Competence is more important than empathy

[IonClaws]

I've noticed that in medical school, esp. during the first 2 years, we are told that it is important to ask open-ended questions and to take in a lot of information because it could all be relevant to the patient's problems. That compassion and empathy are the basis of a great doctor.

As we proceed in training though, I see a change. Questions become problem-focused. We are told to start asking direct questions and to look for a diagnosis rather than take in a lot of information about many different things. In third year, we find more and more that asking open-ended questions and listening to patients talk about whatever, more often than not, leads to a lot of irrelevant information that is useless in taking care of them.

This, combined with the facts that medical school does NOT train on you how to take care of patients, and that 3rd year tends to kill empathy in most medical students, makes me think that empathy and compassion tend to be overblown and sensationalized because they sound nice, and that the real basis of a great doctor lies in competence, and not empathy.

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[Osteoth]

Like-ability is more important than both of those.

You can teach someone to be competent.

You can fake empathy.

You can't make your attending not want to back-hand you with your smug face.

 

[Crayola227]

While it's true that the communication often has to change tacks, for many reasons, not the least of which is time, it's total bullshyte to crap on the therapeutic alliance.

Patients often say to me with resentment, "But do I have to ___???"

And I always say, "You don't HAVE to do anything, not a single thing. It's your life, your choices. You came to me looking for advice, and in my professional estimation, this is the best course of action for what ails you." (this changes the dynamic from a paternalistic stance that can engender resentment and rebellion, to one that acknowledges the autonomy of the patient and creates more of a vibe of collaboration).

The point is, it doesn't matter how brilliant you are. Your patients can't tell if you got your MD from Harvard or barely passed Step 1. We quite literally can't do our jobs if we can't get our patients on board. So how do they decide that, when they have no way of objectively appraising how competent you are?

They did a really neat study where they measured how much doctors liked they patients, how much the patients thought their doctors liked them, and how much they themselves like their doctor. (Consider for a moment, why a sense of your doctor liking you engenders more trust in their care.)

More than a lot of other factors looked at, the study found that patients were surprisingly accurate at telling how much their doctors liked them (so you can't really fake empathy that well, from the standpoint of how well it will build your therapeutic alliance), and that this was the #1 correlated factor in how much the patients liked their doctor.

Taking this one step further, and this study was at least over a year, they found that the scores of how much patients liked their doctors, was highly correlated with various measures of how well patients controlled their diabetes and even measures like ha1c. More than any other factor they looked at.

This was more important even than how much face to face time patients got with their doctor. Chew on that for a minute as you consider efficiency.

Your job, as I see it, is not only to provide the best advice possible, but ALSO to help your patients learn to follow it, AND WANT to follow it.

Since how effective you are at your job *quite literally* rests on your patients' choices, and likely how much your patients like you, I wouldn't say competence matters more than empathy. Competence matters NOT ONE WHIT without it.

 

[Crayola227]

Like-ability is more important than both of those.

You can teach someone to be competent.

You can fake empathy.

You can't make your attending not want to back-hand you with your smug face.

If you read my post, you'll see that actually, you can't fake empathy all that well, that patients can actually see through it quite well.

They do studies that show that we can't tell if people are lying nearly as well as we think we can (especially looking at judges, cops, doctors, groups whose job is often investigative and tend to highly regard their skills in this way), being almost no better than chance.

HOWEVER we are actually quite good at telling how people really feel about us. Which is a bit different than lying, per se. Evolutionarily speaking, it makes total sense that to the degree one might be able to develop this skill, we do.

 

[NuttyEngDude]

I get the impression that the amount of empathy and compassion that remains in a student is directly correlated to how much he/she likes third year.

 

[WingedOx]

Perhaps you need to be less concrete about the concept of empathy and how it exists in practice. Asking open ended questions and having the patient ramble on as a therapy session is not exactly a great example.

Plus, we have students do things a certain way in training that's different from how you do things in reality because you don't know enough yet to know what specific questions to ask. For example, there's a reason why your preceptor on your MS3 psych rotation is having you write out full biopsychosocial assessments while his/hers are only a couple sentences long. An experienced clinician is already thinking about all the social/bio/whatever about his patient, but an MS3 needs to be able to demonstrate that they're doing so... and writing it out forces you to think and consider what you're writing.

 

[Osteoth]

If you read my post, you'll see that actually, you can't fake empathy all that well, that patients can actually see through it quite well.

They do studies that show that we can't tell if people are lying nearly as well as we think we can (especially looking at judges, cops, doctors, groups whose job is often investigative and tend to highly regard their skills in this way), being almost no better than chance.

HOWEVER we are actually quite good at telling how people really feel about us. Which is a bit different than lying, per se. Evolutionarily speaking, it makes total sense that to the degree one might be able to develop this skill, we do.

I don't think that empathy and affection are mutually exclusive tbh. I can like someone but still not understand/have empathy for the situation they put themselves in at that current moment, and I can also be empathetic to someone I dislike because I understand their current predicament.

Furthermore, it really depends on the circumstances you're discussing. If you're a surgeon who has mid-levels do all his therapy/pre-operative/post-operative counseling then how much does empathy really matter in the first place? I'm not saying that it wouldn't make them a superior clinician/physician, but functionally what is the difference?

The entire thing is really an age-old debate. Would you rather have a surgeon who is good, or who is nice? I know what I'd choose.

