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Don't look to a doctor for understanding

September 22, 2008 |  6:00 pm

Doctors provide little in the way of empathy, even when their patients seem to ask for it, according to a study in the Sept. 22 Archives of Internal Medicine. Researchers looked at real doctor/patient encounters between 137 patients and their oncologists or thoracic surgeons from a Veterans Affairs hospital.

Doctor1 Doctors could respond to concrete concerns, such as that a patient was feeling physical pain, or was having trouble getting an appointment. But they largely ignored patients' emotional concerns -- even when that concern was an outcome of surgery, or how long they had left to live.

Here's a sample of an encounter reported in the study when the patient received the diagnosis:

"Patient: But this is kind of overwhelming, you know...I've had anxiety problems before. I go to the [mental health clinic]...

Doctor: Okay."

And if that doesn't warm your heart, here's what a physician said when a patient revealed his life story in relationship to lung carcinogens:

"Patient: ...I worked very hard when I was a young man, young boy. I was doing a man's labor and was always told I had a good strong heart and lungs. But the lungs couldn't withstand all that cigarettes...

Physician: Yeah.

Patient: ...asbestos and pollution and second-hand smoke and all that other stuff, I guess."

Physician: Do you have glaucoma?"

And when it came to delivering the worst news a patient can hear, the news that he or she will die soon, one doctor in the study had this to offer:

"Patient: I don't know what the average person does in just two years, three years, a year?

Physician: I think that you certainly could live two or three years. I think it would be very unlikely ... But I would say that an average figure would be several months to a year to a little bit more."

On average, the physicians in the study responded with empathy only 10% of the time. The oncologists were a little more caring than the surgeons, responding empathically about 14% of the time, compared with about 6% for surgeons.

The authors suggested that doctors may not respond with empathy because they're busy, and fear it would take too much time. But the study suggested that brief comments such as, "I can imagine how difficult this is," turned out not to increase the time spent with the patient. In fact, those rare doctors who acknowledged the patients' concerns and responded as though they could relate actually had shorter visits with the patients.

But, the authors wrote, talking about life and death is difficult for everyone, including doctors.

"This difficulty may be related to limited cure potential that results in a sense of failure and/or identification with the patient that is difficult for the physician to acknowledge or express and may raise within the physician awareness of his or her own vulnerability to illness and mortality."

But there's hope. Studies, like one in a 2002 issue of the journal Lancet, show that physicians can learn better communication skills, including empathy.

-- Susan Brink

Photo credit: Myung J. Chun / Los Angeles Times

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Comments (51)

"This difficulty may be related to limited cure potential that results in a sense of failure and/or identification with the patient that is difficult for the physician to acknowledge or express and may raise within the physician awareness of his or her own vulnerability to illness and mortality."
No, This difficulty may be related to the GOD syndrome, i am 'sick' and tired of American or American-like health-service-workers (doctors),
if it was not for some Nurses we'll all be dead.


Training might help doctors. But I wonder whether a truly empathic person can stand the emotional pressure of each patient's plight and deal with so many traumas day-after-day. It may be that one has to have a thick skin to survive in the midst of so much pain and suffering.

So what?

Would you rather a docotor who's more focused on your physical problem or more focused on your feelings?

Who needed a study to confirm what we already know?

Skewed and sensationalized, like so many interpretations of "Soft" studies ("Soft"- implying that it's very difficult to analyze and correctly interpret information to form "Hard" data from observations of conversations).

Each illustration is but a fragment of whatever went on between the Physician and patient. But, to read the article, it paints a picture of uncaring, disinterested Physicians. To add, many, MANY patients attempt to draw clinicians in to their social and personal problems, well beyond the scope of the medical specialty they are seeking care from.

The comment about clinicians that actually acknowledged their patients concerns taking less time than those that apparently didn't is suspect at best.

The bottom line in our litigious, insurance controlled health care industry is that- "If you want a house built, call a carpenter"/ Have a surgical problem, call a Surgeon. Have an emotional problem or need attention, buy a puppy or see a Psychiatrist.

Patient: Doctor, I have been feeling severe pain in my chest for the past two days.

Doctor: Yeah, whatever.

I find, in general, that surgeons have absolutely no sympathy. They appear to be the "nerds" of the medical world. They are technicians, pure and simple. They patch up a leaky pipe or spackle up a hole in the wall with no detectable feeling or emotion of any kind.
My own dad, who was a physician, preferred not to socialize with surgeons because he said they were egocentric and often didn't speak of anything but their own good work.
Yes, I need one during an emergency but I'd rather get a dog to share my troubles with.

That's just sad...

This article makes some very interesting points, but it really fails to hit home on on what I believe is the key issue. To most doctors, anything other than treating the symptoms is an unbearable burden, but they typically are not looking to the contributions they can make in anothers life. They view most of it from the aspect that time is money.

Interesting. Much of the art of medicine is about detaching oneself from the patients to avoid clouding one's judgment. At the same time, it is important to demonstrate a caring attitude. Finally, certain times, excessive "empathy" could generate a type of emotional overdependence on the part of the patients that is detrimental to the patient. This is of course well known to psychiatrists who routinely set boundaries and limits to their interactions with their patients. An unstructured application of "empathy" is in fact problematic. I wonder if the authors of the article considered these nuisances.

