Jan 18, 2010

Teaching Empathy (Fit Doctors and Sick Patients)

A reader asks:

My doctors are all very fit. It would seem that being a doctor is so demanding that it requires good health. Can doctors ever really understand what it's like to be ill?
Of course, doctors understand illness! We spend our whole lives studying it! ...but if you mean personal understanding of what it is like to feel your body betraying you, or the dread of approaching death, or the strained relationships created by severe illness—actually, most of us have never been there.

With a few notable exceptions, most people able to dedicate a dozen years of their prime to the punishing ordeal of becoming a doctor have always been pretty healthy in body and mind.

The worst Doctor D ever felt was a moderate case of sinusitis. I have no idea what how it feels to be in daily pain, to be unable to walk, to face death.

The Need For Empathy

So how do doctors, who are rarely sick, relate to ill patients?

Often poorly ...but if we do relate well it is through empathy: the emotional intelligence that allows us to experience the feelings of others. Doctors must learn the true experience of illness from our patients. Doctors may teach patients the science of disease, but in the experience of illness patients are the teachers and doctors are the learners.

Unfortunately, life in the medical business strains one's empathy. The sheer volume of suffering we see can make us numb. There is also the professional objectivity that we fear will be compromised if we care about your pain too much. Empathy may atrophy till a fit physician can diagnose and treat all day long without connecting with a single ill person in a humane, healing way.

Teaching Empathy

You—the patient—must teach the doctor.
Empathy is a lesson physicians desperately need to learn. But how can you teach your MD?
The Direct Approach: Speak directly to your doctor about how uncomfortable your symptoms are and how miserable your illness makes your life. Remind your doctor about how horrible it is regularly, just to make sure they don't forget.
Hate to break it to you, but the direct approach doesn't work. In fact, it has the opposite effect. The more someone talks about their suffering the less we identify with it. Yes it's cruel, but it's human nature.

Remember when you were a kid and that elderly relative complained incessantly about their horrible bowels or joints? Chances are your grandmother really was miserable with those symptoms, but how much did you really empathize with her? Not much right? You just wanted her to stop complaining. It's called “compassion fatigue” and it has infected every doctor by about the 2nd year of medical school.

(By the way, I'm not saying you shouldn't tell your doctor your symptoms and how they affect you. Just don't expect compassion as the natural response to your discomfort.)
The Indirect Approach: Tell the doctors your symptoms and cooperate with them to diagnose and manage your disease. Only mention your miserable experience in passing. Instead, ask about how your physician is managing the stress of his or her life. Your doctor likely has a lot of frustrations despite their healthy body. Even if the doctor's problems seem petty compared with yours try to act like you care that it sucks to miss sleep or leave family dinner to care for a patient.
Believe it or not, this is the best way to teach empathy to doctors. The doctor will empathize with you instinctively.

We all naturally focus on our own sorrows and minimize the suffering of others. We awaken to empathy when we see that others care for us.

Doctors are educated in a system that only cares about how much they know and how hard they work. Few of their teachers care how they handle our rigorous training or the suffering they see. Doctors learn that feelings don't matter.

A caring patient's interest in a physician can teach more empathy than watching a whole world of suffering.

Doctor D has been told by patients that he is a caring physician. If so, it isn't because he has ever been ill himself, or any illness he's seen. It was because my first year of residency a patient with a miserable disease actually made an effort to find out about young D and encourage him. With an education like that how could I not want to understand the experience of every patient I met from then on?
What do you think? Is Doctor D too cynical about human nature? Have any patients out there had success with the “indirect approach” for teaching doctors to empathize? Healthcare people: Has a patient ever taught you empathy? Doctor D always loves to hear your thoughts and stories!


Anonymous said...

When I last saw my rheumatologist, there was a scheduled power outage in the building that he and his staff had not been told about. This was on a Saturday; the only way this doctor can see all of his many patients is to hold a Saturday clinic in addition to his weekday clinics.