 

[zero0]

Bedside manner doesn't mean crap if you can't form a differential and plan. Personally, I don't care if my doctor treats me like human garbage, as long as they figure out what's wrong and improve my quality of life I'll keep going back to them again and again. At the end of the day, actually caring enough to think about what's going on with a patient instead of throwing random pills at them until something works or they shut up shows the doctor actually cares more than anything else.

 

[Lnsean]

I've noticed that in medical school, esp. during the first 2 years, we are told that it is important to ask open-ended questions and to take in a lot of information because it could all be relevant to the patient's problems. That compassion and empathy are the basis of a great doctor.

As we proceed in training though, I see a change. Questions become problem-focused. We are told to start asking direct questions and to look for a diagnosis rather than take in a lot of information about many different things. In third year, we find more and more that asking open-ended questions and listening to patients talk about whatever, more often than not, leads to a lot of irrelevant information that is useless in taking care of them.

This, combined with the facts that medical school does NOT train on you how to take care of patients, and that 3rd year tends to kill empathy in most medical students, makes me think that empathy and compassion tend to be overblown and sensationalized because they sound nice, and that the real basis of a great doctor lies in competence, and not empathy.

you can fake empathy and interest and all that sht...but when sht hits the fan, you cannot fake competence

 

[Crayola227]

No one's acting like competence doesn't matter - but you will frequently find your patients aren't as rational as you are in determining whether or not they want to take your advice.

YES - your plan needs to be good or it won't do good.

BUT - if your patients don't feel like following your plan, it won't matter at all how good it was.

Patients will always have the power to subvert all your best intentions. Best to keep that in mind.

 

[WingedOx]

My own philosophy on empathy is that you need to develop it for your own self-preservation. Dealing with awful thankless sh-t from patients is part of the gig regardless of what you're doing in medicine, and without you ability to empathize with where it's coming from, you burn out fast.

 

[Crayola227]

you can fake empathy and interest and all that sht...but when sht hits the fan, you cannot fake competence

Actually, you can't fake empathy as well as you think you can - fact.

Also, you don't have to fake competence. One board certified doctor is about as good as the next when it comes to that.

Producing doctors that are "competent" isn't rocket science. It's the people skills that really separate a great FM doc from a merely competent one. They aren't differentiated by how great they are at calculating insulin requirements in their DM patients. A monkey could be trained to manage most DM. Can a monkey convince someone to manage their DM properly?

 

[VA Hopeful Dr]

And I always say, "You don't HAVE to do anything, not a single thing. It's your life, your choices. You came to me looking for advice, and in my professional estimation, this is the best course of action for what ails you." (this changes the dynamic from a paternalistic stance that can engender resentment and rebellion, to one that acknowledges the autonomy of the patient and creates more of a vibe of collaboration).

My wife and I have almost identical speeches. Its an interesting thing that I think our generation of doctors seems to do.

 

[Mad Jack]

I've noticed that in medical school, esp. during the first 2 years, we are told that it is important to ask open-ended questions and to take in a lot of information because it could all be relevant to the patient's problems. That compassion and empathy are the basis of a great doctor.

As we proceed in training though, I see a change. Questions become problem-focused. We are told to start asking direct questions and to look for a diagnosis rather than take in a lot of information about many different things. In third year, we find more and more that asking open-ended questions and listening to patients talk about whatever, more often than not, leads to a lot of irrelevant information that is useless in taking care of them.

This, combined with the facts that medical school does NOT train on you how to take care of patients, and that 3rd year tends to kill empathy in most medical students, makes me think that empathy and compassion tend to be overblown and sensationalized because they sound nice, and that the real basis of a great doctor lies in competence, and not empathy.

Without empathy, it is hard to gain patient trust. Without trust, it is impossible to form effective relationships with your patients. Without an effective relationship, you cannot maintain patient compliance with treatment and follow-ups, nor can you often get honesty from your patients. When 90% of most diagnoses can be obtained from H&P alone and treatment being worthless without follow-up and compliance, empathy, or at least effective communication and trust, matters more than competence.

 

[zero0]

Actually, you can't fake empathy as well as you think you can - fact.

Also, you don't have to fake competence. One board certified doctor is about as good as the next when it comes to that.

Producing doctors that are "competent" isn't rocket science. It's the people skills that really separate a great FM doc from a merely competent one. They aren't differentiated by how great they are at calculating insulin requirements in their DM patients. A monkey could be trained to manage most DM. Can a monkey convince someone to manage their DM properly?

Isn't knowing when to use motivational interviewing just part of being a competent doctor? Semantics...

I would definitely argue against all board certified doctors being competent though. For example, a buddy of mine struggled with tertiary Lyme disease symptoms for years because he had an atypical presentation that tons of doctors failed to even suspect. Eventually, one of them caught on and ordered the proper tests. Now that doctor was competent. And as for compliance, do you think anyone had to convince him to take his tetracycline at that point? You better believe not, he wolfed it down as happy as could be.

 

[Crayola227]

Isn't knowing when to use motivational interviewing just part of being a competent doctor? Semantics...

I would definitely argue against all board certified doctors being competent though. For example, a buddy of mine struggled with tertiary Lyme disease symptoms for years because he had an atypical presentation that tons of doctors failed to even suspect. Eventually, one of them caught on and ordered the proper tests. Now that doctor was competent. And as for compliance, do you think anyone had to convince him to take his tetracycline at that point? You better believe not, he wolfed it down as happy as could be.

