Thoughts on empathy

[NickNaylor]

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I'm currently doing a study for the research portion of our curriculum that looks at empathy and how various aspects of the clerkship experience in internal medicine, surgery, and psychiatry affect empathy. Surveys are sent out at the beginning and end of the clerkship, and the latter allows people that choose to participate to enter free text about anything they choose with respect to how they feel their experience has impacted their ability to be empathic. I was working on the data today and one of the participants provided this answer to the free response question:

I was struck by the degree to which attendings (one in particular) were selective in how they selectively shared information with patients-- e.g. not telling the pathology results for 1-2 weeks after they were back,even when patients had indicated their worry and desire to know the results. Also residents and attendings tended not to tell patients or families how worried they were about wound infections or adverse effects following surgery.

The system of medicine is sufficiently constraining that I do not think I can honestly be an empathic healthcare provider. I don't feel able to deeply care for patients and then act on that in a culture of rapid interactions and and computerized notes and prescription writing. It doesn't feel like providing healing to people. I don't plan on taking care of patients once I finish medical school.

Thoughts? What do you guys think? Have you had any thoughts similar to this while on the wards? I certainly have, but I wonder if this is the minority view vs. something that is acknowledged but not discussed vs. something that the majority of students don't experience during their clinical experiences.

 

[charmiedermie]

Sorry, but of all the real-life examples to lessen empathy in medical students those are really weak, even for a surgery rotation.

"Also residents and attendings tended not to tell patients or families how worried they were about wound infections or adverse effects following surgery." 🙄

How does a resident/attending telling patients their worries help the family cope?

 

[NickNaylor]

Agreed they might be "weak," and since I have no idea who the person is who knows what their general disposition is like. That being said, I do think things like refusing to tell pathology results to patients that directly ask is somewhat asinine. On my heme/onc rotation, there were patients that frequently asked what their prognosis was, and the attending on duty refused to answer the question (even if he could answer it with some degree of accuracy) for fear of "stepping on the toes" of the primary outpatient attending. I get that perspective, but it's a bit screwed up from an outsider's perspective - and I think rightfully so IMO. It's not about "helping them cope." It's about wanting information directly related to their medical care and condition and the attending refusing to provide it to them for whatever reason. Perhaps that reason is a good one, who knows. But it's an interesting aspect of medical culture that we've adopted that, I think, isn't in the best interest of patients for no real, clear reason.

 

[Wordead]

Often initial heme/onc results are just that, preliminary, and attendings dont want to get into a discussion because it causes unnecessary worry and endless questions about prognosis and treatment that might not even be relevant. Wait for final path before discussing treatment is entirely reasonable in my opinion.

 

[NickNaylor]

Often initial heme/onc results are just that, preliminary, and attendings dont want to get into a discussion because it causes unnecessary worry and endless questions about prognosis and treatment that might not even be relevant. Wait for final path before discussing treatment is entirely reasonable in my opinion.

In this case, the results were often known beforehand the patients were admitted to the heme/onc floor because either 1) they had a medical problem requiring hospitalization with a concurrent cancer diagnosis (which results in admission to the heme/onc floor in out hospital) or 2) were hospitalized for inpatient chemotherapy treatment, i.e., the cancer diagnosis was not a new problem.

 

[Ismet]

Agreed they might be "weak," and since I have no idea who the person is who knows what their general disposition is like. That being said, I do think things like refusing to tell pathology results to patients that directly ask is somewhat asinine. On my heme/onc rotation, there were patients that frequently asked what their prognosis was, and the attending on duty refused to answer the question (even if he could answer it with some degree of accuracy) for fear of "stepping on the toes" of the primary outpatient attending. I get that perspective, but it's a bit screwed up from an outsider's perspective - and I think rightfully so IMO. It's not about "helping them cope." It's about wanting information directly related to their medical care and condition and the attending refusing to provide it to them for whatever reason. Perhaps that reason is a good one, who knows. But it's an interesting aspect of medical culture that we've adopted that, I think, isn't in the best interest of patients for no real, clear reason.

