reread “Misery” after my last series of overnight ER shifts. I needed to feel the weight of Iona’s loneliness and regain intimacy with his granular need for connection. Most importantly, and most embarrassingly, I needed a reminder that the effort of extending oneself to others from within the clutches of deep despair does not come without pain.
Certain patients were complicated in ways that are difficult to describe. I couldn’t tell whether they were acutely ill or whether their symptoms veiled other needs, such as for a warm bed and relief from the streets, for a reprieve from stressful living situations, or, like Iona, for someone to talk to.
Their narrative threads often resembled our healthcare system as a whole, frayed and unsettling to work with. I felt my questions tinged with frustration and resentment. “Why were they using the ER, and my time, in this way?” I wondered. The waiting room was packed, there were few, if any, beds available in the hospital, and the ambulances kept coming.
This is what led me back to “Misery.”
It’s easy to read and think about Iona’s overwhelming despair through the eyes of our best and most compassionate selves. I’m devastated by this father’s grief for a dead son, a tragedy built onto a life already strained under a range of hardships, including poverty, hunger, old age, loneliness, and poor social support.
Chekhov ends the story: “The little mare munches, listens, and breathes on her master’s hands. Iona is carried away and tells her all about it.” Surely healthcare providers, like myself, can offer the level of comfort and companionship provided by a mare.
The truth is, if I had taken care of Iona during one of those particularly stressful nights, there’s a chance he might have left as profoundly disappointed in my answers as he was in those of his passengers.
Let’s imagine that the triage nurse asks Iona his reason for coming to the ER. I don’t suspect he’d admit to pondering, “To whom shall I tell my grief?” Pride might prevent him from exposing his heartbreak and loneliness in such direct terms. It’s hard to confess to loneliness. This profound social state can be interpreted as a demonizing character flaw, a point of weakness. Something must be wrong with you when everyone else appears to have rich and busy social lives, right?
And yet, according to surveys, over a third of Americans report being lonely. And this news should evoke more than sympathy. Individuals without meaningful social relationships are twice as likely to die. Research demonstrates how loneliness has long-term health consequences.
Nonetheless, reaching out for help can be a source of shame in an age of social media, when identity and social currency are often linked to one’s numbers of Facebook friends or Twitter followers. Sometimes loneliness is tied to real or perceived abandonment, to emotional needs that aren’t being addressed elsewhere, and patients come to the emergency department because they have no other choice.
I think about the young man in his twenties with a superficial burn on his finger for a week, who, on further questioning, revealed he was really in the ER due to a strained living situation with his relatives; the somnolent grandmother with multiple medical problems thought to have had a stroke or infection who was really abusing her opiate pain medications; the mother of three who complained of chest pain but ultimately acknowledged that her real issue was housing; and the homeless intoxicant with his third presentation to the ER in twenty four hours, each time with a different complaint.
Narrative analysis and interpretation are critical to what I do as an emergency physician. Patients often cue deep concerns indirectly, leaving it up to the physician to probe further. And physicians are inclined to take these ambiguous stories whose arrows don’t point towards an identifiable answer and brush them aside, or offer pat reassurances, or solely address biomedical issues. When in doubt, physicians have a tendency to order more tests rather than explore emotional terrain.
I’d like think of myself as an emergency physician who’s sensitive to story, especially the ones told by my patients. Over the course of my career, I’ve learned that negotiating uncertainty, asking the right questions, probing silences, and possessing the requisite confidence to admit to what I don’t know serve as vital clinical skills.
But that locus of attention doesn’t operate on an island, it functions in an emergency system that operates under stress and constraints. In 2013, there were more than 133 million visits to emergency departments in the United States, a 19% increase over the decade, while the number of hospitals providing emergency care declined. A RAND study highlighted how emergency departments are shouldering the acute care burden for uninsured and insured populations, as well as operating as the hub for complex diagnostic work-ups for patients with multiple complicated medical problems, including serving as the key decision-maker for hospital admissions.
During the overnight shifts in question, my brain was so heavy I could feel the gears grind as I tried to think analytically and remain attuned emotionally. The entire night I was running around and yet forever running behind. Whether it was another new patient, another test result to check on, another family to talk to, or another consultant to speak with. Every gasp at forward progress met with interruptions to change task. And we can’t forget documentation. One study observed that emergency physicians spend roughly twice as much time with the electronic health records as with flesh and blood patients.
The mare breathes on Iona’s hands, and that’s without ever attending medical school, without a single course in empathy. Surely I’m capable of responding in an emotionally elemental manner that at least equals that comforting gesture?
If Iona sat before me in a hospital gown, would I slow down enough to ask about his evening? Would I care to give his story slack if it unfolded slowly, or detoured elsewhere, or would I interrupt, as one study found, after an average of 23 seconds?
Most dangerously, would I discount this man’s complaints because it didn’t qualify in my rushed mind at that moment as an emergency?
This is what scares me. If his complaint gets discounted prematurely, his complex life circumstances might never surface. An earnest discussion would reveal troubles that warrant close attention as risk factors for suicide. Questions to assess his risk for self-harm are absolutely essential. The emergency department is not the optimal environment to render psychiatric care. However, due to under-utilized psychiatric resources in the community, visits to emergency departments for mental health and substance abuse problems are on the rise.
But the emergency department is a medical space freighted with moral responsibilities to provide non-discriminatory access to “anyone, with anything, at anytime.” It’s been called “the safety net of the safety net for patients who can’t find care elsewhere.”
If Iona denies suicidality, I believe his grief still demands my fullest attention in the emergency department. The origin of the word emergency reaches back to the Latin word emergere, which means “to bring to light.”
This linguistic lineage serves as reminder of what sits at the core of emergency care, though listening to vexing and vague stories in a “narrative disaster zone” can be a difficult endeavor. Competing demands impact how well I listen to individual patients. My focus is also influenced by the brutal reality that meaningful solutions—stronger social fabric, improved financial footing, access to employment, freedom from substance abuse, and a better range of choices from life—are often far beyond my control. This impulse for action, to have an intervention at my fingertips, can lead me to substitute an easier question to focus on, one that I can respond to, even if it’s not the critical issue at hand.
Chekhov’s “Misery” hits like a thwack on the back of the neck. It reminds me that a rush to a solution might be no solution at all. Despite patients’ complicated needs, the problem that drives them to the emergency department at that moment is often basic, but profound beyond scale.
What patients want from me is not only my expertise as a physician, but the warm heart of a fellow human. What they’re asking for is a little time, an open ear, and a high dose of dignity. When Iona asks, “To whom shall I tell my grief?” I must close the curtain, pull up a chair, and say, “Me. I’m here. I’m all yours.”