Perhaps if those doctors had been more empathetic....

People sort of forget too, especially when dealing with atypical presentations, that for a doctor to miss something someone else catches... isn't necessarily a sin of incompetence.

Your example is actually really poor because of how notoriously difficult it is to catch Lyme disease years on down the road of the initial exposure.

 

[VA Hopeful Dr]

Perhaps if those doctors had been more empathetic....

People sort of forget too, especially when dealing with atypical presentations, that for a doctor to miss something someone else catches... isn't necessarily a sin of incompetence.

Your example is actually really poor because of how notoriously difficult it is to catch Lyme disease years on down the road of the initial exposure.

If you can be a doctor for a few years and miss nothing, you're a unicorn. We all miss things. You just really hope that its nothing that makes a huge difference.

 

[Crayola227]

I got an interesting take from surgeons and anesthesiologists on this topic of interpersonal skills.

I was told 3 things regarding the fact that the average patient doesn't have the requisite background knowledge to assess how good you are at surgery. Most patients don't ask what your complications rates are, and even if they did, most don't know how to assess those values or compare them. What they're typically looking for, are cues for why they should trust you.

And most of the time when a patient looks to you to determine your trustworthiness, they're not looking at the things we look at. Especially when you're a trainee trying to get patients to trust you, you don't have fabulous answers. It comes down to, "I care, and I'm being supervised by people who are competent AND care."

So from the surgeons I was told, patients can tell how professional you appear in clinic - this being the justification for why surgeons should be some of the best-dressed docs in the place to create trust.

Also, patients know what their wound looks like when they wake up - they subconsciously use that to evaluate how much care you used during the surgery. This was used to explain a lot of things I saw surgeons do that weren't strictly necessary to get the patient closed and on their way.

Lastly, that there is an interpersonal skill that is ESSENTIAL to being regarded as a good surgeon - and that is engendering a sense of confidence, caring, competency, in a very short space of time with patients.

People say that anesthesiologists don't need good people skills - and I've never heard that from an anesthesiologist. They play an absolutely critical role in the care of the surgical patient, and what surgeons, anesthesiologists, EM docs, and some other fields all have in common - they have an absolutely tiny amount of time to create enough rapport to do some pretty hardcore things to people.

I know of EM docs, anesthesiologists, and surgeons that have all had their training and practice suffer because their people skills were not up to this significant task. They were all competent. Competency will never get you out of needing the requisite people skills.

I will spare us the debate on whether or not the quality of med school applicants has gone up; what is clear to me, is that there is a relative glut of people applying, all of whom have the requisite intelligence and work ethic to be competent. But do they all have the people skills to maximally translate that to effectiveness.

Nevermind the whole bit about interpersonal skills and malpractice. That for the exact same error and even atrocious outcomes, whether or not a patients moves forward with a lawsuit depends so much on feeling that they were heard by the treating physician, and that what were seen as heartfelt apologies made patients more forgiving towards their physician. It's not hard to see why.

 

[operaman]

Empathy and competence are far from mutually exclusive. If anything, the finest surgeons I've worked with are also some of the most empathetic, especially those who are truly world class and have patients flying in from all over. Here's a key point: brilliance and competence are the gifts that allow someone the luxury of time for empathy and rapport. I've definitely noticed a trend where the less empathetic docs are generally less competent as well, much like the truly gifted superstar med students also tend to be the kindest most well rounded because they have that luxury.

What OP is describing is a very real aspect of clinical growth - the need to balance rapport and empathy with efficiency. The answer is not to be a douche and blaze through your clinics or else you will quickly see your referrals dry up and satisfaction scores drop. Of course, if you're a super sweet empathetic person but your clinic runs hours behind, you may find a different set of problems! It's all about finding a balance and this really gets at the heart of the "art" of practicing medicine.

One of our attendings is arguably the best example of this I've ever seen. His clinics typically have 50-60 patients per day, always run on time, and he has all his notes done within an hour of the last patient leaving. His patients adore him and laud his bedside manner and personality and he always devotes some time to building rapport and getting to know people on a personal level. Even with resident help, this is a very high volume clinic when you consider that many of these patients get procedures or require some extensive pre-surgical counseling.

So I've made a point to take notes on how her functions because ideally I'd like to emulate that kind of efficiency and empathy when I'm done with training. First, he doesn't typically ask a totally open ended question to begin with, usually alluding to the reason for their referral or their prior surgery or whatever their chronic issue is. He selectively uses open ended questions to elicit key points that really hinge on how a patient describes something, but is quick to focus them in on the key points of information he needs. You can do this politely and patients don't seem to mind since they don't usually want to spend their whole day in the office either. He'll do ROS and some chit chat during his physical exam and then delivers his A&P, answers questions, etc. Then he always ends the encounter by offering to walk the patients out -- I personally and have seen other docs lose time here when patients may want to chit chat, but the walking them out is a very kind and polite way to end the encounter and get them out the door. He then dictates his note immediately which takes him ~1 minute and he's on to the next one.

You'll find it gets much easier to be efficient as you get better at asking questions and knowing exactly what you need to ask for a given issue. Your exams will be faster because you're going for some very key things and either skipping or very quickly blazing through the rest. You'll get better at knowing which patients you have to be more terse with and which you can be more open and still get out the door reasonably fast.