I had a similar situation with one of my patients, after extensive workup and finally involvement of a specialty team, all labs/path pointed to a specific, fairly grave syndrome. As the primary team, it was not our job to break the news to the family as we would surely not be able to answer all of their specific questions. So we waited on the specialty team. And waited. And waited. It killed me going into that room every day to see this sweet kid whose parents had no idea what was in store for them, and for them to keep asking me if I knew anything when I already knew. Finally when they were told, the way the news was worded to them was in a very positive light (we know what's going on, this is what we're doing next) and nothing about the gravity of the diagnosis (the patient likely won't see her 20s). I can't imagine how hard it must be to deliver that kind of news in pediatrics, and I guess since I'm going into it I'll have to find out sometime, but the way this all went down felt so wrong. Maybe the news has to be delivered in waves. Maybe my personal biases are playing into it, as if I were in their shoes I'd want all the facts all at once, not "here's what we're gonna do" now and "oh yeah kids with this problem only live to an average of X years" later. I'd like to think they know what they're doing in delivering this news, but it made me feel horrible.

 

[moonwake]

I had a similar situation with one of my patients, after extensive workup and finally involvement of a specialty team, all labs/path pointed to a specific, fairly grave syndrome. As the primary team, it was not our job to break the news to the family as we would surely not be able to answer all of their specific questions. So we waited on the specialty team. And waited. And waited. It killed me going into that room every day to see this sweet kid whose parents had no idea what was in store for them, and for them to keep asking me if I knew anything when I already knew. Finally when they were told, the way the news was worded to them was in a very positive light (we know what's going on, this is what we're doing next) and nothing about the gravity of the diagnosis (the patient likely won't see her 20s). I can't imagine how hard it must be to deliver that kind of news in pediatrics, and I guess since I'm going into it I'll have to find out sometime, but the way this all went down felt so wrong. Maybe the news has to be delivered in waves. Maybe my personal biases are playing into it, as if I were in their shoes I'd want all the facts all at once, not "here's what we're gonna do" now and "oh yeah kids with this problem only live to an average of X years" later. I'd like to think they know what they're doing in delivering this news, but it made me feel horrible.

Well I think with diseases that take years to progress I think it would be good to let them know what the outcome usually is with the disease but to not give them a "x amount of years." I agree with not giving people all the information but man that would eat me up inside to know when their life was going to end and neither the parents nor the child knew. Man I would be an awful pediatrician. I don't think I could handle terminal kid patients over time. Props to you though.

 

[masaraksh]

You can always consider a specialty that doesn't do tests and/or doesn't report to patients.

Lets see, psych comes to mind. Perfectly fine to wait a few weeks to make sure someone's dose of antipsychotics is properly titrated before you tell them 'hey, your diagnosis called ... you're f**@ing mental'

 

[ACSurgeon]

I had a similar situation with one of my patients, after extensive workup and finally involvement of a specialty team, all labs/path pointed to a specific, fairly grave syndrome. As the primary team, it was not our job to break the news to the family as we would surely not be able to answer all of their specific questions. So we waited on the specialty team. And waited. And waited. It killed me going into that room every day to see this sweet kid whose parents had no idea what was in store for them, and for them to keep asking me if I knew anything when I already knew. Finally when they were told, the way the news was worded to them was in a very positive light (we know what's going on, this is what we're doing next) and nothing about the gravity of the diagnosis (the patient likely won't see her 20s). I can't imagine how hard it must be to deliver that kind of news in pediatrics, and I guess since I'm going into it I'll have to find out sometime, but the way this all went down felt so wrong. Maybe the news has to be delivered in waves. Maybe my personal biases are playing into it, as if I were in their shoes I'd want all the facts all at once, not "here's what we're gonna do" now and "oh yeah kids with this problem only live to an average of X years" later. I'd like to think they know what they're doing in delivering this news, but it made me feel horrible.

giving bad news can be done in a lot of ways. Some are good, but many are not as good. People inject their bias - those who would want to know all the information will give all the information. Some providers are more thoughtful than others. Some just wanna deliver good news. Some think ignorance is bliss. The list goes on.