After a frantic 45 minutes during which my doc and his staff made calls and arrangements ("I have 25 patients coming today! Many of them are coming from great distances! I can't just tell them to cancel!" he said to someone on the phone, several times), we all trundled over to the VA hospital's emergency department, where my doc was given one of the tiny bays in which to see his patients.

As we walked from one end of the hospital campus to the other, I got to talking with my doc. He'd recently been to Ghana he said; I mentioned that I'd once met the Ghanian ambassador when I lived in Germany, and I asked if he had relatives in Ghana. He laughed and said no, not directly; he'd been in Ghana as a volunteer with Doctors Without Borders, helping people with rheumatoid arthritis and other autoimmune diseases. He said that he'd been doing it there, and in other countries, about once a year for many years.

We talked a little about Ghana, and then we were at the ER and it was time to resume that doctor-patient relationship. I was the first patient on his 25-patient-long list; he was already running an hour late because of the communications mix-up. But he took the time to ask me about my symptoms, the time to reassess the meds I was on and adjust dosages, and to let me ask him the many questions I'd written down prior to the appointment. I only see him once a quarter, so I've learned to make that list. My doc answered them all patiently. Finally, when I asked for referrals to PT and OT, and to the ophthalmologist, he assured me he would make them.

As I left, I wished him good luck in dealing with the rest of what was sure to be a hectic day. We shared a smile, and I left feeling like this doctor cared about me. I hope that he also felt that I cared about him, because I certainly did, and do. I was touched by his volunteer work, his empathy for patients that had to travel a long way to see him, and his patience. I hope that the experience will carry over into the future so that we can both play our roles with more warmth.

Thanks for the tip about empathy, Dr. D. We can all use it.

Anonymous said...

My stoic physicians have fabulous nurses that are very personable, understanding, and friendly; this is not a trait that I worry about in a doctor.

Perhaps I am the exception as a patient, but I spend a lot of time in doctor's offices due to my illness and I will tell anyone that it's the nurses, not the doc, that will make you feel "taken care of" emotionally.

Maha said...

Empathy can be taught but some days it truly is a great effort of will power to exercise it. Especially when someone truly in need walks through the doors after you've had to deal with crackpots all day. I never took compassion fatigue seriously until a couple of months ago.

Anonymous said...

As a patient, I try to be as honest as I can without being too insistent. I explain my concerns in an undemanding manner and as succinctly as possible. I've found that many doctors respond to a patient who is genuinely worried and is reaching out for a little comfort.

Doctor D said...

An interesting point made by Anonymous: not every patient wants empathy from doctors.

I have found that some patients are a bit annoyed when I try to understand how an illness is affecting them. They want me to work for them and not get involved. This is by far the minority of patients, but interesting evidence that every doctor-patient relationship is unique.

WarmSocks said...

Would you believe that it never occurred to me that doctors might empathize with my situation? I tend to be more of a facts/answers kind of person: here’s what’s happening, how can I solve this problem? It wasn’t until I started reading medblogs that I learned doctors might want to have a real conversation with patients.

Things are different; I still want a solution when I visit the doctor, but it would be too depressing to spend all that time dwelling on how I’ve been feeling so we never just stick to the cold facts. It’s a lot more comfortable to chat about other things, too, so I've learned a lot about my doctors. And it’s kinda nice to be seen as a person instead of just another chart.

Helen said...

Thanks for an enlightening and interesting post.

It wouldn't occur to me to go on and on to my doctor about my pain; I suppose I just assume they already get it.

As I've come to know my specialists I think we've developed relationships that are both mutually respectful and mutually empathetic. As we get to know one another better, I feel more and more confident in, and grateful for, the care I receive.

Doctors are human, and I think patients do themselves a great disservice by too frequently forgetting this.

Anonymous said...

It's not that I want a doctor to sit down and hear me go on about how my illness has reshaped my life. I just wonder if they generally realize how much can change when a person gets sick, and that things like fear, awkwardness, and shame are involved. I don't have my same old life plus a new diagnosis. My illness makes my friends freak out, it complicates s**, etc. Even the positive changes are jarring in their own way!