As I'm typing this I remember a gyn attending who taught me more about efficiency in one morning than anything else in med school. I had to have one of those observed and graded encounters, and he did it this way. He told me to go into the room and that if I came out in less than 2 minutes, he'd mark it an honors, 2-3 minutes was a HP, 3-4 a P, and >5 was a fail. He told me the key points he wanted me to get and sent me in --> made it out with 10 seconds to spare and he was true to his word. Even with just 110 seconds, when I presented I realized I had obtained more than enough key information for the visit. This was eye opening to me and he continued to press me for more efficiency throughout the day, always demonstrating it himself as he kindly and personably knocked out visit after visit in just a few minutes, often ending visits with hugs from happy patients and families. Again: empathy and competence are intimately linked and not two disparate concepts that cannot coexist.

 

[Crayola227]

You must be BOTH competent and empathetic

Even radiologists and pathologists talk about this - although often their audience is other doctors.

I've seen in action the empathy and rapport between an ED doc and the typical radiologist they talk to with reads, make a difference in patient care.

Same with nursing care.

 

[Crayola227]

Empathy and competence are far from mutually exclusive. If anything, the finest surgeons I've worked with are also some of the most empathetic, especially those who are truly world class and have patients flying in from all over. Here's a key point: brilliance and competence are the gifts that allow someone the luxury of time for empathy and rapport. I've definitely noticed a trend where the less empathetic docs are generally less competent as well, much like the truly gifted superstar med students also tend to be the kindest most well rounded because they have that luxury.

What OP is describing is a very real aspect of clinical growth - the need to balance rapport and empathy with efficiency. The answer is not to be a douche and blaze through your clinics or else you will quickly see your referrals dry up and satisfaction scores drop. Of course, if you're a super sweet empathetic person but your clinic runs hours behind, you may find a different set of problems! It's all about finding a balance and this really gets at the heart of the "art" of practicing medicine.

One of our attendings is arguably the best example of this I've ever seen. His clinics typically have 50-60 patients per day, always run on time, and he has all his notes done within an hour of the last patient leaving. His patients adore him and laud his bedside manner and personality and he always devotes some time to building rapport and getting to know people on a personal level. Even with resident help, this is a very high volume clinic when you consider that many of these patients get procedures or require some extensive pre-surgical counseling.

So I've made a point to take notes on how her functions because ideally I'd like to emulate that kind of efficiency and empathy when I'm done with training. First, he doesn't typically ask a totally open ended question to begin with, usually alluding to the reason for their referral or their prior surgery or whatever their chronic issue is. He selectively uses open ended questions to elicit key points that really hinge on how a patient describes something, but is quick to focus them in on the key points of information he needs. You can do this politely and patients don't seem to mind since they don't usually want to spend their whole day in the office either. He'll do ROS and some chit chat during his physical exam and then delivers his A&P, answers questions, etc. Then he always ends the encounter by offering to walk the patients out -- I personally and have seen other docs lose time here when patients may want to chit chat, but the walking them out is a very kind and polite way to end the encounter and get them out the door. He then dictates his note immediately which takes him ~1 minute and he's on to the next one.

You'll find it gets much easier to be efficient as you get better at asking questions and knowing exactly what you need to ask for a given issue. Your exams will be faster because you're going for some very key things and either skipping or very quickly blazing through the rest. You'll get better at knowing which patients you have to be more terse with and which you can be more open and still get out the door reasonably fast.

As I'm typing this I remember a gyn attending who taught me more about efficiency in one morning than anything else in med school. I had to have one of those observed and graded encounters, and he did it this way. He told me to go into the room and that if I came out in less than 2 minutes, he'd mark it an honors, 2-3 minutes was a HP, 3-4 a P, and >5 was a fail. He told me the key points he wanted me to get and sent me in --> made it out with 10 seconds to spare and he was true to his word. Even with just 110 seconds, when I presented I realized I had obtained more than enough key information for the visit. This was eye opening to me and he continued to press me for more efficiency throughout the day, always demonstrating it himself as he kindly and personably knocked out visit after visit in just a few minutes, often ending visits with hugs from happy patients and families. Again: empathy and competence are intimately linked and not two disparate concepts that cannot coexist.

Totally agree with bolded.

Not totally sure what I make of this particular example with gyn preceptor, but you are essentially getting at a VERY special skill, which is taking as little time as the next competent doctor (we have to practice in a rush typically), but doing it in a way that leaves the patient feeling good about the encounter.

Not to mention, a stitch saved in time saves nine. I fully believe that patients that walk out a happy camper are more likely to follow your advice. More likely to seek you out when things just start to go wrong, not when the horse has totally left the barn and it's going to take more time to address. Less likely to call with all sorts of complaints and dissatisfaction about their care.

Consider that the interpersonal skills have a placebo or nocebo effect - they might not impact the patient's disease in any sort of hard outcome measures sort of way, but it can make them imagine they are more or less well. That has ripple effects.

I always say, I'll take placebo where I can get it, if it helps.

 

[BestoFriedo-Todo]

We got to understand that not everyone thinks the way we do. For us who want to be doctors, and be logical about everything, competency > empathy. If possible, empathy and compassion are encouraged, but it will definitely take a back seat to competency, in most of our minds. If you can do both, even better.

