During the first follow-up appointment with my (now former) family doctor a few weeks after surviving a heart attack, I noticed something unsettling right away. First, she seemed utterly preoccupied with her own possible part in missing some magical sign that I’d been at risk for this surprising cardiac event. She reviewed lab test after lab test while I sat there watching her claw through a thick file of my lipid and blood pressure results going back years. It struck me that this follow-up visit was somehow all about her – not about ME at all!
Hey! Remember me? The one who actually had the frickety-frackin’ heart attack?
My (now former) doctor’s demeanor was pure CYA defense. In other words, what did my heart attack say about her, the longtime family physician who may or may not have somehow overlooked a pre-disposing cardiac risk factor?
At no point during our visit, for example, did she look me in the eye and simply say something like:
“How frightening this must have been for you!”
To do so would have been what physician, author and award-winning poet Dr. Jack Coulehan has described as compassionate solidarity:*
“This model of doctor-patient communication begins with empathic listening and responding, requires reflectivity and self-understanding, and is in itself a healing act.”
In an Annals of Internal Medicine journal article called “Let Me See If I Have This Right…” – Words That Help Build Empathy, Dr. Coulehan (of the State University of New York at Stony Brook’s Department of Preventive Medicine) and his team of equally-enlightened fellow authors tried to help their medical colleagues understand how powerfully helpful it can be to try putting themselves in the shoes (or the hospital gowns) of patients they treat each day. For example:
“Physicians hear so many difficult and distressing stories, it is no wonder that they often rush to reassure their patients:
- ‘It can’t be as bad as all that’
- ‘Everything will be all right’
- ‘Don’t worry, most of the time it’s a false positive’
“In a profession that values decisiveness and action, it is difficult not to do something to defuse patient distress when it occurs.
“Reassurance springs to the lips. Such statements are usually made in good faith and sometimes may be probably true: that is, it is likely that everything will be all right.
“Nonetheless, such reassurance often fails if the physician does not also communicate an awareness of the patient’s deepest fears or concerns.”
“One of the most widespread and persistent complaints of patients today is that their physicians don’t listen. For their part, physicians complain that they no longer have sufficient time to spend with patients, and they often blame economic pressures imposed by managed care.
“Nonetheless, they acknowledge that personal encounters with patients constitute the most satisfying aspect of their professional lives. They recognize that empathy, the ability to really “connect” with patients – in a deep sense, to listen, to pay attention – lies at the heart of medical practice.
“In clinical medicine, empathy is the ability to understand the patient’s situation, perspective, and feelings and to communicate that understanding to the patient.
“This effective use of empathy promotes:
- diagnostic accuracy
- therapeutic adherence
- patient satisfaction
- time efficiency
- physician satisfaction”
It’s no surprise that empathy for others begins to wane as students progress through medical school – even among naturally empathetic students – according to a study published in the journal Medical Teacher last year from Boston University researchers Dr. D.C. Chen et al. This is particularly true for future doctors entering technology-oriented specialties.
Meanwhile, Dr. Coulehan’s journal article also offers some tools to help express empathy for another. These phrases are useful alternatives for physicians to use instead of clawing through lipid and blood pressure reports while their patients cool their heels staring at them. For example, this article includes:
Words That Work: Statements That Facilitate Empathy
- “Would you (or could you) tell me a little more about that?”
- “What has this been like for you?”
- “Is there anything else?”
- “Are you okay with that?”
- “Let me see if I have this right.”
- “I want to make sure I really understand what you’re telling me. I’m hearing that . . .”
- “I don’t want us to go further until I’m sure I’ve gotten it right.”
- “When I’m done, if I’ve gone astray, I’d appreciate it if you would correct me. Okay?”
- “That sounds very difficult.”
- “Sounds like . . .”
- “That’s great! I bet you’re feeling pretty good about that.”
- “I can imagine that this might feel . . .”
- “Anyone in your situation would feel that way . . .”
- “I can see that you are . . .”
When I first read this list, I actually sighed when I came to the suggested question, “What has this been like for you?” How it would have helped to hear these words from my own doctor at the time, instead of a clearly distracted attempt to pro-actively distance herself from any perceived blame.
Having established a connection of empathy with a patient, Dr. Coulehan writes, physicians are sometimes anxious about what to do next. Some launch into those immediate efforts to reassure. Try to delay that effort, Dr. C. advises, in order to allow a pause of several seconds. A good rule might be:
“Don’t just do something, stand there.”
The pause, he suggests, allows the patient to experience being understood, which in itself has therapeutic value.
But I can almost hear the loud collective eye-rolling among many physicians who read Dr. Coulehan’s advice, his list of words that work to express empathy, or any instructions to just sit there saying nothing for “several seconds”. Who, after all, has time for this?
Some doctors do. Consider London physician Dr. Iona Heath, who wrote this in the journal Medical Humanities:**
“Patients come to doctors to tell their stories; to give an account of when they first became aware of things being not quite right with their body or mind, of how it all seemed to begin, and how it developed to the point when they felt they must seek the attention of their doctor.
“But how much of these stories do we hear? The evidence suggests that the patient’s whole story is seldom heard. On average, the doctor interrupts after only 18 seconds of the patient’s narrative.
“Yet, if the patient is allowed to proceed, the full story lasts, on average, only 28.6 seconds, which seems not much to ask of the listener.
“Too often, as doctors, we hear only what we want to hear, and discount what we consider irrelevant.”
In another well-known essay called “Metaphor and Medicine: Narrative in Clinical Practice”, Dr. Coulehan (who is also the editor of the 5th edition of The Medical Interview: Mastering Skills for Clinical Practice, a best-selling textbook on the clinician-patient relationship) helped to explain why helpful communication phrases from physicians may indeed be a fairly rare conversation. For example, he wrote:***
“For decades, it seems that the art has been slipping away from medicine. Like the ancient Greeks, who lamented the passing of the Golden Age, contemporary physicians, educators, the general public, and especially the sick mourn the loss of the human dimension of medical practice.
“Fragmentation, sub-specialization, lack of continuity, technological demands, burgeoning patient volume, institutional stress, and most recently managed care caused recent generations of physicians to devalue relationship-based medicine in favor of procedures and machines.”
“In theory, at least, most agree that talking with the patient is the single most important element of diagnosis and the key to effective therapy. Harrison’s Textbook of Medicine makes this point in its first few pages, before devoting the next two thousand pages exclusively to organ systems and biochemistry.
* Coulehan JL, Platt FW, Egener B, Frankel R, Lin CT, Lown B, Salazar WH. “Let Me See If I Have This Right…: Words That Help Build Empathy.” Annals of Internal Medicine 2001 Aug 7;135(3):221–227
** Heath, I. “A Fragment of the Explanation: the Use and Abuse of Words”. Medical Humanities 2001;27:64-69 doi:10.1136/mh.27.2.64
*** Coulehan J. “Metaphor and Medicine: Narrative In Clinical Practice”. Perspectives in Biology and Medicine, volume 52, number 4 (autumn 2009):585–603 © 2009 by The Johns Hopkins University Press
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