A small acknowledgment or encouragement from a doctor can go a long way. One time a doctor was leaving the exam room and turned around for a moment just to add, "Hang in there, sweetie." I could tell that he knew that things were hard for me then. I've remembered and taken heart from those four kind words many times.

Anonymous said...

Just came across this blog for the first time- so far impressed.
I would, however, argue that it is presumptuous to assume that most physicians do not know what it is like to experience personal illness. It would be more logical to assume that disease rates are somewhat parallel to the general population, right? And that physicians, due to our role, simply cannot gripe about feeling poorly in our daily life. I personally do know what it is like to struggle with a chronic illness and can think of any number of my colleagues who would echo my sentiment.

Old MD Girl said...

Honestly? Yes, it is a it cynical to say that in order for me to care about your symptoms, you need to show that you care about me, the doctor. (That is what you're trying to say, right?)

I mean, I'm not saying it isn't true.... but it's sort of lame. I mean aren't we supposed to be trained to care regardless? Or at least to fake caring convincingly?

So the bottom line is this: Make sure your doctor likes you, and you will get good care.

Doctor D said...

Excellent point Old MD Girl. Doctors should care regardless. It is our job to care.

But the fact is that when fatigue sets in caring is our first attribute to wear thin. Caring requires a human connection can be exhausting in the context of suffering and death. Doctors subconsciously learn to fake caring, and then we even stop faking sympathy.

I'm not implying this is right or excusable, but it is the natural tendency of someone under stress.

You can still get technically proficient care without your doctor caring about you personally, but most people want their physician to care about them. I'm not saying that people should bribe their docs to care with buttering them up, but I do think that the best way to teach empathy to another person is to demonstrate caring towards them.

I often find that I have gradually grown more hardened toward my patients. I almost always discover it in the context of a patient showing their humanity towards me. There was no excuse for my hardness, but I still appreciate my patients bringing humanity back to my medical care.

Anonymous said...

The discussion has kind of shifted away from whether doctors understand the experience of illness to whether doctors feel compassion for patients, but this is a good topic too.

As a patient, I’ve seen doctors try all sorts of strategies to deal with this cycle of caring, exhaustion, and withdrawal. It seems very difficult, and I get the impression that students and residents aren’t given much guidance in this area. I’ve met both doctors and nurses who actually changed their specialty to reduce patient contact because they couldn’t handle getting “too attached.” (I’ve come to think of radiology as the refuge of the most tender-hearted.)

I like Doctor D’s suggestion that patients find ways to express genuine concern for their caretakers. It’s a good way to wake up everyone involved and keep the encounter from becoming cold and habitual. There are a lot of external and $$ pressures that make seeing a doctor like being processed in a factory, but still, with a little thought and awareness, we can make it more human.

Anonymous said...

I've read too many posts here today :) -- just discovered your blog. I have never thought about this question as I don't have a lot of personal experience with doctors as a patient. I do have experience with vets. I know, they're treating a different species than you are. I will say that I expect that they will at least show empathy and caring towards the animal that I bring in even if they have to fake it. If I don't get that they have that, I find another vet. I'm the same way about my care. At least fake it. I've done that when someone is telling me something that in my mind I may think "get over it, life is too short."

As for myself, the times I have visited a physician, I have a particular issue that needs to be dealt with and I want it taken care of so I can continue on with my life. At least pretend that they realize that I'm human and not a symptom to be treated. Usually I will engage the physician in conversation to take my mind off what needs to be done and to remind him/her that I am a human. For instance I went in for an ear infection that just wouldn't go away (from scubba diving) so I chatted about how fun it was to dive. He chatted with me and stuck around for about 5 minutes after treating me and writing the prescription for he found it to be an interesting topic.

Anonymous said...

My doctor cares about me...probably a hell of a lot more than you ever would!!

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