Take that to the regular population and there are actually a lot of people who demand empathy and desire better bedside manner from their physicians. And a lot of patients are willing to put up with a lot, when they know their doctor really cares and has amazing bedside manner. I know of one PCP who runs 2 hours behind EVERY DAY! And all his pt's know it. They will all sit in that waiting room two hours past their appt time, just to see him. There are other providers available, but they don't care. They want to see him because he is just so empathetic, compassionate and comforting to them.

 

[BestoFriedo-Todo]

Now this is just my personal experience, so it might not mean much, but hear me out. I was the top scorer in my Anatomy class. However, there was one girl who didn't do as well as me, but she did good and got at least an A or a B on most thing. When the finals were closing in, I found out that a lot of people had asked her to lead a study group for them. And I was a bit taken back, because they didn't ask me. So I asked, "why did you have her to teach you guys the material, when I make better grades than her on everything?". And a guy flat out told me, "everyone thinks you're an dingus". I don't recall saying much to any of them throughout the semester. I didn't even know more than 3 of their names out of the 40 person class. I just sat in the back, made good grades and slept when I could (I studied at home). More than half the class got C's, D's and F's, and probably had to retake the course. Regardless, these were people in need, and who were dangerously close to failing a class. Instead of going to the best person, they asked for the second best because the second best seemed nicer and more empathetic.

Competency and logic might mean more to us as Pre-meds, medical students and doctors, but to the general population that make up the patient body, empathy and good people skills might be more important.

 

[Stagg737]

@operaman with another great post.

I agree that there is more to 3rd and 4th years than just trying to become competent and that learning how to incorporate empathy and patient advocacy into your interview is just as important, if not more important, than developing competency. Especially since you'll be on rotations that you'll never do again (get something out of everything you do).

As a med student, you're not going to be competent when you finish a rotation anyway, that's what residency is for. What you should be able to do is understand how to interview and assess your patients, how to work effectively with your patients and team, and how to generally function in that field. Despite what it feels like, you actually have minimal responsibility over your patients and in general. Take advantage of that and become efficient and effective at interviewing patients. That will likely serve you better come residency than trying to develop those skills later when you've got so much more on your plate.

 

[Crayola227]

There isn't always the luxury of time, but wherever possible I've made a point to make patients feel heard, feel that I empathize, understand where they are coming from, and educate.

This is just as important to surgeons as it is to anyone else.

I have so many examples where brilliant colleagues (I'm average at best) spun their wheels because they didn't take the time for the human side of the equation. I am quite proud of the times that I went in the room, used some humanities woo-woo for 5-15 minutes (easier on inpatient medicine, although it often means I'm staying 5-15 minutes later in the hospital), and got patient adherence. The trade off is the time saved by doing this, by getting a patient to consent to things that got them healthier and out the door.

For me, my proudest moments aren't the times I did something any competent doctor could do. It's when I stepped through the door and interacted with a patient in a way, that got adherence that no one else had to date.

As a trainee, basically everyone is more competent than you. So what can you add to the team as you seek to learn mastery?

 

[Lnsean]

Actually, you can't fake empathy as well as you think you can - fact.

Also, you don't have to fake competence. One board certified doctor is about as good as the next when it comes to that.

Producing doctors that are "competent" isn't rocket science. It's the people skills that really separate a great FM doc from a merely competent one. They aren't differentiated by how great they are at calculating insulin requirements in their DM patients. A monkey could be trained to manage most DM. Can a monkey convince someone to manage their DM properly?

I disagree. We aren't talking about following algorithms though. A highly skilled surgeon vs one that is just okay...a highly competent IM clinician vs one that is just okay...it matters in many settings, not just FM. I think your analogy isn't fair and clearly tries to diminish skill for empathy. Empathy is a great thing to have but it can be faked.

 

[operaman]

Just one thing to add:

Patient satisfaction scores are already huge and already tied to reimbursement and overall hospital ratings/rankings. These are heavily tracked internally by all institutions and poor performers are facing ever increasing scrutiny and pressure to improve. The money involved is simply too much to be ignored. Nobody reading this forum is likely to have reached the level of career prominence where a hospital would overlook poor scores to keep you on staff, especially in saturated high-demand areas.

Here's a link to the official survey instruments:
http://www.hcahpsonline.org/en/survey-instruments/

You'll note that there are specific questions about physicians and they are across the board focused on empathy and soft factors rather than sheer competence. We can debate endlessly about the pros/cons of this system, but it's a current reality and is unlikely to go away during our careers.

 

[Lnsean]

Just one thing to add:

Patient satisfaction scores are already huge and already tied to reimbursement and overall hospital ratings/rankings. These are heavily tracked internally by all institutions and poor performers are facing ever increasing scrutiny and pressure to improve. The money involved is simply too much to be ignored. Nobody reading this forum is likely to have reached the level of career prominence where a hospital would overlook poor scores to keep you on staff, especially in saturated high-demand areas.

Here's a link to the official survey instruments:
http://www.hcahpsonline.org/en/survey-instruments/

You'll note that there are specific questions about physicians and they are across the board focused on empathy and soft factors rather than sheer competence. We can debate endlessly about the pros/cons of this system, but it's a current reality and is unlikely to go away during our careers.

