Map of life expectancy at birth from Global Education Project.

Friday, October 24, 2008

Cervantes the Sociologist

I have been discussing with some of my colleagues the question of physician empathy. Presumably, it's good if physicians respond with some form of reassurance or fellow feeling or compassion when patients express concerns, fear, sadness sorrow or pain. That may seem like an obvious proposition but it's actually quite complicated.

In the first place, I use the word "presumably" advisedly. There actually isn't much concrete evidence about the relationship between "empathic" behaviors by physicians and outcomes -- such as adherence to medication regimens, recovery from illness, or patient's sense of well-being -- or even patient satisfaction with their relationships with their physicians. Sure, people say they are happier with their doctors when they also say their doctors "know them as a person" and care about them and so on, and there is also evidence that they take their medications more faithfully when they feel this way, but we don't know much about exactly what kinds of behaviors by doctors cause patients to have these good feelings about them.

Quite a few investigators have used the paradigm of "cues" by patients and physician responses. Essentially they'll identify and count the number of times a patient says something that seems to indicate a concern or a negative affect of some kind, and then give the doctor a brownie point for responding immediately with something they perceive as empathy or support; and a demerit for not doing so.

These studies inevitably find that doctors miss most of these "opportunities" for empathy, and they just think that's a bad thing.

Well now hold on a goldarn minute. Do I really want my doctor weeping and slobbering over me every time I suggest some form of distress or unpleasantness that might be happening to me? The whole point of a physician visit is to try to solve or ameliorate health problems, so of course you're going to mention stuff that bothers you. Sure, I don't want the doctor to be a callous brute but we also have work to do. I'm not telling you these things because I'm looking for a shoulder to cry on, I'm telling them because they're information you need to diagnose and treat, or to figure out what information I need from you.

It seems to me that what we really need is to know that yes, the physician really does care about us, is on our side, really is trying -- and oh yeah, actually knows what she or he is doing and is technically competent. Once I know that -- perhaps because of one or two expressions of empathy at appropriate times -- we can get down to business. As much as overt expressions of caring, what I really want is that the physician correctly understands what is troubling me and comes up with an appropriate response. That means listening, being willing to let me ask questions (and that's a big problem - doctors ask 90% of the questions), and asking me questions about what I want and how I feel about treatment options, rather than just asking about symptoms and whether I do bad stuff like not take my pills or eat wrong or drink too much.

Furthermore, kindness and empathy aren't necessarily manifested in overt utterances; they're something we feel because of a person's tone of voice, body language, and oh yeah -- all of the above paragraph. A doctor who is constantly expressing empathy and caring out loud might easily seem patronizing and infantilizing. I'm not an object of pity, I can handle my problems just fine. You aren't my mommy, you're my doctor.

So how do people feel about this? How do you want your doctor to treat you, in terms of interpersonal process?

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