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.
7 thoughts on “How to treat the scourge of modern medicine—bad bedside manner”
Four years of dealing with serious medical issues meant I was in and out of 3 major hospitals in downtown Toronto on a regular basis. What I witnessed every time I went broke my heart, left me sad and desolate, and some incidents I will never forget. I learned to control my empathy and adopted a wall of coping devices. Medical professionals are true heros, they save lives and they cope with human despair, anxiety and abject fear on a daily basis. Most patients are too afraid to look into the eyes of their doctors, those that do, will see understanding and empathy reflected back.
I recently had to see an ophthalmologist for an eye problem
and the doctor (a veteran in his field) doesn’t even give you 3 seconds to relax in the chair and starts poking his fingers in your eyes and gets annoyed because I cannot stop blinking
if he had just taken a few seconds to explain what he was going to do that would have made a big difference in my reaction instead he made it look like it was my fault
In order for doctors to be good, they must – to some degree – emotionally disconnect, just to cope with the workload. Think about it – they’re entire job is immersed in pain, suffering, injury, sickness…
Unfortunately, after enduring medical school that includes poking at lifeless cadavers and seeing a body as an assemblage of parts, it can be difficult to reintegrate into their view that their patients are human beings.
Here’s a few apt quotes on the topic of “medical aggression”:
“Despite an appalling historical record of dangerous and foolhardy practices, medicine appears bent on learning nothing from the past. Indeed, Canadian medical historiography has been tailor-made to support the mythology of heroism on which professional egos thrive.”
“Other reforms in Canadian medical education might prove helpful…medical schools effectively condition the student to a mindless and simplistic approach to the patient, who comes to be viewed mechanistically as a biological entity to be experimented with [sic].”
“Note too that certain Canadian medical schools do not offer mandatory courses in ethical and political issues in medicine…the fledgling physician who has often studied only sciences in pre-med programs, has scant appreciation for the human side of his work. Instead, he graduates as a much glorified and exceedingly well-paid technician.”
Naylor, C.D. “Medical Aggression,” Conflict, Order and Action: Readings in Sociology. Canadian Scholar’s Press, Inc., Toronto, 1992.
A more contemporary discussion of the insensitivity in the medical profession shows a doctor actually realizing how difficult it is to be a patient! http://askanmd.blogspot.com/2011/03/doctor-d-crossed-line.html
Look, doctors are people, too. Both doctors and patients would do well to acknowledge the plight of the other. However, given the vulnerability of the patient and the power of the doctor in the patient/doctor relationship, it’s reasonable to put the onus on the doctor to proceed with compassion.
I had surgery recently at Mt. Sinai and granted ok they have their rules about care within 24 hours of surgery having someone accompany you home and stay with you for the first 24. Well what do you do when you don’t have anyone to stay with you for that time then. I didn’t want a stranger in my home after an invasive surgery. Though my specialist surgeon would not allow me to go home because they knew this. Though I was under the impression that they were going to let me leave so after hours of bullying I relented and stayed. I asked for a locker to put my things in they did not have any. So this is how it went I was made to wait 20 minutes everytime I needed a bathroom visit. The girl in the bed beyond the curtain though I complained proceeded to talk loudly on the phone for half the night so I did not sleep well having to guard my belongings. The next day although it clearly stated on my arm band that I was celiac, vegetarian and lactose intolerant they brought me a muffin, cereal and milk and orange juice I could not have any of it. The night before they brought me a beef and potato plate of food. I wanted to leave because the hospital was clearly inadequate of staff to care for me I wanted to leave they refused to let me as again I would be home alone again. So finally I got fed up and as soon as the nurses back was turned I walked quickly to the elevator and she ran after me and tried to stop me as she wanted me to wait for them to get a home care person. After being delayed further again I scarpered. I am due for another surgery soon and since they will not let me care for myself again I will have to find another way out including lying if necessary. Where I live I am 5 minutes from a hospital and can call a cab or ambulance and old enough to decide for myself why isn’t there a waiver form for those who do not have anyone to stay with them the right to self care. I know the hospitals are wanting to protect themselves from being sued I get that but in the same token they do not have the staff to attend to patients of minor surgery such as myself. They say they are underfunded and understaffed so why is it I am being forced to stay after surgery then if I don’t want to. I understand doctors, specialist and nurses are only trying to do their job I respect that but where are my rights to be respected.
you are ignorant. there is a waiver called an against medical advice form that you can sign and leave the building if you so please. hospitals are not jails and you are free to leave as you want. people wanting you to stay are looking out for your best interest in addition to preventing a lawsuit.
@georgina that is your opinion and you are entitled to it but not entitled to be a bitch as you don’t know me and perhaps I was misinformed or whatever but I am not ignorant. I was merely expressing an opinion not seeking your nasty comment.
@georgina FYI I did ask about the waiver to several staff including my specialist as I expressed my concern of not wanting to stay in the hospital and they refused to offer any information which led me to believe no such waiver existed when information on this waiver should have been made readily to me it was kept from me based on the staff and specialist ignorance not mine. So you are the ignorant one not me.
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