Aren't those scores more tied to if the patient gets what they want? So these measures aren't exactly markers of empathy anyways...more like good customer service and that's another topic. An opioid seeker in the ER will rate you as unempathetic if he leaves the hospital without a percocet script...

 

[BestoFriedo-Todo]

Aren't those scores more tied to if the patient gets what they want? So these measures aren't exactly markers of empathy anyways...more like good customer service and that's another topic. An opioid seeker in the ER will rate you as unempathetic if he leaves the hospital without a percocet script...

Agreed. You will be hard pressed to find any Pain Management or other physician who frequently says "NO" to people who are seeking opiods, Benzos and other controlled substances, that has good google reviews/patient reviews.

 

[VA Hopeful Dr]

Aren't those scores more tied to if the patient gets what they want? So these measures aren't exactly markers of empathy anyways...more like good customer service and that's another topic. An opioid seeker in the ER will rate you as unempathetic if he leaves the hospital without a percocet script...

This exactly.

At my current job, when I started I was very stingy with antibiotics and steroids. Spent loads of time talking why it wasn't called for and even the potential harms. Got savaged on satisfaction surveys.

Now I spend tops 5 minutes in the room, prescribe whatever non-controlled drugs they want. Scores are awesome.

 

[VA Hopeful Dr]

I disagree. We aren't talking about following algorithms though. A highly skilled surgeon vs one that is just okay...a highly competent IM clinician vs one that is just okay...it matters in many settings, not just FM. I think your analogy isn't fair and clearly tries to diminish skill for empathy. Empathy is a great thing to have but it can be faked.

Meh, for most of what we do OK versus top notch really doesn't matter.

 

[Crayola227]

Just one thing to add:

Patient satisfaction scores are already huge and already tied to reimbursement and overall hospital ratings/rankings. These are heavily tracked internally by all institutions and poor performers are facing ever increasing scrutiny and pressure to improve. The money involved is simply too much to be ignored. Nobody reading this forum is likely to have reached the level of career prominence where a hospital would overlook poor scores to keep you on staff, especially in saturated high-demand areas.

Here's a link to the official survey instruments:
http://www.hcahpsonline.org/en/survey-instruments/

You'll note that there are specific questions about physicians and they are across the board focused on empathy and soft factors rather than sheer competence. We can debate endlessly about the pros/cons of this system, but it's a current reality and is unlikely to go away during our careers.

I think we take for granted that the system does a lot, and I would argue mostly succeeds, to create competent physicians from a knowledge/skills clinical decisions-making standpoint. So how where is the room for improvement?

I think we acknowledge that the ceiling for getting more adherence from soft skills, leaves a lot of room to move.

One hospital gets chosen over another, frequently based on reputation for soft factors. That's what I heard OVER and OVER in the city where I trained, that has at least 4 hospital systems. Insurance plays a factor, but most patients I saw really had a choice between at least 2 of the 4, or more. Many made a point of telling me exactly what they thought of the systems and why they chose the one they did.

So I can see why hospitals care, there is some degree of competition between them, and a good business model doesn't say "should this matter." It just seeks to change the variables where they can, or maximize them. You can't stop patients from caring about soft factors.

 

[W19]

This exactly.

At my current job, when I started I was very stingy with antibiotics and steroids. Spent loads of time talking why it wasn't called for and even the potential harms. Got savaged on satisfaction surveys.

Now I spend tops 5 minutes in the room, prescribe whatever non-controlled drugs they want. Scores are awesome.

That is really sad... I think you should have stood your ground. Someone has to draw the line...

 

[operaman]

Aren't those scores more tied to if the patient gets what they want? So these measures aren't exactly markers of empathy anyways...more like good customer service and that's another topic. An opioid seeker in the ER will rate you as unempathetic if he leaves the hospital without a percocet script...

Partly, but if you read the survey you'll see there are very specific questions addressing aspects of the encounter. Based on your question, it seems like you did not read the survey instruments but rather repeated something you've heard about patient satisfaction surveys.

From an administrative perspective, there's an inherent level of unhappy and unsatisfied people and these will be evenly distributed among physicians and types of hospitals. The truly poor performers will, in theory, have worse numbers overall and especially get dinged on those questions 5,6, and 7 that query physician behavior. If a doc is falling significantly below his colleagues who are treating the same patient population, then there will be increased scrutiny from administration. This is already happening; this is not a hypothetical.

Currently there are institution-wide initiatives at every hospital in the country (and a plethora of high priced outside consultants) looking at ways to improve these scores overall. As systems get more refined and the bigger systems issues are worked out, more and more attention will be paid to individuals who are low performers and dragging scores down. It won't take a genius to figure out that a hospital could fire its lowest 5% of performers and see an immediate jump in scores.

 

[Crayola227]

Besides the obvious situations where you're going to get savaged (pain meds, abx), there's plenty of other circumstances where you can make improvements, and I don't mean satisfaction scores.

I'm talking vaccination rates, like flu, colonoscopies and other screenings, hospitalization for CHF exacerbations, smoking cessation, weight loss, HTN, DM outcomes, asthma ER visits.

This is definitely the sort of stuff that is being tracked in the EHR. And it's no surprise, that there's a strong correlation between satisfaction scores, measures of patient adherence, and improvement in some of these measures.

It's frankly exciting to me how the degree to which a good therapeutic alliance and education can do.

