June 02, 2004

The Child Screams and Looks Back at You

The other day at dinner, Linda Fiorentino and I were talking about whether doctors should strive for empathy. I won't post Linda's positive thoughts, but she asked whether you would ever want to choose empathy over confidence. Then today I read Russell Banks' "The Child Screams and Looks Back at You" (from Banks' collection Trailerpark.) This excerpt seemed apposite:

Most people, when they call in a physician, deal with him as they would a priest. They say that what they want is a medical opinion, a professional medical man's medical opinion, when what they really want is his blessing. Information is useful only insofar as it provides peace of mind, release from the horrifying visions of dead children, an end to this dream. Most physicians, like most priests, recognize the need and attempt to satisfy it.... There was an obvious, if limited, use for this practice, because it soothed and calmed both the patient and the family members, which made it easier for the physician to make an accurate diagnosis and to secure the aid of the family members in providing treatment. It was worse than useless, however, when an overoptimistic diagnosis of a disease or injury led to the patient's sudden, crazed descent into sickness, pain, paralysis, and death.

Discuss, if you please. (And Linda, is your blog still up? I couldn't find it.)

Posted by Matt Weiner at June 2, 2004 07:25 PM

...she asked whether you would ever want to choose empathy over confidence.

That's an interesting way to frame the question. Putting it that way implies that there tradeoff between empathy and confidence. I think this is a question about bedside manner. “Empathy” is probably a misnomer as it is applied to doctors. I think doctors should strive for compassion rather than empathy in the ordinary sense. Ordinary empathy is incompatible with clinical detachment. A doctor just can't relate to a screaming child in the same way as a parent.

Doctors have a social role. Sometimes the doctor must project confidence and authority. In the old days, medical students were socialized to project this air at all times. Authoritative cheerfulness was the only acceptable style. My grandfather was a doctor who treated a lot of patients with inoperable facial cancers. I asked him how he told patients that they were dying. He said he never told patients they were dying, even if a dying patient asked him point blank. He’d always say something like “Your condition is very serious, only X% of people with your type of cancer survive for than 3 months…”

In the past few years, medicine has become more aware of the importance of empathy in bedside manner. The clinical problem with legislated confidence is that patients often see through it. It’s much scarier to have a doctor you can’t trust than a doctor who admits uncertainty.

Posted by: Lindsay Beyerstein at June 3, 2004 05:12 PM

In "From Detached Concern to Empathy" (which, BTW, I am not done reading yet since I am not a speed reader--my inability to speed read is probably somehow linked to my inept GRE taking ability!) Jodi Halpern argues that physicians should move away from the currently accepted model of detached concern. On this current model, to avoid burn-out that may result from becoming emotionally invested in one's patients, doctors should care for the well-being of their patients (and we expect as much) while still remaining professionally distanced. Halpern argues that patients would benefit therapeutically if physicians strive to develop an empathetic connection with their patients. My view is that this is impossible given the nature of empathy, as well as just wrong-headed, though well intentioned. At best, physicians can only develop a genuine sympathetic or compassionate connection with their patients which would seem to do the positive work that Halpern expects of empathy. As I understand empathy (roughly, a kind of emotional identification with another person) a necessary though not sufficient condition for empathy is that one person has experienced whatever a second person is experiencing. For example, to empathize with a breast cancer survivor, one has to have had direct experience with breast cancer. Otherwise, all you can do is establish a sympathetic connection with the breast cancer survivor. And sympathy often gets a bad rap because sympathy can often come off as pity and no one wants that--fair enough. But in my view, physicians who try to develop an empathetic connection with their patients are arrogant for thinking that they could ever know what it is like (where is Nagel when you need him?!) for their patient to be experiencing what they are experiencing. To me, sympathy masquerading as empathy (which I think is all we could ever get) is equivalent to a man telling me he knows what it is like to be a woman--the response I would have to such a person (besides a punch in the face) is that they should not even pretend for a moment that they know what it is like. Admitting, instead, that they do not know what it is like, while offering a sympathetic ear is what I would much rather. More on this to follow...I would like to respond to both Matt's post and Lindsay's and I will soon. Also, Matt, I think I put the question in the following way--do we want our doctors to care or to be competent (is this what you meant by confident?)? While I admit that these are not mutually exclusive (sometimes the best doctors are also the most caring) if I had to choose, I might have to go with competence as opposed to the physician who exemplifies an ethic of care.

Posted by: Linda Fiorentino at June 3, 2004 10:26 PM

Matt--my blog is up, though it is not searchable by google or any other web engine. It is:

Posted by: Linda Fiorentino at June 3, 2004 10:29 PM

I might have to go with competence as opposed to the physician who exemplifies an ethic of care.

I agree, Linda. If it's a choice between competence and caring, competence should win every time.

Clinical empathy is mostly emotional intelligence. "Empathy" might even be a bad term for these skills. Basically, I think a good clinician should be able to relate to her patients. This isn't necessarily an exalted humanistic goal. Good salesmen also have the knack.

Quite simply, empathy is the ability to figure out what makes people tick. A doctor has to win the patient's trust. She has to extract embarrassing personal information. She has to convince him to follow her instructions. Not all patients will respond to the same approach. Some people want stern lectures, others need gentle encouragement, etc.

Maybe some doctors manage to make the right inferences by reason alone. But I suspect that for most physicians clinical empathy often contributes to clinical competence.

Posted by: Lindsay Beyerstein at June 7, 2004 12:01 AM