I have a friend who had cancer and was able to be treated at City of Hope. This is a wonderful place where everyone, from doctor to nurse to gardener, keeps the patient first in their minds. For people with conditions which are life-threatening, to have such a supportive, caring environment during such a difficult time makes a huge difference. I just want people to know there are such wonderful places out there.

Many internal medicine doctors are torn between trying to understand the patient's emotional language about their condition while getting the information about the problem they present. This is all done in a shortened time frame. It is no wonder that doctors are less empathetic at times. It is easy to sue for a missed diagnosis, but hard to sue for a missed empathetic response. Too bad that the medical community has been forced into this difficult position. Too bad for us as patients to have to choose between the lesseer of two evils.

If it's empathy that's needed in any given situation, talk to a nurse. These professionals treat the whole person, including psychosocial concerns, with therapeutic communication and EMPATHY.

So what? Doctors exist to give you some approximation of *facts*. "There's hope"? That's what chaplains are for. "Specialization" - it's why we aren't out hunting mammoths and starving to death. Who funded this worthless study?

Susan Brink has churned out an issue which barely scratches the surface of the deep disconnect between legislators payors non-medical academics journalists and the rest of us deeply entrenched in in our increasingly hopeless and shallow healthcare and medical culture. That is not to say your piece and the author of this study are irrelevant. They certainly are. However lets skip the polyannish mindsets and deal with more pithy topics. A day doesnt go by when some journo digs up a soft piece such as this and blatantly ignores the vast minefield of serious medical issues with huge relevance to patient safety and public health.

Lets see now. If you are truly not shilling for a commercial healthcare giant and are genuinely interested in the concerns of physicians, then click on the linked petition below. Better yet link up with the UAPD.org and check out the concerns of physicians and wonder why for a change, our patients dont seem to be clamoring with any sympathies for those they expect more from.

http://www.petitiononline.com/patients/petition.html

Sociopaths lack empathy. I guess 90% of doctors are sociopaths. That pretty much fits my personal experience with them.

This is a thinly veiled doctor bashing attempt.

If doctors empathized with every patient (and almost every patient has a problem or thet shouldn't be seeing a doctor), they would only see one patient every 30-45 minutes, instead of the 3 minutes they get paid to see a patient.

It's very sad that so few people have support mechanisms to rely upon when they get bad news.

Has our society disintegrated so much that the only person a patient can get empathy from is his or her doctor?

Your title is very misleading--it should read, Do not look to your oncologist or your thoracic surgeon for empathy as those are the only doctors in the study. It is hard to make any conclusions about doctors in general from the study as it was very small--it was only recorded visits for ten patients at a VA hospital and involved the patients' interactions with their Oncologists and their Thoracic surgeons. The number is so small that the study is subject to Beta error--too small a sample to make a conclusion. Also, this study was done at a VA--a type of hospital system that has been criticised nationwide for substandard care and that is known for rushing doctors to take care of more and more veterans in a shorter time. A VA may be the worst place to study and draw conclusions on empathy when it has some of the most time pressured visits of any system. The results may be different in private practice where bedside manner is more a factor in patients chosing, bonding and returning to a healthcare provider. Also the specialties studied, Oncology and Thoracic surgery, are not known to be the most empathetic in medical circles. Surgeons are widely felt to rank low on interpersonal skills as a group--even showing a notorious lack of empathy when training their own interns and residents. Surgeons are mostly doers and not talkers and often feel that excessive talking with patients slows them down from their other duties, Oncology is also not a warm or empathetic specialty--they have to face the death of patients more often than many doctors and they see the treatments they order cause hideous side effects so some emotional distance and numbing is a part of this specialty to just survive it emotionally. If the oncologist gets too upset about the patient's emotions, then they fear they will lose the ability to function so emotional distance is encouraged during medical training.

Some specialities do not encourage emotional distance but rather encourage patient-doctor bonding and communication. The most empathetic doctors by specialty tend to be family practice, pediatricians,and the primary care internal medicine doctors who see patients on a long term basis and have more of a traditional doctor-patient relationship. I suspect that the study would have come out quite differently had the study included doctors from these specialites instead of Oncology and Surgery only. Our family doctor not only was with us in the hospital to answer our questions after a cancer diagnosis in the family but helped with the hospice aftercare when chemo failed and even went to mother's funeral when she passed on in 2004.

Q: What's the difference between God and a doctor?
A: God doesn't think he's a doctor.

Q: What do you call the guy who graduated last in his class from medical school?
A: Doctor!

Nuff said.

Most doctors didn't go into medicine because they were caring compassionate people ... they went into the field for the money ... period. That doesn't necessarily mean that they aren't good doctors ... they just don't get personally involved ... it's their job. I have never gone to a physician for compassion and don't expect it ... that's what family and friends are for. So if you go to the doctor and get bad news ... don't take it personally ... take it home and look to the people who love you to support you.