Plenty of research suggests that the real limitation is patients walking out the door *understanding* what needs to be done, and feeling like doing it.

I agree a doctor can only do so much when it comes to that, but we have data that says there's no much we can do towards better outcomes with the woo-woo.

 

[68PGunner]

As a medical student, my job is to focus on my competence and efficiency first. Empathy and all of that bs can easily be done with a little bit more time when I'm super good at my job.

 

[Lnsean]

Partly, but if you read the survey you'll see there are very specific questions addressing aspects of the encounter. Based on your question, it seems like you did not read the survey instruments but rather repeated something you've heard about patient satisfaction surveys.

From an administrative perspective, there's an inherent level of unhappy and unsatisfied people and these will be evenly distributed among physicians and types of hospitals. The truly poor performers will, in theory, have worse numbers overall and especially get dinged on those questions 5,6, and 7 that query physician behavior. If a doc is falling significantly below his colleagues who are treating the same patient population, then there will be increased scrutiny from administration. This is already happening; this is not a hypothetical.

Currently there are institution-wide initiatives at every hospital in the country (and a plethora of high priced outside consultants) looking at ways to improve these scores overall. As systems get more refined and the bigger systems issues are worked out, more and more attention will be paid to individuals who are low performers and dragging scores down. It won't take a genius to figure out that a hospital could fire its lowest 5% of performers and see an immediate jump in scores.

Again, it's not what the intended purpose of the surveys is originally or how the questions are being asked. Patients are using these surveys to rate poorly...encounters in which they did not get what they wanted. This alone distorts any claim you're trying to make. Yes, I know these surveys are being used...but they are being used in a sense for customer service...patient satisfaction...and not as a marker for empathy (something you are saying). It's a big leap to say that this measures empathy.

 

[Crayola227]

As a medical student, my job is to focus on my competence and efficiency first. Empathy and all of that bs can easily be done with a little bit more time when I'm super good at my job.

This is a bit silly. You have more time now than you EVER will have to develop the interpersonal skills. You will never good at your job if your "BS" skills aren't up to par and growing in skill of application, right alongside the rest of your skills.

In fact, the challenge, should you choose to accept it, is to start out with a maximum amount of interpersonal skill and empathy, and then learn how to whittle down the amount of time you have to apply it - essentially, getting more efficient with it, as @operaman used as an example.

The trick for me, has been to learn how to direct the interview, use transactional communication, redirect patients, educate them - ie, railroad them in conversation, interrupt them - while still making them feel all the warm fuzzy things I've always wanted my doctoring to be about.

There was another thread, the one about attending issues, where I break down how just knowing how to phrase things, ie manipulation, basically, makes all the difference in the world.

As @VA Hopeful Dr says with dealing with stuff, a lot of docs can do the same thing in the same 15 minutes, and the Step 1 260 gets it done the same as the 199. However what's really interesting is how different that 15 minutes can be with a doctor weak on interpersonal skills vs the savvy one.

 

[Lnsean]

This is a bit silly. You have more time now than you EVER will have to develop the interpersonal skills. You will never good at your job if your "BS" skills aren't up to par and growing in skill of application, right alongside the rest of your skills.

In fact, the challenge, should you choose to accept it, is to start out with a maximum amount of interpersonal skill and empathy, and then learn how to whittle down the amount of time you have to apply it - essentially, getting more efficient with it, as @operaman used as an example.

The trick for me, has been to learn how to direct the interview, use transactional communication, redirect patients, educate them - ie, railroad them in conversation, interrupt them - while still making them feel all the warm fuzzy things I've always wanted my doctoring to be about.

There was another thread, the one about attending issues, where I break down how just knowing how to phrase things, ie manipulation, basically, makes all the difference in the world.

As @VA Hopeful Dr says with dealing with stuff, a lot of docs can do the same thing in the same 15 minutes, and the Step 1 260 gets it done the same as the 199. However what's really interesting is how different that 15 minutes can be with a doctor weak on interpersonal skills vs the savvy one.

The person with the 260 may come to an accurate diagnosis within 15 minutes and the person with the 199 might miss the diagnosis completely. I'd rather my doctor not miss the diagnosis...I mean that is our job first and foremost.

 

[Crayola227]

The person with the 260 may come to an accurate diagnosis within 15 minutes and the person with the 199 might miss the diagnosis completely. I'd rather my doctor not miss the diagnosis...I mean that is our job first and foremost.

No one is acting like you shouldn't be capable of the basics of your job, like correct diagnosis and treatment.

Might as well state how important it is to have 1 not 2 heads or whatever is on the list for technical requirements for med school and particular residencies/other appointments.

It's essential that you're not a serial killer when you're a doctor too. What bearing does that have on the importance of empathy and other professional skills?

Look at the ACGME competencies. If you fail one by the end of residency, you fail. One of them is professionalism and communication. I argue that empathy is essential in *that* particular part of the job.

Your "first and foremost" aspect won't matter at all if your patients don't want to take your advice because they didn't like the amount of empathy you showed them.

 

[VA Hopeful Dr]

The person with the 260 may come to an accurate diagnosis within 15 minutes and the person with the 199 might miss the diagnosis completely. I'd rather my doctor not miss the diagnosis...I mean that is our job first and foremost.

You'd be surprised the added, often very, important details you get if the patient likes/trusts you.

