How to treat the scourge of modern medicine—bad bedside manner
When I was pregnant and working as a foreign correspondent in Beijing, my obstetrician suggested an amniocentesis test for Down’s syndrome. Afterwards, I was told to call in three weeks for the results, by which time I could already feel the baby’s first kicks. “There’s a problem,” the nurse said when I phoned, adding that the doctor was out. She advised me to call back in an hour. I hung up the phone and burst into tears. Worst-case scenarios overwhelmed me. Did “a problem” mean I’d have to terminate the pregnancy? Did it mean this, my first pregnancy, would be my last?
One hour later, I dried my eyes and phoned back. “Everything’s fine,” my doctor said. I was too relieved to complain about the nurse. Eventually it dawned on me that all she had meant by “problem” was that the doctor was out.
I recalled that experience in the wake of several new studies about miscommunication, patient outcomes and the widespread lack of empathy among health professionals. One study, published this year in the Canadian Medical Association Journal, found that oncologists fail up to 90 per cent of the time to respond to emotional cues from their patients.
That’s not news to the legions of us who have encountered a brusque nurse or an arrogant physician. But I was surprised to discover that nicer doctors have healthier patients. At Thomas Jefferson University in Philadelphia, researchers monitored 891 diabetic patients between 2006 and 2009 and found that those whose doctors scored highest on empathy tests were better at controlling their blood sugar and cholesterol levels and had fewer hospitalizations. Two more studies, not yet published, involving 242 primary care physicians and more than 284,000 patients in Parma, Italy, are currently in the works. Preliminary results suggest that there, too, the more empathic doctors have better patient outcomes.
While we often conflate empathy and sympathy in everyday conversation, the two are not the same. Empathy is a cognitive skill. It’s the intellectual ability to understand another’s emotion without actually experiencing the feelings of the other. Once upon a time, we called this good bedside manner, and some doctors come by it naturally. By contrast, sympathy is affective. It’s the quality of being emotionally moved by the state of another’s feelings. Sympathy in doctors is bad because it reduces objectivity and can lead to compassion fatigue, vicarious trauma and burnout. Empathy, which includes the ability to respond appropriately, sometimes with humour, is good. It elicits better information, leading to more accurate diagnoses and better patient cooperation. For doctors, this can also mean fewer errors, complaints and malpractice suits.
The accepted tool for measuring empathy in the profession is a 20-question, self-administered test created at Thomas Jefferson. It takes less than 10 minutes to complete, is available in 39 languages and is used in 54 countries, with separate tests for students, doctors and non-physician health-care professionals such as nurses and pharmacists. Sample statement from the doctor’s test: I do not enjoy reading non-medical literature or the arts. Agree or disagree. Mohammadreza Hojat, a psychologist at Jefferson who helped write the test, explains: “Classic novels make the reader familiar with human suffering and pain. And improving their narrative skills helps them communicate better.” He notes that some medical schools now include courses on literature and the arts, subjects that undergrad students often skip to concentrate on pre-med programs in science.
None of this surprises Robert Buckman, a 62-year-old medical oncologist at Princess Margaret Hospital and a co-author of the study on empathy in the CMAJ. Buckman is a one-man band for the empathy industry. He has more than a dozen books to his credit, including a lab-coat-pocket-sized idiot’s guide to “difficult conversations in medicine” and the recent bestselling Cancer Is a Word, Not a Sentence. A mane of white hair, a prominent nose, bulging brown eyes and a slight hunch conspire to give him a gnome-like aspect. He limps slightly because his right leg is numb, as is his arm, the result of a near-fatal bout of shingles 20 years ago. The shingles triggered an inflammation of the spinal cord, an autoimmune reaction, joint problems and, at the time, really bad skin.
He’d already been an advocate of empathic doctoring for years, but his own health problems solidified his conviction. “My doctor said, ‘You know, Rob, this must be really awful for you. I’m really sorry.’ Relief flooded over me. He was giving me permission to feel as terrible as I wanted.”
Buckman believes the intensity of medical training often wipes out natural empathy in student doctors. “It’s beaten out of them,” he says. “Their brains are crammed with 16 causes of hypercalcemia. If they only know 14, they’re humiliated.”
When he started advocating empathic doctoring while working in England in the ’80s, the medical establishment mocked him. “People said, ‘Fuzzy. Useless. That’s women’s work.’ ” But the profession is coming around. Empathy can be taught, and fairly quickly at that. “It’s the difference between disease doctoring and disease-and-patient doctoring,” says Buckman. “In the past, nobody taught you to say: This is a terrible shock. Here’s a Kleenex.”
One in four American medical schools now includes empathy training in its curriculum. Buckman gives an annual lecture for second-year medical students at U of T, which includes role-playing and showing realistic, unscripted videos of himself breaking bad news to actor-patients. (Hint: try saying, I’m sorry.)
“You can do it, even if you’re not naturally empathic. Look, I’ve got three strikes against me. I’m a doctor. I’m English—John Cleese has called us the most emotionally constipated people in the world. And I’m male, and we know that relative to females, males are emotionally blind,” he says, citing several scientific papers to back up the claim. Indeed, the influx of women into medicine—they now account for more than half of med-school enrolment—is effectively upping the empathy quotient. Women score higher on the Jefferson tests to a statistically significant degree.
U of T tests med-school applicants for empathy. The one in five who make it to the interview stage are asked a few leading questions by teams of two interviewers, who then write up a line or two about the applicant’s empathic ability (a subset of their communication skills, which make up about 20 per cent of the overall assessment). Buckman, who is an interviewer, asks applicants to role-play a doctor breaking bad news. For instance, he asked one young woman to announce that an EKG test indicated a “small” heart attack. Buckman, playing the patient, panicked at the news.
“I did say it was a small heart attack,” chided the applicant.
Never one to miss a teachable moment, Buckman explained that she needed to identify the patient’s emotion and respond to it. He urged her to say something like, I know this is hard for you. The applicant tried again. “In 16 seconds, she got it,” says Buckman happily.