Empathy (noun) — the ability to understand and share the feelings of another; derived from the Greek pathos, or feeling.
Humanism -vs- Technology
Over 125 years ago, at the beginning of modern medicine, William Osler advised young physicians to cultivate the skill of imperturbability — aequanimitas (Latin) — to remain objective and not influenced by the doctor’s own bias and emotions. Osler noted how difficult this is to master, that being dispassionate can seem detached and put doctors are risk of hardening their hearts.
Almost 50 years ago, Robert Young starred on TV as Marcus Welby, MD, portraying an old-time family physician whose approach to patient care relied heavily on avuncular advice. In contrast, his young partner (Dr. Steve Kiley, played by James Brolin) embraced technology. An aging Welby versus youthful Kiley, they portrayed a receding humanist element of medicine being replaced by modernity.
Today, physicians have unparalleled diagnostic, interventional and pharmaceutical technology, but our system’s focus on outcomes (usually a euphemism for mortality) has caused us to forget that quality-of-life is often more important to people than quantity-of-life. Patients often say, “I’d rather be dead than ______” (fill-in the space with some non-fatal outcome). Heart-to-heart discussions with doctors have become sufficiently rare that Americans no longer see doctors in the Marcus Welby role. Medical schools have countered this trend by adding training in empathy.
No Metrics for Empathy
Health informatics advocates wax enthusiastic about using data to activate patients to improve health status, seeing patient generated data and wearable devices — the quantified self — as a pathway to reducing disease care costs. In this rush towards Big Data, one might imagine that technology could provide analytics and decision support while doctors provide human empathy, but it isn’t working that way. Health care workers of all types, not just doctors, have become inured to being sophisticated data entry clerks.
Without any mechanism to quantify caring and pay doctors for empathy, health information technology is exacerbating medicine’s drift away from humanism. Accounting software has spread its electronic tentacles to the electronic medical record (EMR), leading people to complain that doctors now focus on completing checkboxes rather than on patients. EMRs can't quantitate the doctor’s human interaction with the patient, empathy is not readily reduced to a data field, and there are no evidence-based algorithms connecting emotional state to molecular biology. But the EMR does keep track of how many checkboxes are needed to increase the doctor’s charge!
Osler did warn us that aequanimitas isn’t easy.
Patient-Centered - Really?
Tight clinic schedules driven by checkbox business models make it difficult to delve into the patient’s underlying issues. It’s much easier to keep on schedule if emotions remain restrained, especially in primary care, where most doctors would prefer to have the time to connect with patients. Yet, with no mechanism to pay for that work, it’s tempting to refer to a specialist and keep the clinic on time.
Emotion (noun) — a natural instinctive state of mind deriving from one’s circumstances, mood, or relationships with others; any of the particular feelings that characterize such a state of mind, such as joy, anger, love, hate, horror, etc.; instinctive or intuitive feeling as distinguished from reasoning or knowledge.
The words motivation and emotion both derive from the Latin movere, to move.
In successful motivation to overcome barriers to better health, patients must engage with their feelings, often including fears and frustrations that can make tears flow. Life is sometimes scary and much of the scariest stuff isn’t about death but about loss of vitality and quality-of-life, about feeling trapped, frustrated and increasingly impoverished by the burdens of chronic disease. When a patient does break into tears, it’s certainly not empathetic to leave the room to do other work and come back after the patient stops crying. So doctors delve into feelings warily. Such practices can be good with checkboxes and earn recognition for being patient-centered, but…are they, really? What does the business-like and unemotional name patient-centered really mean?
Thought Experiment About Your Mom
Medicine has an admonition to treat each patient like they are your own mother, and pretending that a patient is your Mom is an enlightening exercise. For this thought experiment, let’s say Mom is a widow, living alone…
Do you worry about your Mom’s independence, about what would happen to her if she needs assisted living, or if she can’t afford that and loses her independence and vitality? Is she staying hardy and robust enough to be able to take care of herself without any help? Does she take her medicines properly?
Do you worry whether she feels safe, if she’s eating well, is she getting out among her friends? Is her vision making it unsafe to drive at night? Is she happy?
Does being with her children still give her a glow that brightens the room? Does she have dreams and goals, does she awaken every day thinking about what she wants to achieve today?
If her health falters, where is she going to go? Is she going to come live with you?
Ah! The secret of treating everyone like they were your own mother is to treat yourself like you’re that patient’s daughter or son. Doing so brings up an entirely different discussion, less about ‘meeting metrics’ than about making her life good, about finding what she wants out of life, about how health issues get in the way of her dreams.
Connecting to Well-Being and Quality-of-Life
Wellness visits, too, have been configured to fill-in checkboxes about vaccinations, screenings or social and behavioral risks. Those tasks can be quickly achieved, and the rest of the visit should be about well-being and quality-of-life.
Chronic conditions have a way of making life seem long and hard, a downward spiral of cardiometabolic disease and disability. An awful lot of folks don't have good quality-of-life because they can’t move, they hurt, they get winded because they’re too heavy and sedentary, so they stay shut-in because they’re afraid of falling or getting hurt or are anxious in public. Such patients really need sincere discussions on tough topics:
Is your health getting in the way of being happy?
Would you like to make life better, maybe get off of some of these medications you take?
Would you like to avoid having to go on insulin?
Is your life fulfilling?
Asking such questions risks triggering fears while revealing problems that are difficult to solve and can’t be fixed with technology. It’s not hard to understand why medicine would drift away from Marcus Welby and towards Steve Kiley.
Society cannot afford for the house of medicine to hide from emotionally tough territory by focusing on facts. America needs doctors to do the tough work of empathizing, of emotionally connecting with patients, and then working to make their lives better. Fortunately, it might not be all that hard to show disease care workers how to have empathy. Our mothers have already taught us what we need to know.
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Photo of William Osler courtesy of Alan Mason Chesney Medical Archives of The Johns Hopkins Medical Institutions.
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