It's good to have insight early on, and try to be perceptive about what patients and families actually like as you develop your style.

 

[RedSHIFT]

Specialists are known to sugar coat things.

 

[alpinism]

The second paragraph is something I strongly agree with to a certain extent.

One of my favorite attendings used to say that everything you need to know about a patient can be written on a 3x5 notecard.

Unfortunately, we spend most of our day charting on a computer instead of being with patients. Seems like 90% of the time some days. Which quite frankly is absurd. Between trying to find an open computer, logging back in and out, reading a patient's chart (often thousands of long convoluted notes), looking over their extensive med and allergy list, putting in orders, checking labs, ordering consults, and writing never-ending H&Ps/progress notes/discharge summaries, etc... you barely have any time to spend talking to patients. Couple that with the fact that most computer workstations are located in back rooms behind locked doors far from patients, you completely feel separated from actual patent care.

Now add in the fact that many patients have 10+ chronic medical conditions on top of their multiple chief complaints, and you can't fix most of their problems, and you're in a hurry and have a ton of patents to see in a short time, and you have all these rounds/seminars/lectures to attend, and you're hungry, tired, and sleep deprived...

Sucks the humanity out of it all.

Including your ability to feel empathy towards patients.

Sadly that's modern medicine today.

 

[operaman]

I'm going to be a contrarian again and venture that the student who wrote that free response in the OP really has very little clue what is actually going on. While we've all seen communication issues in the hospital, I don't think that one qualifies. Not even close. I can think of 100 different reasons the attending didn't discuss the path and diagnosis with them on rounds, though my gut feeling is that he/she probably did discuss it with them or wanted to do so in a more private setting. There are countless issues with tissue diagnoses and there may have been additional testing/2nd opinions in the works that didn't get discussed on rounds. Often, people like to break that kind of news along with the person who will be managing it. I don't know what the actual facts on the ground were, but my sense is that the student wasn't fully aware of what was going on and probably never bothered to ask. I question our management decisions all the time on rounds or afterwards when there's some time; most of the time I find out that my hypothetic plan is quite flawed and we have a good discussion about the reasons why. Sure, I feel stupid pretty much every day, but I'm learning.

I agree that modern medicine is definitely losing some of the humanity, but there is such a hunger for it among both patients and physicians that I think it will make a comeback. I also think that students miss a lot of the human interaction that happens as many attendings will have one-on-one interactions with patients and families after rounds are over.

I guess my tl;dr summar would be that the student never bothered to ask himself/herself a very important question: what if I might be wrong? What if the problem isn't medicine, but me? Probably a good question we should always ask ourselves whenever we lament a systemic problem.

 

[Morsetlis]

Ive witnessed that situation very often at my community teaching hospitals. I would rather that the student learn from it and strive to do better than leave medicine altogether.

There are also specialties that dont deliver bad news and are very rewarding. Anesthesiology comes to mind...

 

[Psai]

I'm going to be a contrarian again and venture that the student who wrote that free response in the OP really has very little clue what is actually going on. While we've all seen communication issues in the hospital, I don't think that one qualifies. Not even close. I can think of 100 different reasons the attending didn't discuss the path and diagnosis with them on rounds, though my gut feeling is that he/she probably did discuss it with them or wanted to do so in a more private setting. There are countless issues with tissue diagnoses and there may have been additional testing/2nd opinions in the works that didn't get discussed on rounds. Often, people like to break that kind of news along with the person who will be managing it. I don't know what the actual facts on the ground were, but my sense is that the student wasn't fully aware of what was going on and probably never bothered to ask. I question our management decisions all the time on rounds or afterwards when there's some time; most of the time I find out that my hypothetic plan is quite flawed and we have a good discussion about the reasons why. Sure, I feel stupid pretty much every day, but I'm learning.

I agree that modern medicine is definitely losing some of the humanity, but there is such a hunger for it among both patients and physicians that I think it will make a comeback. I also think that students miss a lot of the human interaction that happens as many attendings will have one-on-one interactions with patients and families after rounds are over.