 

[68PGunner]

This is a bit silly. You have more time now than you EVER will have to develop the interpersonal skills. You will never good at your job if your "BS" skills aren't up to par and growing in skill of application, right alongside the rest of your skills.

In fact, the challenge, should you choose to accept it, is to start out with a maximum amount of interpersonal skill and empathy, and then learn how to whittle down the amount of time you have to apply it - essentially, getting more efficient with it, as @operaman used as an example.

The trick for me, has been to learn how to direct the interview, use transactional communication, redirect patients, educate them - ie, railroad them in conversation, interrupt them - while still making them feel all the warm fuzzy things I've always wanted my doctoring to be about.

There was another thread, the one about attending issues, where I break down how just knowing how to phrase things, ie manipulation, basically, makes all the difference in the world.

As @VA Hopeful Dr says with dealing with stuff, a lot of docs can do the same thing in the same 15 minutes, and the Step 1 260 gets it done the same as the 199. However what's really interesting is how different that 15 minutes can be with a doctor weak on interpersonal skills vs the savvy one.

In the real world, empathy and compassion mean pt satisfaction as in giving them what they want or kindly explaining to them ways to work the system as in the proper documentation and paper trail in order to get what they want.

Compassion is straight up bs. I'll let you know if my feelings have changed as I progress further in my training. However, that's my honest opinion at this moment.

 

[VA Hopeful Dr]

That is really sad... I think you should have stood your ground. Someone has to draw the line...

I did that when I first got out of school. Cost me a job I really wanted.

This time it was "shape up or we're putting you on a remediation pathway".

So instead I turned in my notice and am on cruise control for the next 2 months.

 

[Lnsean]

No one is acting like you shouldn't be capable of the basics of your job, like correct diagnosis and treatment.

Might as well state how important it is to have 1 not 2 heads or whatever is on the list for technical requirements for med school and particular residencies/other appointments.

It's essential that you're not a serial killer when you're a doctor too. What bearing does that have on the importance of empathy and other professional skills?

Look at the ACGME competencies. If you fail one by the end of residency, you fail. One of them is professionalism and communication. I argue that empathy is essential in *that* particular part of the job.

Your "first and foremost" aspect won't matter at all if your patients don't want to take your advice because they didn't like the amount of empathy you showed them.

I didn't know that not being a serial killer is what qualifies as empathetic now. I think your definition has changed alot since the debate began. I don't know what your position is anymore. Yea, being able to talk to the patient is part of being competent.

 

[Crayola227]

Look at the discussion taking place -

Med students that are trying to attain competency on exams and such, thinking that coming to the right diagnosis is most important.

Compared to docs who have passed their licensing exams, gotten licenses, passed residencies and boards, and are practicing. They are taking for granted getting the "right" answer, because the whole system has seen to it that we have that very teachable skill.

The shift in thinking becomes much more about how to interact with people. That's frequently where one doctor shines compared to the next.

 

[Lnsean]

Look at the discussion taking place -

Med students that are trying to attain competency on exams and such, thinking that coming to the right diagnosis is most important.

Compared to docs who have passed their licensing exams, gotten licenses, passed residencies and boards, and are practicing. They are taking for granted getting the "right" answer, because the whole system has seen to it that we have that very teachable skill.

The shift in thinking becomes much more about how to interact with people. That's frequently where one doctor shines compared to the next.

It doesn't take being an attending to see the flaws in your logic. There are plenty of people here on both sides of the argument. I hate it when people throw out their titles to win arguments. Yea, you've been practicing but that doesn't mean your logic is all there. Your arguments should stand on their own.

 

[VA Hopeful Dr]

In the real world, empathy and compassion mean pt satisfaction as in giving them what they want or kindly explaining to them ways to work the system as in the proper documentation and paper trail in order to get what they want.

Compassion is straight up bs. I'll let you know if my feelings have changed as I progress further in my training. However, that's my honest opinion at this moment.

I felt the same as you do when I was at your stage of training.

Now I really wish stuff like that didn't matter, but it absolutely does. Can you make a fine living without it? Sure. Will you have more patients, and more loyal patients, with it? Absolutely you will.

 

[Crayola227]

It doesn't take being an attending to see the flaws in your logic. There are plenty of people here on both sides of the argument. I hate it when people throw out their titles to win arguments. Yea, you've been practicing but that doesn't mean your logic is all there. Your arguments should stand on their own.

So then explain to me how "competency" matters more than empathy when we have evidence that a lack of empathy leads to less patient adherence and more lawsuits.

I just don't get how people can argue that having this "brilliant" ability to come up with an A/P (and more than one doc here has said that frequently it's less difficult/original than you think) matters so much in a context where the patient never consents to it or adheres to it.

 

[VA Hopeful Dr]

It doesn't take being an attending to see the flaws in your logic. There are plenty of people here on both sides of the argument. I hate it when people throw out their titles to win arguments. Yea, you've been practicing but that doesn't mean your logic is all there. Your arguments should stand on their own.

Except facts don't always follow logic perfectly.

 

[Lnsean]

I felt the same as you do when I was at your stage of training.

Now I really wish stuff like that didn't matter, but it absolutely does. Can you make a fine living without it? Sure. Will you have more patients, and more loyal patients, with it? Absolutely you will.

But is that empathy though? Or is it just good customer service. just saying...