Physicians And Empathy

I recently read an essay by a woman who described her experiences being employed as a medical actor. She’d been hired, along with some retirees, local theater majors, and a few people who were just curious, to play the role of patient in a training program for a local medical school.

To start, she was assigned an identity that actually contained a lot of detail: “You’re a 23-year-old unemployed graphic designer with recurring abdominal pain. You’re from a small town in Iowa, where your father was killed in a car accident.” All fictional, of course, but from a medical perspective all potentially important information.

Wearing a hospital gown and lying in a hospital bed in a specially designed suite that allowed observers to watch the interaction unobserved, she’d be interviewed by a medical resident, who would then perform a physical exam and leave. Both she and the hidden observers had checklists of what was supposed to be covered and what might be overlooked.

She’d been told that her response to Question #31 was especially important to the examination. Namely, “Did the examining resident voice empathy for your problem?”

Empathy is neither sympathy nor compassion

This issue of empathy in the medical profession is a difficult one, and probably a significant factor in the public’s rising disenchantment not only with doctors but with the healthcare system in general.

Empathy as used in this setting is your doctor’s ability to share your emotions and be involved enough in your situation to share your distress. Your doctor must, at least for a moment or two, think of herself as you.

Empathy is not the same as sympathy. With sympathy, we have a concern for someone else and a wish to see them happier. We send recently bereaved people sympathy cards hoping to help them through a difficult time. We don’t send empathy cards.

Empathy is not the same as compassion. Compassion is more transcendent. It may even trigger an active desire to help. We feel compassion toward a village of starving children, but our prevailing emotion is neither empathy nor sympathy.

All this said, when I talk to new patients about their experiences with other physicians, or to longstanding patients about their experiences with specialists, I usually hear one of two things:

• The hoped-for “I love my doctor. We’ve known each other for years.”
• Or the opposite, “I’ve got to find someone else. She (or, when in a big medical center, they) never listened to me.”

The apparently rising tide of empathy-free physicians would be patent failures at Question #31 (“the doctor expressed concern for your problem”) and this is very worrisome.

Here’s what I think is happening

First, there’s virtually no screening during the medical school application process that might filter out students with personalities that make them totally wrong for becoming doctors. This won’t change until someone creates a screening process for the pre-med years. Frankly, it’s logistically impossible. When you see the sheer numbers of applications you have to feel compassion for the medical school admission committees.

Rush Medical College gets more than 10,000 applications for roughly 140 openings. All medical schools in the US base acceptance mainly on college grade point average and MCAT (Medical College Admission Test) scores. Yes, there’s a personal interview, but as a friend who was on an admission committee acknowledged, “They become a blur of really motivated, smart students.”

Second, testing for empathy, which British medical schools (but not those is the US) have been trying to work into their system for years, just isn’t consistent. Interestingly enough, an extensive review of personality testing results (not limited to med school applicants) published in 1983 showed that four personality traits emerged that could predict an empathic person:

1. Even-temperedness
2. Sensitivity
3. Nonconformity
4. Social self-confidence

When this article was first published, there were some stirrings in the UK that every medical school applicant should undergo psychological testing before being allowed to apply. Unfortunately, the project was simply too overwhelming and nothing came of it. But think for a moment how a doctor who isn’t listening to patients would score on a personality test. How much of health care is a mess because your doctor had the academic smarts but zero empathy?

Cultivating empathy

Interestingly, empathy can be cultivated in just about anyone. Yes, most of us can change parts of our personality we don’t like. Think about medical students being required to undergo personality testing in their first year and getting a D+ or C- in empathy. They’d then be required to take training in empathy enhancement.

Psychologist Roman Krznaric, PhD, from the UK is actually an empathy advisor to both Oxfam and the United Nations. Here are some of his researched habits of highly empathic people. When you read this list, think about the last doctor you liked, and the last one you didn’t.

Highly empathic people…

1. Cultivate a curiosity about strangers. They’ll talk to the person sitting next to them on a bus. They find other people more interesting than themselves.
2. Challenge their own prejudices and discover commonalities. Search for what you share with people rather than what separates you from them.
3. Try another person’s life.  The Native American proverb “Walk a mile in another person’s moccasins before you criticize him” fits in here.
4. Listen hard and open up. You’ve got to be really present and grasp another person’s emotional state and needs. Make yourself vulnerable–empathy is a two- way street.

Stop here. Pause for a moment of empathy for those physicians who would have failed Question #31 and those doctors with terrible Yelp reviews (“doesn’t listen”).

I suspect that many truly empathic physicians are too beaten down by the mechanics of the healthcare system to function well. In an interview last December, the new president of the AMA said doctors are overwhelmed by the demands of government regulators and insurance companies.

Surveys among physicians show that job satisfaction is melting away. A full 65% would leave medicine if they could afford to. Most doctors actively discourage their children from entering the profession. Added to the incessant hyper-regulation, electronic medical record (EMR) systems–forced on doctors by the government and insurance companies–are a particular point of fury.

Who has time for empathy when you’re staring at a computer screen and each of your overscheduled patients is little more than dozens of point-click, point-click, point-clicks. These days, most doctors are salaried employees of the mega-health care systems. They’re forced into user-unfriendly EMRs, given production quotas by pencil-pushers (“you’re spending too much time with patients,” “you’re behind on your paperwork”), and often waste hours of each day arguing with insurance companies over every possible aspect of patient health care, from a referral to a specialist to a prescription drug, from a diagnostic test to a hospital admission.

So what I’m saying is that before you get too angry at the doctor who isn’t listening, walk a mile in her shoes.

Come to think of it, why not take this little online quiz to help find out how empathic you happen to be.

Be well,
David Edelberg, MD