I guess my tl;dr summar would be that the student never bothered to ask himself/herself a very important question: what if I might be wrong? What if the problem isn't medicine, but me? Probably a good question we should always ask ourselves whenever we lament a systemic problem.

Aint nothing wrong with me, the whole system is just horrible

 

[NickNaylor]

I'm going to be a contrarian again and venture that the student who wrote that free response in the OP really has very little clue what is actually going on. While we've all seen communication issues in the hospital, I don't think that one qualifies. Not even close. I can think of 100 different reasons the attending didn't discuss the path and diagnosis with them on rounds, though my gut feeling is that he/she probably did discuss it with them or wanted to do so in a more private setting. There are countless issues with tissue diagnoses and there may have been additional testing/2nd opinions in the works that didn't get discussed on rounds. Often, people like to break that kind of news along with the person who will be managing it. I don't know what the actual facts on the ground were, but my sense is that the student wasn't fully aware of what was going on and probably never bothered to ask. I question our management decisions all the time on rounds or afterwards when there's some time; most of the time I find out that my hypothetic plan is quite flawed and we have a good discussion about the reasons why. Sure, I feel stupid pretty much every day, but I'm learning.

I agree that modern medicine is definitely losing some of the humanity, but there is such a hunger for it among both patients and physicians that I think it will make a comeback. I also think that students miss a lot of the human interaction that happens as many attendings will have one-on-one interactions with patients and families after rounds are over.

I guess my tl;dr summar would be that the student never bothered to ask himself/herself a very important question: what if I might be wrong? What if the problem isn't medicine, but me? Probably a good question we should always ask ourselves whenever we lament a systemic problem.

I think those are worthwhile questions to ask, and certainly this person may or may not be "cut out" for medicine. Perhaps they had an unrealistic expectation of what "medicine" was before getting pounded on the wards. I do tend to think of this as a systemic problem, though, given that the dehumanization of medicine and the sterilization of the doctor-patient relationship is something that is bemoaned by many physicians, particularly those of the older generation that practiced in a time when those things weren't the case (or were less so the case).

I do think there is some truth to the statement. Rather than simply refusing to be involved in patient care, though, I've decided to make it a point in my own career to bring a tinge of humanism to my practice. I think a lot of people see what happens in big academic centers as "what medicine is" while lacking the creativity (fortitude? confidence?) to forge a new path that allows them to do the things they want to do and value the things they value. Not everything is possible, sure, but one of the great things about medicine is the myriad of paths you can take your career. It doesn't have to be "go be a hospitalist" if you don't want it to. But given how regimented and "certain" the medical path is, I wonder if we indirectly recruit people that are generally uncomfortable with the idea of going off the beaten path.

 

[Mad Jack]

I had a similar situation with one of my patients, after extensive workup and finally involvement of a specialty team, all labs/path pointed to a specific, fairly grave syndrome. As the primary team, it was not our job to break the news to the family as we would surely not be able to answer all of their specific questions. So we waited on the specialty team. And waited. And waited. It killed me going into that room every day to see this sweet kid whose parents had no idea what was in store for them, and for them to keep asking me if I knew anything when I already knew. Finally when they were told, the way the news was worded to them was in a very positive light (we know what's going on, this is what we're doing next) and nothing about the gravity of the diagnosis (the patient likely won't see her 20s). I can't imagine how hard it must be to deliver that kind of news in pediatrics, and I guess since I'm going into it I'll have to find out sometime, but the way this all went down felt so wrong. Maybe the news has to be delivered in waves. Maybe my personal biases are playing into it, as if I were in their shoes I'd want all the facts all at once, not "here's what we're gonna do" now and "oh yeah kids with this problem only live to an average of X years" later. I'd like to think they know what they're doing in delivering this news, but it made me feel horrible.

That's messed up. I feel like specialists tend to paint far too rosy of a picture, focusing on what can be done at the expense of what the reality of the situation actually is.