Doctor's and empathy -- why don't they go together? Well, many people have trouble expressing caring. Husbands to wives and vice versa. Studies have shown that although medical students express as their main motivation for chosing the profession of medicine the desire "to help others." In reality their main motivations are most often affluence (ie. money) and having a sense of power.

Not alll doctors lack empathy, but often their training knocks that out of them.

It is considered unprofessional to actually show caring to a patient. My own internist, whom I like and respect, declined to have lunch at my invitation -- because "that might interfere with my ability to be impartial and affect my judgement." In other words, "I might get to know and like you as a person and that could be dangerous for me." (One of my previous doctors, back in the 60's asked me to lunch, and our "professional" relationship was even better for it.)

"Let's both stay in our places! That's why it is called a "doctor-patient" relationship instead of a "patient-doctor" relationship. As that same internist told me a few months ago, when I suggested what might be troubling my digestive system, "Let me be the doctor." And that involves keeping empathy, if there actually is any, at arms length.

I have a doctor , he is an internist. He has much impathy about what I tell him. he told me he teaches 3 days a week. The first time i walked into his office, he red my history, he told me not to wear my hat anymore. Sometimes when I am running out of the house instead of doing my hair I will top my head off with a cotton floppy fishing hat. He told me that I have sad eyes( I didn't know I revealed that! ) Told me to find somebody and fill my life. He has wonderful feelings and understanding.

Thanks for printing this! Will take this to heart as I enter my second year of medschool!

I always treat my patients with empathy and compassion, This study is full of bias during this time, as it is well known that all physicians in the nation had a new NPI imposed by goverment and we all had to apply for new medicare number.

We specially those like me who work in areas of hispanics and black heavily depend in medicare payments, and we have not received a single payment from medicare for 4 or 6 months. We are paying our bills from bank credit lines with high interest, our debt grows every month. Physician are not happy, we work long hours, medicare is not allowing us even to make a single claim. The Claims are only entered in the office computer, we receive one e-mail every 21 day from medicare, just to be ask to correct one line of the application.

I have an overhead of almost 15 000.00. I decided to trust that the goverment will pay me so I can pay the bank, I had no let go of my employees, all of them has health insurance and other benefits.

It is a lack of consideration and empathy someone can write an article like this,

"Its lymphoma.” the surgeon said abruptly to my wife in the waiting room. She was stunned. He walked away not saying another word. She decided the surgeon was a jerk. "Good thing people are anesthetized when he’s around." Then it was my turn. "You have Hodgkin's. It's the good kind. If I had cancer I'd want it to be Hodgkin's.” said the surgeon. He recommended a local oncologist. I asked why him? “It doesn't matter which oncologist you choose. They read the same books” said the surgeon. Not sure what to ask when choosing an oncologist I called the one recommended by the surgeon. They have cable TV in the chemotherapy room said the local oncologist's assistant. This lame answer sent me looking for a highly regarded oncologist. I found an expert in lymphoma at a famous cancer center 90 minutes from my home. On display in the hospital's lobby are pictures of the oncologists and the books they had written. The oncologist I selected walked into the examining room, sat down, opened my file, he squinted "What are you doing here? You have Hodgkin's. You're not sick enough to need my help. I'm the Supreme Court in the world of Oncology. Any local oncologist can treat Hodgkin’s." He sent me to a radiation oncologist in the same building who told me that radiation wasn’t my best option. So these oncologists start arguing about me on their cell phones. Unable to agree on the best course of treatment these cancer experts insisted that I decide. A patient choosing which cancer treatments isn’t unusual but at the time I didn’t know that. Sometimes you have options. I chose the combination special with a little chemo and a light dose of radiation. That turned out to be repeated doses of battery acid in the veins followed by the worst sunburn ever inside and out. During a check-up my medical textbook writing oncologist became annoyed because I was joking and smiling away my anxiety. He asked if I had any idea how serious the side effects can be. I lost the smile and nodded yes. “Then why don’t you explain it to me?” the oncologist demanded. I recalled a grim list of complications that could happen during and years after treatment. He was satisfied. “OK, you’re smart” he said. I didn’t mind that his bedside manner sucked. Sometimes he was so insensitive the weirdness was kind of comical. All I cared about was his reputation as a leading oncologist. I didn't care about cable TV in the chemotherapy rooms but it was there too. His team of nurses and medical students were very nice and they would snicker when I asked how "Dr. Crazy Man" was treating them. Maybe I wasn’t “sick enough” but I sure was scared enough to put up with him. Over the past 7 years I’ve made it to every follow up appointment with this oncologist who pokes me in the belly warning me to lose weight or I will die of a heart attack. In hindsight someone with a more serious cancer probably needed his attention more than I did. Yet, he didn’t refuse to treat me for whatever reason. Maybe these “heartless” doctors do have a heart despite their bad behavior. There’s nothing easy about battling cancer even the “good kind.” Not for the doctors, not for the patients; not the treatments, not the decisions, not the insurance, not anything. But they try and sometimes they succeed. Thanks for the article. I thought my experience with surgeons and oncologists was unique. Apparently not.

 


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