 

[Nasrudin]

It's the constant charting and endless bureaucratic nonsense that demands all your time. Forms, insurance prior auth's, buffing the chart for cya tactics, etc.

You don't know the half of it as a medical student. And I don't know the half of it as junior resident. My attending is busy swatting away at the constant battle with insurance companies so that I can actually learn from seeing patients more clinically than economically. They just smother us in more and more nonsense every year. Obama care has been a total disaster for us and it's only now becoming apparent in this regard. And I'm not ashamed to say I'm one of the ones that who did t know what the Reforms would mean for clinicans. What I now realize is that it's a win for all the middle managers of of health care payment and compliance people and all it means for us is more and more and more paper work.

It's even starting to affect the quality of our training. Because you can't learn much from filling out forms.

And empathy is major collateral damage for these processes. We are slowly getting pulled away from patient care.

The NP solution is just to move slower and see less patients. And given the complexities of monitoring those economic sequellae vs an easily managed salary comparison, they win. They and the patient and the people zealously monitoring patient happy scales will win. No one noticing that the inertia rewards stasis and the architects of bureaucratic morass.

 

[NickNaylor]

It's the constant charting and endless bureaucratic nonsense that demands all your time. Forms, insurance prior auth's, buffing the chart for cya tactics, etc.

You don't know the half of it as a medical student. And I don't know the half of it as junior resident. My attending is busy swatting away at the constant battle with insurance companies so that I can actually learn from seeing patients more clinically than economically. They just smother us in more and more nonsense every year. Obama care has been a total disaster for us and it's only now becoming apparent in this regard. And I'm not ashamed to say I'm one of the ones that who did t know what the Reforms would mean for clinicans. What I now realize is that it's a win for all the middle managers of of health care payment and compliance people and all it means for us is more and more and more paper work.

It's even starting to affect the quality of our training. Because you can't learn much from filling out forms.

And empathy is major collateral damage for these processes. We are slowly getting pulled away from patient care.

The NP solution is just to move slower and see less patients. And given the complexities of monitoring those economic sequellae vs an easily managed salary comparison, they win. They and the patient and the people zealously monitoring patient happy scales will win. No one noticing that the inertia rewards stasis and the architects of bureaucratic morass.

But I thought everyone was getting insurance so it's great?!?!?!?!?

 

[PL198]

It's the constant charting and endless bureaucratic nonsense that demands all your time. Forms, insurance prior auth's, buffing the chart for cya tactics, etc.

You don't know the half of it as a medical student. And I don't know the half of it as junior resident. My attending is busy swatting away at the constant battle with insurance companies so that I can actually learn from seeing patients more clinically than economically. They just smother us in more and more nonsense every year. Obama care has been a total disaster for us and it's only now becoming apparent in this regard. And I'm not ashamed to say I'm one of the ones that who did t know what the Reforms would mean for clinicans. What I now realize is that it's a win for all the middle managers of of health care payment and compliance people and all it means for us is more and more and more paper work.

It's even starting to affect the quality of our training. Because you can't learn much from filling out forms.

And empathy is major collateral damage for these processes. We are slowly getting pulled away from patient care.

The NP solution is just to move slower and see less patients. And given the complexities of monitoring those economic sequellae vs an easily managed salary comparison, they win. They and the patient and the people zealously monitoring patient happy scales will win. No one noticing that the inertia rewards stasis and the architects of bureaucratic morass.

this is what the profession gets for physicians not putting an organized stand against obamacare.

who knew, if you don't fight to defend your food, someone else will take it away?

 

[Psai]

It's the constant charting and endless bureaucratic nonsense that demands all your time. Forms, insurance prior auth's, buffing the chart for cya tactics, etc.

You don't know the half of it as a medical student. And I don't know the half of it as junior resident. My attending is busy swatting away at the constant battle with insurance companies so that I can actually learn from seeing patients more clinically than economically. They just smother us in more and more nonsense every year. Obama care has been a total disaster for us and it's only now becoming apparent in this regard. And I'm not ashamed to say I'm one of the ones that who did t know what the Reforms would mean for clinicans. What I now realize is that it's a win for all the middle managers of of health care payment and compliance people and all it means for us is more and more and more paper work.

It's even starting to affect the quality of our training. Because you can't learn much from filling out forms.

And empathy is major collateral damage for these processes. We are slowly getting pulled away from patient care.

The NP solution is just to move slower and see less patients. And given the complexities of monitoring those economic sequellae vs an easily managed salary comparison, they win. They and the patient and the people zealously monitoring patient happy scales will win. No one noticing that the inertia rewards stasis and the architects of bureaucratic morass.

No worries, we will just implement arbitrary goals that are unrelated to actual indicators of quality and will pay you less for the same work + more paperwork. The beatings will continue until morale improves

 

[charmiedermie]

this is what the profession gets for physicians not putting an organized stand against obamacare.

who knew, if you don't fight to defend your food, someone else will take it away?

We had an "organized voice" it's called the American Medical Association.

 

[username456789]

We had an "organized voice" it's called the American Medical Association.

I assume he meant an organized voice that had physicians' interests in mind.

 

[PL198]

We had an "organized voice" it's called the American Medical Association.

its physicians' fault that the AMA turned out as it did. as soon as the avg physician realizes they can't turn a blind eye at politics, maybe their interests will start to be represented.

again, who knew if you don't defend your food, that someone would take it away?

 

[charmiedermie]

its physicians' fault that the AMA turned out as it did. as soon as the avg physician realizes they can't turn a blind eye at politics, maybe their interests will start to be represented.

again, who knew if you don't defend your food, that someone would take it away?

But have you done MS-3 rotations? There is a reason we don't defend eachother and stand as one group like nurses do.

 

[NickNaylor]

its physicians' fault that the AMA turned out as it did. as soon as the avg physician realizes they can't turn a blind eye at politics, maybe their interests will start to be represented.

again, who knew if you don't defend your food, that someone would take it away?

I forgot where I read it, but there was an interesting interview with the head of a state physician lobbying group where he/she discussed the issue of midlevel creep. He said that the group wasn't really tackling that issue because he found that most of his constituents didn't care about it. This makes sense: more and more younger physicians are simply becoming hospitalists and working in large group practices/hospitals/academic centers. In those realms, midlevel creep is less of an issue. It's really the physicians out in private practice that have to "worry" about this more, and because fewer folks are going that route, it simply isn't a concern. His point was that until that becomes an issue it's simply not something they're going to worry about.

It's interesting how the culture has changed over a generation.

 

[username456789]

I forgot where I read it, but there was an interesting interview with the head of a state physician lobbying group where he/she discussed the issue of midlevel creep. He said that the group wasn't really tackling that issue because he found that most of his constituents didn't care about it. This makes sense: more and more younger physicians are simply becoming hospitalists and working in large group practices/hospitals/academic centers. In those realms, midlevel creep is less of an issue. It's really the physicians out in private practice that have to "worry" about this more, and because fewer folks are going that route, it simply isn't a concern. His point was that until that becomes an issue it's simply not something they're going to worry about.

It's interesting how the culture has changed over a generation.

I think you're probably misunderstanding a bit. I don't think I'd say more people are becoming hospitalists, although I suppose more and more outpatient specialists are becoming part of a hospital owned specialty practice model. That said, many private practitioners actively employ and LIKE having mid levels, because it helps increase revenue. The problem is that on one hand, the overall issue of mid level encroachment is a problem, but on the smaller day to day schedule having them there to work for you helps increase your take home pay.

 

[NickNaylor]

I think you're probably misunderstanding a bit. I don't think I'd say more people are becoming hospitalists, although I suppose more and more outpatient specialists are becoming part of a hospital owned specialty practice model. That said, many private practitioners actively employ and LIKE having mid levels, because it helps increase revenue. The problem is that on one hand, the overall issue of mid level encroachment is a problem, but on the smaller day to day schedule having them there to work for you helps increase your take home pay.

The bolded was more what I was getting at as well as the general trend of physicians becoming with greater frequency employees rather than employers.